Assessment of turmeric DS quality at point of sale is difficult for consumers and may best be managed in partnership with knowledgeable healthcare professionals.

Turmeric dietary supplement sales, which accounted for US$69 million in spending in 2016, have been increasing exponentially in the USA, making this one of the most popular botanical supplements sold in the USA. Herbal supplement use, which is generally regarded as safe by consumers, is not usually reported to healthcare providers. We reported here on a case of autoimmune hepatitis, occurring in a 71-year-old woman taking turmeric dietary supplements for the maintenance of cardiovascular health, which resolved rapidly following discontinuation of the turmeric supplements. Of particular note, turmeric use was not documented in the patient's medical records and the potential causative role of the turmeric supplementation was ultimately identified by the patient rather than the healthcare providers. To our knowledge, this is the first documented report of turmeric supplement-induced autoimmune hepatitis.

We present the case of a young female on oral contraceptives (OCs) who was diagnosed with focal nodular hyperplasia (FNH) and remained on oral contraceptives. Months later, the patient presented with acute abdominal pain and intratumoral hemorrhage in the liver. The patient was taken to the operating room (OR) and was diagnosed with a ruptured hepatic adenoma (HA). We review the key diagnostic features of FNH and HA, the different management guidelines including use of OCs, and potential surgical indications. HA compared to FNH has a significantly higher rate of sequelae despite being a benign lesion, thus providers must accurately distinguish between the two diagnoses to prevent potential morbidity and mortality.

Autoimmune hepatitis (AIH), a chronic disorder of unknown etiology characterized by hypergammaglobulinemia and autoantibody positivity, is induced by drug injury in a minority of cases. Herbal supplements are increasingly being recognized as a potential cause of drug‐induced hepatitis (DIH). We report here on a case of drug‐induced, autoimmune hepatitis (DIAIH) attributable to ingestion of a turmeric dietary supplement. Autoimmune hepatitis (AIH) was diagnosed, as per Hennes criteria (score = 7 of 8 total), in a 76‐year old Caucasian woman presenting with an asymptomatic elevation in liver transaminases (alkaline phosphatase and bilirubin, normal). Diagnostic work up was notable for: 1) elevated IgG levels (1.3 X ULN); 2) positive antibody titers (> 1:80) for atypical pANCA and smooth muscle actin; 3) liver histology on biopsy compatible with AIH, and 4) exclusion of viral hepatitis. The patient's medical records, while not including mention of turmeric dietary supplement use, did document concurrent use of 15 other prescription or over the counter (OTC) medications which remained unchanged throughout the course of transaminase elevations. Attribution of AIH to turmeric supplementation, which the patient had begun 10‐months prior to her diagnosis, was elucidated by the patient, who stopped turmeric supplementation 2 months after her AIH diagnosis upon reading of a possible risk of turmeric‐induced hepatitis. Within 1 month of turmeric discontinuation, transaminase levels, which had risen to a maximum of 4–8 X ULN (for AST and ALT, respectively) began to decline and returned to normal within a year, where they have remained until the present time (3 years). Assessment of updated RUCAM drug‐induced hepatitis (DIH) criteria (Danan et al, Int J Mol Sci 17:2016) yielded a score of 6 (of 13 total, with ≥9 being highest category of attribution [“highly probable”]), consistent with probable attribution of turmeric use to hepatic injury in this patient. As is common in situations of supplement induced side‐effects, the actual product, which the patient had taken as directed on the label, was not identified or available for testing. In summary, this case illustrates several key points: 1) consumers and healthcare professionals should be aware that turmeric supplements, a top selling herbal in the US, can be associated with hepatoxicity, including induction of AIH; 2) the role of turmeric, concomitant medications, and/or potential contaminants in mediating supplement‐induced liver damage cannot be assessed at present; and 3) open conversations about OTC supplement use between healthcare providers and patients remains imperative to ensure delivery of high quality practice, particularly in situations of increased risk of drug‐supplement interactions.Support or Funding InformationNIH‐NCCIH#R34 AT007837

Rheumatoid arthritis (RA) is an autoimmune disease that primarily targets the joints, leading to synovial inflammation. Turmeric supplementation markedly reduces joint inflammation in pre‐clinical models of RA, suggesting a potential benefit in reducing joint inflammation in patients with RA. Here, we evaluate the percentage of patients eligible for a randomized controlled trial (RCT) of turmeric dietary supplements in RA, evaluating tolerability and pharmacokinetics. Recruitment materials were distributed in both rheumatology offices and community settings. Study entry eligibility criteria included having active disease (presence of inflamed and/or swollen joints), no current biologic use, as well as other health and medication criteria. Individuals were screened for basic eligibility through a telephone interview followed by a more comprehensive in‐clinic screening. In total, 200 patients were referred between September 2015 through October 2016; the majority (85%, n= 170) were self‐referred from community‐based recruitment strategies. From a pool of 171 (86%) who completed telephone screening, 40% (n=68) were disqualified from participation due to geographical location or having no clinical diagnosis of RA. Of the remaining 103 referrals, only 4% of local RA patients (n= 4) met all eligibility criteria; 15 (15%) discontinued the screening process and 84 (82%) were ineligible. Primary reasons for ineligibility included current or failed biologics (37%, n= 31) and no active disease (18%, n= 15). Other reasons included a serious comorbid medical condition (14%, n=12), unstable medication doses (13%, n= 11), high non‐steroidal anti‐inflammatory use (12%, n=10) or a history of malignancy (6%, n= 5). A greater proportion of patients referred from rheumatology practices passed telephone screening than those self‐referred from the community (20%, n= 6 vs. 8%, n= 14). Few of the patients screened met all eligibility requirements. Although uncommon, some patients did not wish to participate in the trial due to the possibility of receiving a placebo, as well as having to discontinue current turmeric supplement use. In summary, recruitment strategies that are primarily community‐based are inefficient in enrolling subjects who meet eligibility criteria for a RCT of turmeric dietary supplements in RA.Support or Funding InformationNIH (NCCIH): R34AT007837‐03