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Kleiner DE. Role of liver biopsy in the management of idiosyncratic DILI. Liver Int 2024. [PMID: 39254214 DOI: 10.1111/liv.16097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 08/12/2024] [Accepted: 08/23/2024] [Indexed: 09/11/2024]
Abstract
Drug-induced liver injury (DILI) presents unique challenges in clinical practice. While some types of DILI are mild and resolve quickly after removing the drug, other situations are more complex, with competing aetiologies or underlying liver disease. Guidelines from professional societies agree that the liver biopsy retains a role in understanding and managing DILI in certain situations. Liver biopsy allows characterization of the histological pattern of injury as well as assessment of severity. Inflammatory infiltrates, bile duct injury or loss and vascular injury are all revealed by liver biopsy. Communication between the hepatopathologist and clinical team with clinicopathological correlation of the findings is necessary for the best determination of causality and differentiation from other diseases of exclusion, like autoimmune hepatitis and graft-versus-host disease. This review highlights important aspects of the role of liver biopsy in DILI evaluation.
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Affiliation(s)
- David E Kleiner
- Chief Post-Mortem Section, Laboratory of Pathology, National Cancer Institute, Bethesda, Maryland, USA
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Elvir Lazo OL, White PF, Lee C, Cruz Eng H, Matin JM, Lin C, Del Cid F, Yumul R. Use of herbal medication in the perioperative period: Potential adverse drug interactions. J Clin Anesth 2024; 95:111473. [PMID: 38613937 DOI: 10.1016/j.jclinane.2024.111473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 02/26/2024] [Accepted: 04/08/2024] [Indexed: 04/15/2024]
Abstract
Use of herbal medications and supplements has experienced immense growth over the last two decades, with retail sales in the USA exceeding $13 billion in 2021. Since the Dietary Supplement Health and Education Act (DSHEA) of 1994 reduced FDA oversight, these products have become less regulated. Data from 2012 shows 18% of U.S. adults used non-vitamin, non-mineral natural products. Prevalence varies regionally, with higher use in Western states. Among preoperative patients, the most commonly used herbal medications included garlic, ginseng, ginkgo, St. John's wort, and echinacea. However, 50-70% of surgical patients fail to disclose their use of herbal medications to their physicians, and most fail to discontinue them preoperatively. Since herbal medications can interact with anesthetic medications administered during surgery, the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA) recommend stopping herbal medications 1-2 weeks before elective surgical procedures. Potential adverse drug effects related to preoperative use of herbal medications involve the coagulation system (e.g., increasing the risk of perioperative bleeding), the cardiovascular system (e.g., arrhythmias, hypotension, hypertension), the central nervous system (e.g., sedation, confusion, seizures), pulmonary (e.g., coughing, bronchospasm), renal (e.g., diuresis) and endocrine-metabolic (e.g., hepatic dysfunction, altered metabolism of anesthetic drugs). During the preoperative evaluation, anesthesiologists should inquire about the use of herbal medications to anticipate potential adverse drug interactions during the perioperative period.
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Affiliation(s)
| | - Paul F White
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; White Mountain Institute, The Sea Ranch, CA 95497, USA.
| | - Carol Lee
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Hillenn Cruz Eng
- Department of Anesthesiology, Adena Health System, Chillicothe, OH, USA.
| | - Jenna M Matin
- Tulane University School of Medicine, New Orleans, LA, USA.
| | - Cory Lin
- Department of Anesthesiology and Perioperative Care, University of California Irvine, CA, USA.
| | - Franklin Del Cid
- Department of Anesthesiology, Hospital Escuela, Tegucigalpa, Honduras.
| | - Roya Yumul
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; David Geffen School of Medicine-UCLA, Charles R, Drew University of Medicine and Science, Los Angeles, CA, USA.
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Chittiboyina AG, Khan IA. Current issues in phytomedicine research - Conundrum on the chemistry of ashwagandha and its biological effects. JOURNAL OF ETHNOPHARMACOLOGY 2024; 325:117871. [PMID: 38325672 DOI: 10.1016/j.jep.2024.117871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/29/2024] [Accepted: 02/04/2024] [Indexed: 02/09/2024]
Affiliation(s)
| | - Ikhlas A Khan
- National Center for Natural Products Research, United States; Division of Pharmacognosy, Department of BioMolecular Sciences, School of Pharmacy, The University of Mississippi, University, MS, 38677, United States.
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Philips CA, Valsan A, Theruvath AH, Ravindran R, Oommen TT, Rajesh S, Bishnu S, Augustine P. Ashwagandha-induced liver injury-A case series from India and literature review. Hepatol Commun 2023; 7:e0270. [PMID: 37756041 PMCID: PMC10531359 DOI: 10.1097/hc9.0000000000000270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 07/25/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Ashwagandha herb is commonly used in Ayurveda and a "fad" dietary supplement for a host of indications based on low levels of evidence. Recently, ashwagandha was implicated in multiple reports of herb-induced liver injury (HILI), mainly from the United States. We present the first, and currently largest, series of ashwagandha-HILI from multiple centers in India. METHODS We retrospectively analyzed the respective institutional electronic medical records for ashwagandha-HILI. Patients consuming ashwagandha as part of multiherbal formulations or along with other known hepatotoxic supplements or medicines were excluded. All patients underwent a detailed diagnostic workup to exclude competing causes reasonably. Where possible, the implicated herbal formulation was retrieved and subjected to chemical analysis. RESULTS Out of 23 patients with liver injury from ashwagandha (January 2019 to December 2022), we report 8 patients with single-ingredient formulation-related HILI. Study cohort was male predominant, and cholestatic hepatitis was the commonest presentation. Five patients had underlying chronic liver disease; 3 presented with acute-on-chronic liver failure, and all 3 died on follow-up. In others, the liver injury was prolonged, nonetheless self-limiting. Liver biopsy revealed cholestatic features predominantly with hepatocellular necrosis and lymphocyte/eosinophil predominant portal-based inflammation. One patient progressed to chronic HILI. Chemical analysis revealed only natural phytochemicals without adulteration or contamination. CONCLUSIONS Ashwagandha-HILI presents with cholestatic hepatitis and can lead to the syndrome of acute-on-chronic liver failure with high mortality in those with pre-existing liver disease. Educating the public on avoiding the use of potentially toxic and unrecommended herbal supplements can help mitigate the avoidable liver disease burden in the community.
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Affiliation(s)
- Cyriac A. Philips
- Clinical and Translational Hepatology, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
- Department of Hepatology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Arun Valsan
- Department of Clinical Research, Division of Complementary and Alternative Medicine, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Arif H. Theruvath
- Department of Hepatology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Resmi Ravindran
- Department of Hepatology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Tharun T. Oommen
- Clinical and Translational Hepatology, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
- Gastroenterology & Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Sasidharan Rajesh
- Interventional Hepatobiliary Radiology, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Saptarshi Bishnu
- Department of Gastroenterology and Hepatology, Astha Medical Centre, Koshbagan, Burdwan, West Bengal, India
| | - Philip Augustine
- Clinical and Translational Hepatology, The Liver Institute, Center for Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
- Gastroenterology & Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
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Kumar P, Banik SP, Goel A, Chakraborty S, Bagchi M, Bagchi D. A critical assessment of the whole plant-based phytotherapeutics from Withania somnifera (L.) Dunal with respect to safety and efficacy vis-a-vis leaf or root extract-based formulation. Toxicol Mech Methods 2023; 33:698-706. [PMID: 37533233 DOI: 10.1080/15376516.2023.2242933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/26/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023]
Abstract
Withania somnifera (L.) Dunal, popularly known as Ashwagandha or Indian ginseng, is well acclaimed for its health-enhancing effects, including its potent immunomodulatory, anti-inflammatory, neuroprotective, and anti-tumorigenic properties. The prime biological effectors of these attributes are a diverse group of ergostane-based steroidal lactones termed withanolides. Withanones and withanosides are distributed differentially across the plant body, whereas withanolides and withanones are known to be more abundant in leaves, while withanosides are found exclusively in the roots of the plants. Standardized W. somnifera extract is Generally Recognized as Safe (GRAS)-affirmed, however, moderate to severe toxic manifestations may occur at high dosages. Withaferin A, which also happens to be the primary bioactive ingredient for the effectiveness of this plant. There have been contrasting reports regarding the distribution of withaferin A in W. somnifera. While most reports state that the roots of the plant have the highest concentrations of this phytochemical, several others have indicated that leaves can accumulate withaferin A in proportionately higher amounts. A comprehensive survey of the available reports suggests that the biological effects of Ashwagandha are grossly synergistic in nature, with many withanolides together mediating the desired physiological effect. In addition, an assorted formulation of withanolides can also neutralize the toxic effects (if any) associated with withaferin A. This mini-review presents a fresh take on the recent developments regarding the safety and toxicity of the plant, along with a critical assessment of the use of roots against leaves as well as whole plants to develop therapeutic formulations. Going by the currently available scientific evidence, it is safe to infer that the use of whole plant formulations instead of exclusively root or leaf recipes may present the best possible option for further exploration of therapeutic benefits from this novel medicinal plant.HighlightsTherapeutic potential of withanolides owes to the presence of α,β unsaturated ketone which binds to amines, alcohols, and esters and 5β, 6β epoxy group which react with side chain thiols of proteins.At concentrations above NOAEL (no observed adverse effect level), the same mechanisms contribute towards toxicity of the molecule.Although withanosides are found exclusively in roots, whole plants have higher contents of withanones and withanolides.Whole plant-based formulations have other metabolites which can nullify the toxicity associated with roots.Extracts made from whole plants, therefore can holistically impart all therapeutic benefits as well as mitigate toxicity.
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Affiliation(s)
- Pawan Kumar
- R&D Department, Chemical Resources (CHERESO), Panchkula, Haryana, India
| | - Samudra P Banik
- Department of Microbiology, Maulana Azad College, Kolkata, India
| | - Apurva Goel
- Regulatory Department, Chemical Resources (CHERESO), Panchkula, Haryana, India
| | - Sanjoy Chakraborty
- Department of Biological Sciences, New York City College of Technology/CUNY, Brooklyn, NY, USA
| | | | - Debasis Bagchi
- Department of Biology, College of Arts and Sciences, and Dept of Psychology, Gordon F. Derner School of Psychology, Adelphi University, Garden City, NY, USA
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Bokan G, Glamočanin T, Mavija Z, Vidović B, Stojanović A, Björnsson ES, Vučić V. Herb-Induced Liver Injury by Ayurvedic Ashwagandha as Assessed for Causality by the Updated RUCAM: An Emerging Cause. Pharmaceuticals (Basel) 2023; 16:1129. [PMID: 37631044 PMCID: PMC10459262 DOI: 10.3390/ph16081129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 07/26/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Herb-induced liver injury (HILI) caused by herbal supplements, natural products, and products used in traditional medicine are important for differential diagnoses in patients with acute liver injury without an obvious etiology. The root of Withania somnifera (L.) Dunal, commonly known as ashwagandha, has been used in Ayurvedic medicine for thousands of years to promote health and longevity. Due to various biological activities, ashwagandha and its extracts became widespread as herbal supplements on the global market. Although it is generally considered safe, there are several reported cases of ashwagandha-related liver injury, and one case ended with liver transplantation. In this paper, we review all reported cases so far. Additionally, we describe two new cases of ashwagandha hepatotoxicity. In the first case, a 36-year-old man used ashwagandha capsules (450 mg, three times daily) for 6 months before he developed nausea, pruritus, and dark-colored urine. In the second case, a 30-year-old woman developed pruritus after 45 days of using ashwagandha capsules (450 mg). In both cases, serum bilirubin and liver enzymes (aspartate transaminase (AST), alanine transaminase (ALT), and alkaline phosphatase (ALP) were increased. The liver injury pattern was hepatocellular (R-value 11.1) and mixed (R-value 2.6), respectively. The updated Roussel Uclaf Causality Assessment Method (RUCAM) (both cases with a score of seven) indicated a "probable" relationship with ashwagandha. Clinical and liver function improvements were observed after the discontinuation of ashwagandha supplement use. By increasing the data related to ashwagandha-induced liver injury, these reports support that consuming ashwagandha supplements is not without its safety concerns.
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Affiliation(s)
- Goran Bokan
- Internal Medicine Clinic, Department of Gastroenterology and Hepatology, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Republic of Srpska, Bosnia and Herzegovina (Z.M.)
| | - Tanja Glamočanin
- Internal Medicine Clinic, Department of Gastroenterology and Hepatology, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Republic of Srpska, Bosnia and Herzegovina (Z.M.)
- Faculty of Medicine, University of Banja Luka, 78000 Banja Luka, Republic of Srpska, Bosnia and Herzegovina
| | - Zoran Mavija
- Internal Medicine Clinic, Department of Gastroenterology and Hepatology, University Clinical Centre of the Republic of Srpska, 78000 Banja Luka, Republic of Srpska, Bosnia and Herzegovina (Z.M.)
- Faculty of Medicine, University of Banja Luka, 78000 Banja Luka, Republic of Srpska, Bosnia and Herzegovina
| | - Bojana Vidović
- Faculty of Pharmacy, University of Belgrade, 11000 Belgrade, Serbia
| | - Ana Stojanović
- Bežanijska Kosa Clinical Hospital Center, 11000 Belgrade, Serbia;
| | - Einar S. Björnsson
- Landspitali University Hospital, 101 Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, 101 Reykjavik, Iceland
| | - Vesna Vučić
- Group for Nutritional Biochemistry and Dietology, Centre of Research Excellence in Nutrition and Metabolism, Institute for Medical Research, National Institute of Republic of Serbia, University of Belgrade, 11000 Belgrade, Serbia;
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