Remarks on "Herbal Immune Booster-Induced Liver Injury in the COVID-19 Pandemic - A Case Series"

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

Complementary and alternative medicine-related liver injuries are increasing globally. Alternative medicine, as an inclusive healthcare practice, is widely accepted in developing and underdeveloped countries. In this context, the traditional systems of medicine in India have been at the forefront, catering to the preventive and therapeutic spectrum in the absence of conclusive evidence for benefits and lack of data on safety. Contrary to popular belief, it is evident that apart from adverse events caused by contamination and adulteration of alternative medicines, certain commonly used herbal components have inherent hepatotoxicity. This narrative review updates our current understanding and increasing publications on the liver toxicity potential of commonly used herbs in traditional Indian systems of medicine (Ayush), such as Tinospora cordifolia (Willd.) Hook.f. & Thomson (Giloy/Guduchi), Withania somnifera (L.) Dunal (Ashwagandha), Curcuma longa L. (Turmeric), and Psoralea corylifolia L. (Bakuchi/Babchi). This review also highlights the importance of the upcoming liver toxicity profiles associated with other traditional herbs used as dietary supplements, such as Centella asiatica (L.) Urb., Garcinia cambogia Desr., Cassia angustifolia Vahl (Indian senna), and Morinda citrofolia L. (Noni fruit). Fortunately, most reported liver injuries due to these herbs are self-limiting, but can lead to progressive liver dysfunction, leading to acute liver failure or acute chronic liver failure with a high mortality rate. This review also aims to provide adequate knowledge regarding herbalism in traditional practices, pertinent for medical doctors to diagnose, treat, and prevent avoidable liver disease burdens within communities, and improve public health and education.

Complementary and alternative medicines and liver disease

Complementary and alternative medicines (CAM) include conventional medical treatments. Patients worldwide use CAM at alarming rates; thus, reports of CAM-related DILI have been on the rise. The clinical presentations include asymptomatic liver test abnormalities, acute hepatitis with or without jaundice, acute cholestatic liver disease (bland or with hepatitis), acute liver failure, severe hepatitis with features of portal hypertension, and acute decompensation of known or unknown cirrhosis that can lead to acute-on-chronic liver failure. Acute hepatitis with or without necrosis, hepatocellular and canalicular cholestasis, herb-induced or CAM-triggered autoimmune hepatitis, granulomatous hepatitis, severe steatohepatitis, and vanishing bile duct syndrome are common liver biopsy findings in CAM-DILI. The presence of preexisting liver disease predicts severe liver injury, risk of progression to liver failure, and decreased transplant-free survival in patients with CAM-DILI. This review discusses global epidemiology and trends in CAM-DILI, clinical presentation, assessment and outcomes, commonly emerging threats in the context of hepatotoxic herbs, pragmatic assessment of "liver beneficial" herbs and health care myths, patient communication, regulatory framework, and future directions on research in CAM.

Herb-induced Liver Injury-A Guide to Approach. Lessons from the Tinospora cordifolia (Giloy) Case Series Story

Background

Tinospora cordifolia (TC) is being increasingly consumed in India for its health and suggested immune-enhancing benefits in preventing and countering COVID-19. We previously published our experience of hepatotoxicity with self-medication of TC in six individuals. Since herb-induced liver injury (HILI) has been described with Tinospora crispa (TCR) consumption, it was contested that our patients may have mistakenly self-medicated with TCR which is similar in appearance to TC.

Methods

We collected the four plant samples and two commercial preparations that were consumed by our patients for further analysis. The six samples underwent high performance thin layer chromatography phytochemical analysis and DNA barcoding studies for the confirmation of the genus and species. The four plant part samples which included stems and leaves were also analysed by a botanist for the characteristic morphological and microscopic features.

Results

Based on morphological, microscopic, phytochemical and DNA studies, the four plant part samples were identified as TC. The two commercial preparations could not be analysed on phytochemical analysis or DNA barcoding studies due to other ingredients that most likely interfered with the analysis. The herb consumed by our study subjects was confirmed to be Tinospora cordifolia.

Conclusion

We have highlighted the key morphological and phytochemical differences between these two species. We propose an algorithmic approach to accurately identify the implicated herb in cases of HILI. Future studies on causality need to focus on the serological/histopathological identification of active herb/metabolites in human tissues.

Golden Ager Chyawanprash with Meager Evidential Base from Human Clinical Trials

Chyawanprash (CP) is one of the most revered, effective, and best-selling health supplements of Indian Ayurvedic system of medicine, which is high on the trust and health quotient among Indian consumers. CP is an ancient synergistic blend of around fifty (50) medicinal herbs, herbal extracts with jam-like consistency, traditionally used to improve respiratory health, strengthen the immune system, prevent recurrence of infections, and over the decades is known for its anti-inflammatory and antioxidant properties. With the recent growth of commercialization, this traditional preparation is gaining popularity across the world. Various pharma firms are engaged in its commercial production, and this recipe is easily available on market shelves, with a common brand name “Chyawanprash.” The consumers generally pop up with some genuine queries or doubts regarding its usage and benefits. Though CP is well-trusted traditional preparation, however, limited scientific literature is available on understanding its clinical role. This critical review discusses the general consumer queries apropos its usage, critically analyzing the reported clinical studies, perspectives, and unmapped areas for future research.

In Vivo Anti-Inflammatory, Analgesic, Muscle Relaxant, and Sedative Activities of Extracts from Syzygium cumini (L.) Skeels in Mice

In the current study, the folklore medicine, Syzygium cumini, was experimentally evaluated for anti-inflammatory, analgesic, sedative, and muscle relaxant effects. The extract and fractions of S. cumini were found safe up to 1000 mg/kg with no mortality, except for slight sedation as a minor side effect. Both, the extract and various fractions of S. cumini demonstrated significant inhibition (86.34%) of carrageenan-induced inflammation in mice. Acetic acid induced writhes were attenuated (p < 0.001) by S. cumini in a dose-dependent manner, except for the n-hexane fraction. The maximum effect was observed at a dose of 500 mg/kg in mice. The maximum muscle relaxant effect of all tested samples was recorded at a dose of 500 mg/kg bodyweight, where the percent inhibition exhibited by dichloromethane fraction was 82.34%, followed by chloroform fractions (71.43%) and methanolic extract (70.91%). Our findings validate the folklore medicinal claims of S. cumini, as an analgesic and anti-inflammatory agent.