Clinical outcomes associated with complementary and alternative medicine-related “immunity-boosting” practices in patients with cirrhosis during the COVID-19 pandemic – an observational study

Abstract

During the coronavirus disease 2019 pandemic, Ayurvedic herbal supplements and homeopathic immune boosters (IBs) were promoted as disease-preventive agents. The present study examined the clinical outcomes among patients with chronic liver disease who presented with complications of portal hypertension or liver dysfunction temporally associated with the use of IBs in the absence of other competing causes. This single-center retrospective observational cohort study included patients with chronic liver disease admitted for the evaluation and management of jaundice, ascites, or hepatic encephalopathy temporally associated with the consumption of IBs and followed up for 180 days. Chemical analysis was performed on the retrieved IBs. From April 2020 to May 2021, 1022 patients with cirrhosis were screened, and 178 (19.8%) were found to have consumed complementary and alternative medicines. Nineteen patients with cirrhosis (10.7%), jaundice, ascites, hepatic encephalopathy, or their combination related to IBs use were included. The patients were predominantly male (89.5%). At admission, 14 (73.75%) patients had jaundice, 9 (47.4%) had ascites, 2 (10.5%) presented with acute kidney injury, and 1 (5.3%) had overt encephalopathy. Eight patients (42.1%) died at the end of the follow up period. Hepatic necrosis and portal-based neutrophilic inflammation were the predominant features of liver biopsies. IB analysis revealed detectable levels of (heavy metals) As (40%), Pb (60%), Hg (60%), and various hepatotoxic phytochemicals. Ayurvedic and Homeopathic supplements sold as IBs potentially cause the worsening of preexisting liver disease. Responsible dissemination of scientifically validated, evidence-based medical health information from regulatory bodies and media may help ameliorate this modifiable liver health burden.

Complementary and alternative medicines and liver disease

“… 65 Hepatic necrosis and portal-based neutrophilic inflammation were predominant in CAM-DILI due to Ayurvedic multiherbal products and necrosis, portal and lobular neutrophilic inflammation, and eosinophilic infiltration with cholestasis in homeopathic-remedies related DILI. 68 , 69 A study on Ayush-related “immune boosting” leading to liver injury, 68 as well as a series of homeopathic-remedies–related DILI 69 demonstrated that CAM products sold as wellness supplements could potentially cause worsening of preexisting liver disease or result in severe liver injury with progression to liver failure, resulting in a mortality rate as high as 45%.…”

“…A report from India on outcomes related to “Ayush-related immune boosting” practices among patients with cirrhosis during the COVID-19 pandemic revealed that retrieved Ayurvedic, Homeopathic, and other CAM formulations contained detectable levels of arsenic (40%), lead (60%), and mercury (60%), along with a host of other plant-derived hepatotoxic compounds, toxic industrial solvents, and alcohol. 68 The use of Ayurvedic and Homeopathic products with alcohol and heavy metal contamination and adulteration, resulting in severe morbidity and loss of life, has continually been reported in the medical literature. Theruvath et al published the first large series of homeopathic remedies related to CAM-DILI and analyzed multiple formulations retrieved from patients.…”

COVID-19 and the Liver: A Complex and Evolving Picture

“…22 While the transaminitis may reflect direct liver injury other factors might also contribute including an associated immune-related inflammatory response, congestive hepatopathy, hepatic ischaemia, venous and arterial thrombosis, muscle breakdown, and drug-induced liver injury, including use of specific experimental COVID-19 treatments, such as lopinavir-ritonavir and tocilizumab, and complementary or alternative medicines. 3,[22][23][24][25]…”

A comprehensive review on the hepatotoxicity of herbs used in the Indian (Ayush) systems of alternative medicine

“…[7][8][9] Furthermore, a large series of patients with "Ayush-immune boosting" and homeopathic remediesrelated liver injury were recently published from the Indian subcontinent. [10,11] The Asia-Pacific Association for Study of Liver (APASL) drug-induced liver injury (DILI) guidelines faculty coined the term "Ayush-liver injury" for liver injury originating specifically from Indian CAM. [12] A multicentre study from the APASL demonstrated that ACLF in Asia-Pacific countries was predominantly due to CAM (inclusive of Ayurvedic herbs and herbal and dietary supplements) in approximately 72% of patients.…”