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General Hospital. Puerta del Mar Hospital. Costa del Sol Hospital. Badalona, Barcelona. Nueve dice at presentation. Key words: Hepatotoxicity. Palabras clave: Hepatotoxicidad. Natural remedies. Productos herbales. Medicina natural. Received: Acknowledgements and support: We are grateful to D. Andrade Bellido. Departamento de Medicina.
Boulevard Louis Pasteur, Rev Esp Enferm Dig ; Within the framework of alternative medi- liver toxicity cases that was founded in and is co- cine, the use of plant products has grown most during ordinated by two of the present authors R. A study in between drug administration or toxic exposure onset our country pointed out that one in five patients on and liver disease, and between suspect agent discontin- drug therapy also used herbal remedies concomitantly uation and liver function improvement or recovery; ex- 4.
How- er damage outcome. Other causes of liver disease were excluded: studied and discussed 5. Moreover, there is no regula- ethanol, recent A- anti-HAV IgM , B- anti-HBV IgM tion for botanical compounds in many countries, in- or C- anti-HCV and PCR virus hepatitis, autoimmune cluding the US, where these products are considered diseases ANA, antimitochondrial antibodies, anti- dietary supplements, and thus escape effectiveness and LKM1 antibodies, and anti-smooth muscle antibodies , safety requirements as demanded for conventional drug and bile obstruction abdominal ultrasounds plus mag- products 6.
In addition, there are no specific post- netic resonance imaging or endoscopic cholangiogra- marketing surveillance programs, hence the incidence phy when needed. When suggested by the clinical set- and characteristics of their related adverse effects are ting, cytomegalovirus, Epstein-Barr virus, herpes virus unknown. However, evidence on the toxicity risks as- or hepatitis E infection, and a positive serology for bac- sociated with a wide variety of such remedies has teria such as Salmonella, Campylobacter and Listeria emerged in the last few years, and these remedies are were ruled out.
In patients younger than 40 years ceru- now the most common cause of hepatotoxicity in Asian loplasmin and urinary copper excretion were measured countries 7. The presence of other The Spanish government, together with the Spanish metabolic liver conditions such as hemochromatosis or pharmacovigilance agency, has published a list of alpha-1 antitrypsin deficiency was similarly assessed, plants whose sale to the public is forbidden or restrict- and ischemic hepatitis was ruled out in patients with a ed outside healthcare facilities and outside the legisla- recent history of hypotension.
In ing the liver had a liver biopsy indicated in order to ob- said list, products associated with hepatotoxicity events tain further etiologic data. In the re- possible, probable or definite were included in the data- maining subjects the problem was identified upon hy- base. Three patients underwent liver a 2-fold increase in alanine aminotransferase ALT or biopsy, and results were consistent with toxic hepatitis conjugated bilirubin levels above the upper limit of in all three Table I.
Lesion type was categorized according to pathol- jury. This reexposure was accidental in all cases, main- ogy findings, or alternatively based on biochemical ly due to lack of suspicion or diagnosis regarding the findings when no biopsy was available.
Liver damage index episode. Baseline laboratory parameters were used for this patient required referral to a hospital with a liver trans- categorization. The pathogenetic mechanism of liver plant program, but her liver failure eventually im- damage was ultimately established by considering it ei- proved spontaneously. A complete resolution was seen ther intrinsic or idiosyncratic, the latter also immunoal- in eleven patients; one patient showed persistently ele- lergical when hypersensitivity data were present.
Contrary to popular belief, herbal and neuroleptics. Table I lists the demographic and remedies are not safe and do entail a risk for liver toxi- clinical data for cases included in the present series. Substances responsible for hepa- of liver illnesses, including acute or chronic hepatitis, totoxicity cases in the registry included Camellia cholestasis, vascular lesions, and even acute liver fail- sinensis green tea in three cases, Rhamnus purshianus ure 14, Moreover, a US study revealed that herbal cascara buckthorn in two cases, and Aesculus hip- products were responsible for a high percentage of re- pocastanum horse chestnut , Coutarea latiflora co- ferrals for liver transplant as a result of fulminant liver palchi , chitosan, Cassia angustifolia senna , valerian, failure Piper methysticum kava-kava , phytosoy, and biosoy Factors that may contribute to hepatotoxicity from one case each.
The remaining pa- part of the plant, inappropriate storage, plant contami- tients ingested these substances to relieve menopause nation by chemicals, heavy metals or microorganisms, symptoms, anxiety, constipation, dyspepsia, peripheral adulteration during manufacture, and poor or absent la- venous insufficiency, and diabetes mellitus, and as a beling 17, Therefore, establishing a diagnosis of restorative.
Despite current under-reporting with hepatotoxicity case reports in various countries. Of these 22 patients, two present- fore , and a total of case reports were submit- ed with fulminant liver failure and 5 had positive read- ted to FDA between and The relative contribution of cases attributed in the literature 25, Potential mechanisms include the pres- age secondary to other forms of Camellia sinensis in- ence of substances known for their hepatotoxic effects gestion, including infusions, have been reported since Camellia sinensis and Aloe vera concentrates , ingre- their withdrawal 33, Anthracene glycosides stance was discontinued.
Furthermore, other causes of are a part of these remedies, and were previously de- liver changes were excluded, and reexposure was posi- scribed as causal agents for chronic liver injury Such pre- As depressive-anxiety disorders because of the sedative this statement has been questioned by recent epidemio- properties of kavapirones, which are GABA receptor logical studies, whether increased hepatotoxicity rates agonists A number of European countries, includ- by natural remedies results from a greater use of said ing Spain, banned the marketing of products containing products or increased susceptibility among women re- this plant after more than 20 cases of liver toxicity were mains unclear.
At any rate the prototypical profile of a reported; such measure was then extended to the other patient in this series was a female with hepatocellular countries in the European Union and Canada This is a risk profile for a fulmi- Kava toxicity seems to result from an idiosyncratic nant outcome in the context of a hepatotoxic reaction mechanism with three potential pathogenetic mecha- as was demonstrated in a recent study It should be nisms: CYP inhibition, intracellular glutathione re- highlighted that in most cases these products were indi- duction, and less likely cyclooxygenase inhibition To this anxiety.
Losing weight has become a goal for a sub- day, 4 cases of liver injury secondary to senna ingestion stantial percentage of the population in developed have been reported, two of them with positive readmin- countries whether for esthetic or health reasons, hence istration Hepatotoxicity may result from its a considerable number of people turn to natural medi- contents of sennosides, alkaloids that confer their laxa- cine and miracle products rather than dietary and exer- tive actions to this plant and are converted to anthrone cise recommendations A similar case of hepatotoxicity stance readministration 29, Lastly, we have found no prior reactions in the current series, some have been widely reports in the literature on hepatotoxicity secondary related to this condition.
More than 30 cases of hepato- to other substances such as phytoestrogens or chi- toxicity secondary to green tea Camellia sinensis as tosan. Most likely, our understand- lance agency and 9 such cases in France However, cases of liver dam- involved were reported 28, Aguilar, S. Reina, A. Ramos, their potential role as causes of adverse events To conclude, knowing that J. San- encourage clinicians to advise caution to their patients talla, C. Pons, R. Hospital Xeral-Calde, Lugo: S. Blanco, P.
Participating sites: Hospital General de Valencia: M. Primo, J. Centro Coordinador : R. Andrade, M. Lucena, Y. Ulzurrun, S. Robles, K. Patchkoria, Hospital de Laredo, Cantabria: M.
Verge, E. Hospital Clinic, Barcelona: M. Daza, M. Casado, J.
NEJM Journal Watch
Acute liver failure in a patient consuming Herbalife products and Noni juice. Key words: Acute liver failure. Liver toxicity. There is a perception in the general population that herbal products are "natural" and safe without side effects. We present a case of a year-old female patient without previous liver disease. No relevant medical history was reported with only regular consumption of Herbalife products and Noni juice.
Hepatotoxicidad Por Herbalife
Slimming at all costs: herbalife-induced liver injury. Toxic hepatitis by consumption herbalife products a case report. Toxicidad hepatica por t e verde camellia sinensis revision. Rev cluding rare hepatotoxicity.
NCBI Bookshelf. Kava kava is an herbal derived from roots of the plant Piper methysticum, which has been used for centuries as a recreational and ceremonial drink in Oceania and more recently in concentrated forms in herbal medications to treat anxiety and insomnia. Products labeled as kava have been linked to the development of clinically apparent acute liver injury which can be severe and even fatal. It is prepared from the roots of the plant which are ground into a fine pulp to which water is added. The active ingredients are kavapyrones kavalactones , which have effects similar to alcohol, such as relaxation, talkativeness, and euphoria, while reportedly maintaining mental clarity. For these reasons, kava has been proposed to be anxiolytic and used in patients with anxiety disorders and as treatment for insomnia, premenstrual syndrome and stress.