Chinese Skullcap in Move Free Arthritis Supplement Causes Drug Induced Liver Injury and Pulmonary Infiltrates

Abstract

Herbal medications are being increasingly used by the American population especially for common conditions like arthritis. They have been reported to cause adverse effects, including significant hepatotoxicity, but reporting remains sporadic. We report here a patient who developed drug induced liver injury following the intake of Move Free, which is an over-the-counter arthritis supplement. We propose that Chinese skullcap, which is one of the herbal ingredients of the medication, is responsible for the adverse event. There was a strong temporal association between the intake of supplement and onset of symptoms, and also there have been a few recent case reports implicating the same component. A unique observation in our case is the occurrence of pulmonary infiltrates simultaneously with the hepatotoxicity, and this side effect has not been well documented before. Both the hepatic and pulmonary complications completely resolved over few weeks after the patient stopped taking the medication. Since these supplements are readily available over the counter, we feel that it is important to document possible adverse outcomes to raise awareness in the medical community and also among patients.

Traditional Chinese Medicine (TCM) and Herbal Hepatotoxicity: RUCAM and the Role of Novel Diagnostic Biomarkers Such as MicroRNAs

“…Instead, these patients experienced a variety of symptoms such as anorexia (58.0%), fatigue (67.3%), jaundice (60.3%), nausea (35.9%), and fever (35.9%), but signs such as rash, pruritus, and pale colored stools have also been reported [181], in support of many case reports and case series [70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,…”

“…Assumed causality was mostly based on clinical judgment, rarely on the results of liver specific causality assessment methods [70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135…”

Herbal and Dietary Supplement–Induced Liver Injury

“…(81) In one patient, pulmonary infiltrates developed simultaneous with the hepatotoxicity and resolved completely with cessation of the supplement. (82) Diterpenoid compounds in Scutellaria baicalensis , have previously been shown to cause apoptosis in isolated rat hepatocytes, through reactive metabolites formed by CYP3A. (83)…”

Review article: herbal hepatotoxicity - an update on traditional Chinese medicine preparations

“…Since 2011, highlighted new case reports and case series of herbal hepatotoxicity by TCM appeared . These related to the TCM products Ban Tu Wan, Chai Hu, Du Huo, Huang Qin, Jia Wei Xia Yao San, Jiguja, Kamishoyosan, Long Dan Xie Gan Tang, Lu Cha, Polygonum multiflorum products, Shan Chi, White flood and Xiao Chai Hu Tang . The NIH and LiverTox provided actual information on Chi R Yun ( Breynia officinalis ), Dai Saiko To, Jin Bu Huan ( Lycopodium serratum ), Ma Huang ( Ephedra sinica ), Sho Saiko To, Shou Wu Pian ( Polygonum multiforme ) and Xiao Chai Hu Tang…”

“…In 2011, a new detailed report estimated the risk of hospitalisation for liver injury associated with the use of traditional Chinese herbal products containing Chai Hu ( Radix bupleuri ), referring to 61 liver injury cases in 639 779 patients with chronic hepatitis B virus infection . The first case of liver injury by the herbal TCM Du Huo ( Angelica archangelica ) was reported in 2013, hepatotoxicity by the herbal TCM Huang Qin ( Scutellaria baicalensis ) was confirmed by four new cases in 2012 and 2013 . In 2011, the liver injury risk of the TCM Jia Wei Xia Yao San was quantified in reference to seven new patients .…”