Slimming at all costs: Herbalife-induced liver injury

HERBALIFE® ASSOCIATED SEVERE HEPATOTOXICITY IN A PREVIOUSLY HEALTHY WOMAN

Lately there has been an increased consumption of herbal preparations, distributed as nutritional supplements, often claimed to be ‘natural’ and harmless. However, as their use is not subjected to strict pre-marketing testing and regulations, their ingredients are not clearly defined and there is no quality control or proof of their effectiveness and safety. A growing body of references accentuate their harmful effects, in particular hepatotoxicity, which varies from minimal hepatogram changes to fulminant hepatitis requiring liver transplantation. This case report describes liver damage that was highly suspected to originate from Herbalife® products consumption. We excluded alcohol, viral, metabolic, autoimmune and neoplastic causes of liver lesions, as well as vascular liver disease, but we noticed a connection between the use of Herbalife® products and liver damage. The exact mechanism of liver damage in our patient was not determined. After removing the Herbalife® products, liver damage resolved and there was no need to perform liver biopsy. Taking into consideration the growing consumption of herbal products and their potential harmfulness, we consider that more strict regulations of their production process and sale are necessary, including exact identification of active substances with a list of ingredients, toxicologic testing and obligatory side effect report.

Weight Loss Supplements: Boon or Bane?

Dietary health supplements for weight loss seem to be the future nowadays. However, this industry is plagued by lack of regulations and ignorance regarding the constituents of the supplements. Of all the supplements consumed, the ones for weight loss are most commonly found in the market. Reports of liver failure, kidney impairment and worsening of chronic ailments in patients who consume these supplements are surfacing recently which make us question the credibility of these products. The safety of these products lie in the clear stating of the ingredients by the manufacturer, well informed patient, knowledgeable physician and tight regulations from the regulatory board.

Plants used in the traditional medicine of Mesoamerica (Mexico and Central America) and the Caribbean for the treatment of obesity

ETHNOPHARMACOLOGICAL RELEVANCE

Obesity is a worldwide medical concern. New ethnobotanical information regarding the antiobesity effect of medicinal plants has been obtained in the last 30 years in response to socio-demographic changes and high-fat diets became common.

AIM OF THE STUDY

This review provides a summary of medicinal plants used in Mexico, Central America and the Caribbean for the empirical treatment of obesity in terms of ethnobotany, toxicity, pharmacology, conservation status, trade and chemistry.

MATERIALS AND METHODS

Bibliographic investigation was performed by analyzing recognized books, undergraduate and postgraduate theses and peer-reviewed scientific articles, consulting worldwide accepted scientific databases from the last four decades. Medicinal plants used for the treatment of obesity were classified in two categories: (1) plants with pharmacological evidence and (2) plants without pharmacological evidence.

RESULTS

A total of 139 plant species, belonging to 61 families, native to Mexico, Central America and the Caribbean that are used for the empirical treatment of obesity were recorded. From these plants, 33 were investigated in scientific studies, and 106 plants lacked scientific investigation. Medicinal plants were experimentally studied in vitro (21 plants) and in vivo (16 plants). A total of 4 compounds isolated from medicinal plants used for the empirical treatment of obesity have been tested in vitro (2 compounds) and in vivo (4 compounds) studies. No clinical trials on obese subjects (BMI>30 kg/m(2)) have been performed using the medicinal plants cited in this review. There are no herbal-based products approved in Mexico for the treatment of obesity.

CONCLUSIONS

There are a limited number of scientific studies published on medicinal plants from Mexico, Central America and the Caribbean used for the treatment of obesity. This review highlights the need to perform pharmacological, phytochemical, toxicological and ethnobotanical studies with medicinal flora to obtain new antiobesity agents.

Herbalife hepatotoxicity: Evaluation of cases with positive reexposure tests

AIM

To analyze the validity of applied test criteria and causality assessment methods in assumed Herbalife hepatotoxicity with positive reexposure tests.

METHODS

We searched the Medline database for suspected cases of Herbalife hepatotoxicity and retrieved 53 cases including eight cases with a positive unintentional reexposure and a high causality level for Herbalife. First, analysis of these eight cases focused on the data quality of the positive reexposure cases, requiring a baseline value of alanine aminotransferase (ALT) < 5 upper limit of normal (N) before reexposure, with N as the upper limit of normal, and a doubling of the ALT value at reexposure as compared to the ALT value at baseline prior to reexposure. Second, reported methods to assess causality in the eight cases were evaluated, and then the liver specific Council for International Organizations of Medical Sciences (CIOMS) scale validated for hepatotoxicity cases was used for quantitative causality reevaluation. This scale consists of various specific elements with scores provided through the respective case data, and the sum of the scores yields a causality grading for each individual case of initially suspected hepatotoxicity.

RESULTS

Details of positive reexposure test conditions and their individual results were scattered in virtually all cases, since reexposures were unintentional and allowed only retrospective rather than prospective assessments. In 1/8 cases, criteria for a positive reexposure were fulfilled, whereas in the remaining cases the reexposure test was classified as negative (n = 1), or the data were considered as uninterpretable due to missing information to comply adequately with the criteria (n = 6). In virtually all assessed cases, liver unspecific causality assessment methods were applied rather than a liver specific method such as the CIOMS scale. Using this scale, causality gradings for Herbalife in these eight cases were probable (n = 1), unlikely (n = 4), and excluded (n = 3). Confounding variables included low data quality, alternative diagnoses, poor exclusion of important other causes, and comedication by drugs and herbs in 6/8 cases. More specifically, problems were evident in some cases regarding temporal association, daily doses, exact start and end dates of product use, actual data of laboratory parameters such as ALT, and exact dechallenge characteristics. Shortcomings included scattered exclusion of hepatitis A-C, cytomegalovirus and Epstein Barr virus infection with only globally presented or lacking parameters. Hepatitis E virus infection was considered in one single patient and found positive, infections by herpes simplex virus and varicella zoster virus were excluded in none.

CONCLUSION

Only one case fulfilled positive reexposure test criteria in initially assumed Herbalife hepatotoxicity, with lower CIOMS based causality gradings for the other cases than hitherto proposed.

Continuous reporting of new cases in Spain supports the relationship between Herbalife® products and liver injury

PURPOSE

Previous publications have linked Herbalife® products to hepatotoxicity. The identification of earlier cases in which the culprit agent could not be established raised the hypothesis of a possible contamination of some specific batches of Herbalife products.

METHODS

We searched the Spanish Pharmacovigilance Centres' database of adverse reactions for reports of liver injury associated with the use of Herbalife products from 2003, when the first case was submitted, through September 2010.

RESULTS

The search resulted in 20 reports of liver damage (mean age, 49 years; 16 women), with 12 patients (60%) requiring hospitalization. Hepatocellular damage predominated, and nine (53%) of the hepatocellular cases with bilirubin values were jaundiced, fulfilling the Hy's law criteria, which increases the risk for serious outcomes. Two patients experienced a positive rechallenge. One patient developed cirrhosis, whereas all the others recovered. Causality assessment by the Karch and Lasagna modified algorithm showed a category of definite in 1 case, probable in 14, and possible in 5. Analysis of the different Herbalife products that each patient had taken did not enable us to identify any commonly known hepatotoxic ingredient.

CONCLUSIONS

Our results support the relationship between the consumption of Herbalife products and hepatotoxicity, underscore the concern regarding the liver-related safety of this dietary supplement, and emphasize the need to establish further regulatory measures.

Acute liver injury induced by weight-loss herbal supplements

We report three cases of patients with acute liver injury induced by weight-loss herbal supplements. One patient took Hydroxycut while the other two took Herbalife supplements. Liver biopsies for all patients demonstrated findings consistent with drug-induced acute liver injury. To our knowledge, we are the first institute to report acute liver injury from both of these two types of weight-loss herbal supplements together as a case series. The series emphasizes the importance of taking a cautious approach when consuming herbal supplements for the purpose of weight loss.

Recent status of drug-induced liver injury

Drug-induced liver injury is an major cause of acute liver injury and the incidence of drug-induced liver injury seems to be increasing with an increase in the number of new drugs available. The diagnostic scale of drug-induced liver injury was been modified by the International Consensus Meeting during Digestive Disease Week, Japan 2004, which includes the score of the drug-lymphocyte stimulation test and eosinophilia. Although the modified diagnostic scale is useful, and widely used in Japan, there will be many issues to be investigated in the future. According to a recent survey of drug-induced liver injury cases in Japan, drug-induced liver injury from dietary supplements are increasing, as has been observed in foreign countries. More research is needed to elucidate the mechanisms of drug metabolism and the pathophysiology of liver injury by various drugs to prevent drug-induced liver injury.