Ayurvedic and herbal medicine-induced liver injury: It is time to wake up and take notice

Devarbhavi, Harshad

doi:10.1007/s12664-018-0820-6

Cited by 25 publications

(22 citation statements)

References 9 publications

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“…This finding agrees with previous studies which have showcased toxic levels of heavy metals, mislabeling of herbal products and volatile organic compounds, and heavy metal-related higher death rates among patients on unidentified and complex CAMs. 6,9,25,26 Our study also confirms the fact that certain well known and currently heavily utilized proprietary Ayurvedic agents (such as Himalaya ® Liv.52) is associated with high death rate among patients with advanced liver disease. This particular product has undergone extensive preclinical study, mostly from the Indian subcontinent, from the year 1966 up until 2012, without any quality trials to confirm its true efficacy in human related liver diseases.…”

supporting

confidence: 80%

“…The presence of autoantibodies associated with herbal medicines has been previously well described, which agrees with our findings. 6,25,40 We did not apply the Roussel Uclaf Causality Assessment Method (commonly known as RUCAM) to assess DILI causality, since this tool has not been validated in patients with concurrent acute liver injury. However, our biopsy findings inarguably confirmed a second insult, most probably CAM-related DILI due to the heterogeneity in biopsy findings, that skewed from the expected findings.…”

mentioning

confidence: 99%

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Outcomes and Toxicology of Herbal Drugs in Alcoholic Hepatitis – A Single Center Experience from India

Philips¹,

Rajesh²,

George³

et al. 2019

Journal of Clinical and Translational Hepatology

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Background and Aims: We aimed to study clinical outcomes and liver biopsy features of alcoholic hepatitis (AH) patients on complementary and alternative medicines (CAMs) and to analyze the retrieved drugs for chemical and toxic components linked to drug-induced liver injury. Methods: We retrospectively assessed clinical, biochemical and liver biopsy features of AH patients on CAM with drug-induced liver injury (AH-CAM, n = 27) and compared them to a control group (classical AH, n = 29) on standard of care. Patients without liver biopsy evaluation and other causes for liver disease were excluded. Samples of the CAMs (n = 42) from patients were retrieved and assessed for chemical and toxins. Results: All were males, and significantly worse clinical presentation, biochemical severity, and liver disease scores were notable in patients with AH-CAM. Traditional Ayurvedic-polyherbal formulations were the most commonly used CAM. On liver histology, varying grades of severe-necrosis, severe hepatocellular, canalicular, cholangiolar cholestasis with predominant lymphocytic-portal-inflammation and varying grades of interface-hepatitis were noted in AH-CAM. Analysis of CAMs revealed presence of heavy metals up to 100,000 times above detectable range and adulterants, such as antibiotics, chemotherapy agents, nonsteroidal anti-inflammatory drugs, alcohols, antidepressants, anxiolytics, and recreational drugs. On follow up, a significantly higher number of patients with AH on CAM died at end of 1, 3-and-6-months compared to controls (37% vs. 83%, 29% vs. 62%, 18% vs. 52% respectively; p < 0.001). Conclusions: Patients with AH and CAM-related druginduced liver injury have extremely poor short-term survival in the absence of liver transplantation compared to those patients with AH on evidence-based management. Early transplant referral and educating on and curbing of CAM use in severe liver disease through strict monitoring of unregulated traditional health practices can help ease the burden of liver-related death.

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supporting

confidence: 80%

mentioning

confidence: 99%

Outcomes and Toxicology of Herbal Drugs in Alcoholic Hepatitis – A Single Center Experience from India

Philips¹,

Rajesh²,

George³

et al. 2019

Journal of Clinical and Translational Hepatology

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“…Acute‐on‐chronic liver failure (ACLF) is a catastrophic disease that can occur as a consequence of severe drug‐induced liver injury (DILI). Ayurvedic herbal drugs have been implicated as a cause for severe DILI . The potential role and outcomes of DILI‐related ACLF has not been studied in detail, and CAM‐DILI‐related ACLF data are not available …”

mentioning

confidence: 99%

“…Ayurvedic herbal drugs have been implicated as a cause for severe DILI. (6) The potential role and outcomes of DILI-related ACLF has not been studied in detail, and CAM-DILI-related ACLF data are not available. (7) We performed a retrospective analysis at our center in a large cohort of patients with liver disease to study CAM-related health-seeking behavior and clinical outcomes among patients with cirrhosis.…”

mentioning

confidence: 99%

A Single‐Center Experience on Outcomes of Complementary and Alternative Medicine Use Among Patients With Cirrhosis

Philips¹,

Paramaguru

Augustine³

et al. 2019

Hepatol Commun

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Drug‐induced liver injury (DILI) due to complementary and alternative medicine (CAM) use is on the rise throughout the world by patients looking for “safer” alternatives. However, data on acute‐on‐chronic liver failure (ACLF) due to CAM are lacking. In a large cohort of patients with cirrhosis, we retrospectively studied CAM‐related health‐seeking behavior and attempted to identify those who developed possible CAM‐DILI‐related ACLF. In this study, we examine the clinical, biochemical, and liver histopathologic characteristics of possible CAM‐DILI‐related ACLF, describe implicated CAM agents, and discuss predictors of patient outcomes. Out of 1,666 patients with cirrhosis, 68% used CAM at some point. A total of 35.7% (n = 30/84) patients presented with CAM‐related DILI leading to ACLF in the whole CAM‐DILI‐related decompensation cohort. The most common CAM was unlabeled polyherbal Ayurvedic formulations. Of possible patients with ACLF, 63% self‐medicated with CAM based on social media sharing. Mean age ± SD was 51.9 ± 9.9 years, 83% were male patients, median follow‐up duration was 173 (range, 14‐584) days, median Child‐Turcotte‐Pugh score was 13 (range, 10‐14), Model for End‐Stage Liver Disease‐sodium score was 30.1 ± 4.8, median chronic liver failure‐organ failure (CLIF‐C‐OF) score was 11 (range, 8‐14), and median CLIF‐C‐ACLF score was 98 (range, 87‐127). Portal‐based neutrophilic predominant mixed inflammation, hepatocyte ballooning, autoimmune‐like features, and severe cholestasis were seen on liver biopsy. Overall, 53% of patients died (median survival 194 days). Baseline overt hepatic encephalopathy and CLIF‐C‐OF score, total bilirubin, hyponatremia and leukocytosis, and grade of ACLF predicted 1‐, 3‐, 6‐ and 12‐month mortality, respectively. Conclusion : Possible CAM‐DILI‐related ACLF has a high mortality. Strict monitoring and identification of CAM use among people with cirrhosis and an integrative public health educational practice can help ameliorate this modifiable risk factor that potentiates heavy liver disease burden and resource use.

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“…Traditional and herbal medicines were the most common cause of hepatotoxicity, being implicated in more than 72% of the cases . In India, Ayurvedic medicines, which are part of the health care system and are considered traditionally safe when purchased via the Internet, contain detectable lead, mercury, or arsenic (19.5%‐21.7%), and cases of hepatotoxicity are being increasingly detected and reported . In China, a large, retrospective, single‐center study including more than 1900 DILI cases showed that Chinese herbal medicine accounted for the 28.4% of the cases with a signature similar to that reported in a prospective series …”

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confidence: 99%

Landscape of Liver Injury From Herbal and Dietary Supplements in Europe, Latin America, and Asia

Andrade

2019

Clinical Liver Disease

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Ayurvedic and herbal medicine-induced liver injury: It is time to wake up and take notice

Cited by 25 publications

References 9 publications

Outcomes and Toxicology of Herbal Drugs in Alcoholic Hepatitis – A Single Center Experience from India

Outcomes and Toxicology of Herbal Drugs in Alcoholic Hepatitis – A Single Center Experience from India

A Single‐Center Experience on Outcomes of Complementary and Alternative Medicine Use Among Patients With Cirrhosis

Landscape of Liver Injury From Herbal and Dietary Supplements in Europe, Latin America, and Asia

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