High prevalence of potentially hepatotoxic herbal supplement use in patients with fulminant hepatic failure

Abstract

The use of potentially hepatotoxic herbal and dietary supplements is highly prevalent in the fulminant hepatic failure (FHF) patient population at our institution, and this subgroup of patients has a worse prognosis.Design: Retrospective case series.Settings: An adult tertiary care university hospital and a Veterans Affairs hospital in Oregon.Patients: All patients referred to the liver transplantation service for FHF from January 2001 through October 2002 (N = 20). We defined FHF as onset of encephalopathy within 8 weeks of onset of jaundice in the absence of preexisting liver disease. All patients underwent investigation for potential causes of liver injury. Potentially hepatotoxic supplements were defined as those with previously published reports of hepatic injury related to their use.Results: Ten patients (50%) were recent or active users of potentially hepatotoxic supplements or herbs; 10 had no history of supplement use. In the supplement group, 7 patients (35%) had no other identified cause for hepatic failure. Six patients in the supplement group and 2 patients in the nonsupplement group underwent orthotopic liver transplantation. Five patients in each group died. There were no significant differences in transplantation rate (P=.07) or survival (PϾ.99) between groups. Supplement use alone accounted for the most cases of FHF during this period, exceeding acetaminophen toxicity and viral hepatitis.

Drug-Induced Liver Injury

“…For example, acute hepatitis and liver failure were reported for LipoKinetix, a weight loss product containing norephedrine, caffeine, yohimbine, diiodothyronine and sodium usniate, leading to its withdrawal from the US market in 2001. 161,162 Chinese herbal medicines comprised of multiple compounds have been shown to result in liver injury; for example, Dai-Saiko-To and Sho-Saiko-To can induce acute hepatitis. [163][164][165] …”

Drug and herb induced liver injury: Council for International Organizations of Medical Sciences scale for causality assessment

“…The lower threshold of ALT > 2N will include multiple cases with nonspecific enzyme increases and requires more stringent exclusion of causes unrelated to drug(s) and herb(s) [24] . Also for low threshold N values, the inclusion rate of alternative diagnoses must be higher; false positive fulfilment of a hepatotoxicity definition results in high numbers of misattributed cases due to overdiagnosing and overreporting [8,12,17,24,[34][35][36][37][38][39][40][41][42][43][44][45][46][47][48] . This phenomenon is illustrated in a recent HILI study where initial ALT values were available in only 8/22 cases (36%), including 3 cases with a range of 50-69 U/L serum activity [36] .…”

Complementary and alternative medicine therapies for the anesthesiologist and pain practitioner: a narrative review

“…The induction of hepatic enzymes is involved in some of the most serious adverse events related to nutraceuticals. 44,45 Patients' use of herbal medications can have twofold significance during the perioperative period. First, these supplements are most often used to treat an underlying condition or as prevention.…”