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Kassimu K, Milando F, Omolo J, Mdemu A, Nyaulingo G, Mbarak H, Mohamed L, Rashid R, Ahmed S, Rashid M, Msami H, Damiano D, Simon B, Mbaga T, Issa F, Lweno O, Balige N, Hassan O, Mwalimu B, Hamad A, Olotu A, Mårtensson A, Machumi F, Jongo S, Ngasala B, Abdulla S. Safety and Tolerability of an Antimalarial Herbal Remedy in Healthy Volunteers: An Open-Label, Single-Arm, Dose-Escalation Study on Maytenus senegalensis in Tanzania. Trop Med Infect Dis 2022; 7:tropicalmed7120396. [PMID: 36548651 PMCID: PMC9787516 DOI: 10.3390/tropicalmed7120396] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/15/2022] [Accepted: 11/21/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Though Maytenus senegalensis is one of the medicinal plants widely used in traditional medicine to treat infectious and inflammatory diseases in Africa, there is a lack of safety data regarding its use. Therefore, the study aimed to asselss the safety and tolerability of the antimalarial herbal remedy M. senegalensis. MATERIAL AND METHODS The study design was an open-label, single-arm, dose-escalation. Twelve eligible male healthy Tanzanians aged 18 to 45 years were enrolled in four study dose groups. Volunteers' safety and tolerability post-investigational-product administration were monitored on days 0 to 7,14, and 56. RESULTS There were no deaths or serious adverse events in any of the study groups, nor any adverse events that resulted in premature discontinuation. The significant mean changes observed in WBC (p = 0.003), Neutrophils (p = 0.02), Lymphocytes (p = 0.001), Eosinophils (p = 0.009), Alanine aminotransferase (p = 0.002), Creatinine (p = 0.03) and Total bilirubin (p = 0.004) laboratory parameters were not associated with any signs of toxicity or clinical symptoms. CONCLUSIONS M. senegalensis was demonstrated to be safe and tolerable when administered at a dose of 800 mg every eight hours a day for four days. This study design may be adapted to evaluate other herbal remedies.
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Affiliation(s)
- Kamaka Kassimu
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
- Department of Parasitology and Medical Entomology, Muhimbili University of Health and Allied Sciences, Dar es Salaam P.O. Box 65001, Tanzania
- Correspondence: or ; Tel.: +255-713-488-238
| | - Florence Milando
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Justin Omolo
- Department of Traditional Medicine, National Institute for Medical Research, Dar es Salaam P.O. Box 9653, Tanzania
| | - Abel Mdemu
- Department of Traditional Medicine, National Institute for Medical Research, Dar es Salaam P.O. Box 9653, Tanzania
| | - Gloria Nyaulingo
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Hussein Mbarak
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Latipha Mohamed
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Ramla Rashid
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Saumu Ahmed
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Mohammed Rashid
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Hania Msami
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - David Damiano
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Beatus Simon
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Thabit Mbaga
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Fatuma Issa
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Omar Lweno
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Neema Balige
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Omary Hassan
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Bakari Mwalimu
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Ali Hamad
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Ally Olotu
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Andreas Mårtensson
- Department of Women’s and Children’s Health, International Maternal and Child Health (IMCH), Uppsala University, S-751 85 Uppsala, Sweden
| | - Francis Machumi
- Institute of Traditional Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam P.O. Box 65001, Tanzania
| | - Said Jongo
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
| | - Billy Ngasala
- Department of Parasitology and Medical Entomology, Muhimbili University of Health and Allied Sciences, Dar es Salaam P.O. Box 65001, Tanzania
- Department of Women’s and Children’s Health, International Maternal and Child Health (IMCH), Uppsala University, S-751 85 Uppsala, Sweden
| | - Salim Abdulla
- Bagamoyo Clinical Trial Facility, Ifakara Health Institute, Bagamoyo P.O. Box 74, Tanzania
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Tan K, Yang W, Pang L, Hou F. Differences in clinical characteristics among 726 patients with Chinese herbal medicine- or Western medicine-induced liver injury. Medicine (Baltimore) 2022; 101:e29909. [PMID: 35960048 PMCID: PMC9371566 DOI: 10.1097/md.0000000000029909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The differences between Chinese herbal medicine (CHM)- and Western medicine (WM)-induced liver injury have rarely been reported. Our aim was to investigate the clinical features of patients with drug-induced liver injury (DILI) caused by CHM or WM. The medical records of 726 DILI patients were retrospectively collected at Peking University First Hospital from January 1995 through August 2019. The number of inpatients with DILI in our hospital showed an increasing trend over time. The incidence of DILI caused by CHM exhibited a linear trend toward an increase with time (P = .0012). Of the 726 DILI patients, females accounted for 65.8%. There were 353 cases (48.6%) caused by CHM and 225 cases (40.0%) caused by WM. The 3 most common causative CHMs were Polygonum multiflorum (38 cases), Fructus Psoraleae (35 cases), and Epimedium (26 cases). The proportions of female patients, alanine aminotransferase (ALT) levels, aspartate aminotransferase (AST) levels, total bilirubin (TBIL) levels and antinuclear antibody (ANA) positivity rates among cases caused by CHM were higher than those of cases caused by WM (P < .05). There were more patients with severe cases caused by CHM than with severe cases caused by WM (P < .05). The clinical characteristics of DILI caused by CHM differ from those caused by WM. The incidence of DILI caused by CHM is increasing yearly. The medication time of DILI caused by CHM is longer than that of DILI caused by WM, and the severity is greater. Therefore, it is necessary to scientifically and rationally use traditional CHM and monitor liver function. For DILI caused by CHM, the CHM prescription should be recorded in detail to provide detailed clinical data for scientific research on the liver toxicity of CHM.
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Affiliation(s)
- Kangan Tan
- Department of Infectious Diseases, Peking University First Hospital, Beijing, China
| | - Wanna Yang
- Center of Liver Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Lili Pang
- Department of Gastroenterology, Amht Group Aerospace 731 Hospital, Beijing China
| | - Fengqin Hou
- Department of Infectious Diseases, Peking University First Hospital, Beijing, China
- Department of Infectious Diseases, Peking University International Hospital, Beijing, China
- *Correspondence: Fengqin Hou, No. 8, XiShiKu Street, XiCheng District, 100034 Beijing, China (e-mail: )
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Qiu L, Jia K, Huang L, Liao X, Guo X, Lu H. Hepatotoxicity of tricyclazole in zebrafish (Danio rerio). CHEMOSPHERE 2019; 232:171-179. [PMID: 31154177 DOI: 10.1016/j.chemosphere.2019.05.159] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/17/2019] [Accepted: 05/18/2019] [Indexed: 06/09/2023]
Abstract
Tricyclazole is widely used in agriculture as a pesticide, but its toxicity in vertebrates is currently poorly evaluated. In this study, we used zebrafish to assess the toxicity of tricyclazole. We found that tricyclazole induces liver damage, or hepatotoxicity, in zebrafish, during both development and adulthood. In embryos, we found that tricyclazole affected the liver development rather than other endodermal tissues such as gut and pancreas. In both embryos and adult zebrafish livers, tricyclazole disrupted the relationship between oxidant and antioxidant system and resulted in reactive oxygen species (ROS) overload. Meanwhile, it triggered hepatocyte apoptosis and disturbed carbohydrate/lipid metabolism and energy demand systems. These results suggested that tricyclazole could cause severe consequences for vertebrate hepatic development and function.
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Affiliation(s)
- Lingyu Qiu
- Jiangxi Engineering Laboratory of Zebrafish Modeling and Drug Screening for Human Diseases, Ji'an, Jiangxi, China; Jiangxi Key Laboratory of Developmental Biology of Organs, Ji'an, Jiangxi, China
| | - Kun Jia
- Jiangxi Engineering Laboratory of Zebrafish Modeling and Drug Screening for Human Diseases, Ji'an, Jiangxi, China; Jiangxi Key Laboratory of Developmental Biology of Organs, Ji'an, Jiangxi, China; Center for Developmental Biology of Jinggangshan University, College of Life Sciences, Jinggangshan University, Ji'an, Jiangxi, China
| | - Lirong Huang
- Jiangxi Engineering Laboratory of Zebrafish Modeling and Drug Screening for Human Diseases, Ji'an, Jiangxi, China; Jiangxi Key Laboratory of Developmental Biology of Organs, Ji'an, Jiangxi, China; Center for Developmental Biology of Jinggangshan University, College of Life Sciences, Jinggangshan University, Ji'an, Jiangxi, China
| | - Xinjun Liao
- Jiangxi Engineering Laboratory of Zebrafish Modeling and Drug Screening for Human Diseases, Ji'an, Jiangxi, China; Jiangxi Key Laboratory of Developmental Biology of Organs, Ji'an, Jiangxi, China; Center for Developmental Biology of Jinggangshan University, College of Life Sciences, Jinggangshan University, Ji'an, Jiangxi, China
| | - Xinchun Guo
- School of Geography and Environmental Engineering, Gannan Normal University, Ganzhou, Jiangxi, China.
| | - Huiqiang Lu
- Jiangxi Engineering Laboratory of Zebrafish Modeling and Drug Screening for Human Diseases, Ji'an, Jiangxi, China; Jiangxi Key Laboratory of Developmental Biology of Organs, Ji'an, Jiangxi, China; Center for Developmental Biology of Jinggangshan University, College of Life Sciences, Jinggangshan University, Ji'an, Jiangxi, China.
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Wang R, Qi X, Yoshida EM, Méndez-Sánchez N, Teschke R, Sun M, Liu X, Su C, Deng J, Deng H, Hou F, Guo X. Clinical characteristics and outcomes of traditional Chinese medicine-induced liver injury: a systematic review. Expert Rev Gastroenterol Hepatol 2018; 12:425-434. [PMID: 29323538 DOI: 10.1080/17474124.2018.1427581] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUNDS Traditional Chinese medicine (TCM) is becoming increasingly popular and related adverse events are often ignored or underestimated. AIMS This systematic review aimed to evaluate the clinical characteristics and outcomes of TCM-induced liver injury (TCM-ILI) and to estimate the proportion of TCM-ILI in all drug-induced liver injuries (DILI). METHODS China National Knowledge Infrastructure, Wanfang, VIP, PubMed, and Embase databases were searched. Demographic, clinical, and survival data were extracted and pooled. Factors associated with worse outcomes were calculated. For the proportion meta-analyses, the data were pooled by using a random-effects model. RESULTS Overall, 21,027 articles were retrieved, of which 625 were finally included. There was a predominance of female and older patients. The proportion of liver transplantation was 2.18% (7/321). The mortality was 4.67% (15/321). Male, higher aspartate aminotransferase and direct bilirubin, and lower albumin were significantly associated with an increased risk of death/liver transplantation in TCM-ILI patients. The proportion of TCM-ILI in all DILI was 25.71%. The proportion was gradually increased with year. CONCLUSIONS Our work summarises current knowledge regarding clinical presentation, disease course, and prognosis of TCM-ILI. TCM can result in hepatotoxicity, even death or necessitate life-saving liver transplantation. Governmental regulation of TCM products should be strictly established.
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Affiliation(s)
- Ran Wang
- a Department of Gastroenterology , General Hospital of Shenyang Military Area , Shenyang , China
- b Postgraduate College , Liaoning University of Traditional Chinese Medicine , Shenyang , China
| | - Xingshun Qi
- a Department of Gastroenterology , General Hospital of Shenyang Military Area , Shenyang , China
| | - Eric M Yoshida
- c Division of Gastroenterology , Vancouver General Hospital , Vancouver , Canada
| | - Nahum Méndez-Sánchez
- d Liver Research Unit Medica Sur Clinic & Foundation Mexico City , Mexico City , Mexico
| | - Rolf Teschke
- e Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Teaching Hospital of the Medical Faculty , Goethe University Frankfurt/Main , Hanau , Germany
| | - Mingyu Sun
- f Institute of Liver Diseases , Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine , Shanghai , China
| | - Xu Liu
- a Department of Gastroenterology , General Hospital of Shenyang Military Area , Shenyang , China
| | - Chunping Su
- g Library of Fourth Military Medical University , Xi'an , China
| | - Jiao Deng
- h Department of Pharmacy , General Hospital of Shenyang Military Area , Shenyang , China
| | - Han Deng
- a Department of Gastroenterology , General Hospital of Shenyang Military Area , Shenyang , China
| | - Feifei Hou
- a Department of Gastroenterology , General Hospital of Shenyang Military Area , Shenyang , China
| | - Xiaozhong Guo
- a Department of Gastroenterology , General Hospital of Shenyang Military Area , Shenyang , China
- b Postgraduate College , Liaoning University of Traditional Chinese Medicine , Shenyang , China
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Teschke R, Danan G. Causality Assessment Methods in Drug-Induced Liver Injury. METHODS IN PHARMACOLOGY AND TOXICOLOGY 2018. [DOI: 10.1007/978-1-4939-7677-5_27] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Liang J, Chen SX, Huang S, Wu YY, Zhou CJ, Jiang DX, Liang CY, Yuan HQ, Hou SZ, Lai XP. Evaluation of toxicity studies of flavonoid fraction of Lithocarpus polystachyus Rehd in rodents. Regul Toxicol Pharmacol 2017; 88:283-290. [PMID: 28697995 DOI: 10.1016/j.yrtph.2017.07.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 11/23/2016] [Accepted: 07/07/2017] [Indexed: 11/18/2022]
Abstract
The aim of the study was to evaluate the safety of flavonoid fraction of Lithocarpus polystachyus Rehd (Sweet Tea-F, ST-F) in mice and rats through acute and sub-chronic toxicity studies respectively. For acute toxicity study, a single dose of 5000 mg/kg of ST-F was given orally to healthy KM mice. The mice were observed mortality and toxic symptoms for 24 h, then once a day up to 14 days. In the sub-chronic toxicity study, ST-F was administered orally at doses of 0, 70, 140, 560 mg/kg/day to rats for 26 weeks. Body weight and food intake were recorded weekly. Hematological, biochemical, coagulation and organ parameters were analyzed at the end of 26 weeks administration. Vital organs were evaluated by histopathology. In the acute toxicity study, ST-F caused neither significant toxic symptoms, nor mortality in mice. In sub-chronic toxicity study, daily oral administration of ST-F at the dose of 70 mg/kg resulted in a significant increase (P < 0.05) in the relative body weight at the 10-week, and the same situation brought at the dose of 140 mg/kg/day at the 22-week. Hematological and biochemical showed significant changes (P < 0.01 or P < 0.05) in WBC, GLU, ALP, AST and serum electrolytes levels at the dose of 560 mg/kg/day. The amount of RBC decreased significantly (P < 0.05) while the content of PLT slightly increased (P < 0.05) at the dose of 140 mg/kg/day. In additional, no obvious histological changes were observed in vital organs of ST-F treated animals compared to control group. The ST-F may be exit slight side effects at the dose of 560 mg/kg/day in rats. Thus, the overall results show that the no-observed adverse effect level (NOAEL) of ST-F was considered to be 140 mg/kg for male SD rats.
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Affiliation(s)
- Jian Liang
- Guangdong Provincial Key Laboratory of New Chinese Medicinals Development and Research, Guangzhou University of Chinese Medicine, Guangzhou Higher Education Mega Center, Guangzhou 510006, China
| | - Shu-Xian Chen
- Department of Hepatobiliary Surgery, The Third Affiliated Hospital of Sun Yat-sen University, No.600, Tianhe Road, Guangzhou 510630, China
| | - Song Huang
- Guangdong Provincial Key Laboratory of New Chinese Medicinals Development and Research, Guangzhou University of Chinese Medicine, Guangzhou Higher Education Mega Center, Guangzhou 510006, China
| | - Ya-Yun Wu
- Guangdong Provincial Key Laboratory of New Chinese Medicinals Development and Research, Guangzhou University of Chinese Medicine, Guangzhou Higher Education Mega Center, Guangzhou 510006, China
| | - Cai-Jie Zhou
- Guangdong Provincial Key Laboratory of New Chinese Medicinals Development and Research, Guangzhou University of Chinese Medicine, Guangzhou Higher Education Mega Center, Guangzhou 510006, China
| | - Dong-Xu Jiang
- Guangdong Provincial Key Laboratory of New Chinese Medicinals Development and Research, Guangzhou University of Chinese Medicine, Guangzhou Higher Education Mega Center, Guangzhou 510006, China
| | - Chu-Yan Liang
- Guangdong Provincial Key Laboratory of New Chinese Medicinals Development and Research, Guangzhou University of Chinese Medicine, Guangzhou Higher Education Mega Center, Guangzhou 510006, China
| | - Hui-Qi Yuan
- Guangdong Provincial Key Laboratory of New Chinese Medicinals Development and Research, Guangzhou University of Chinese Medicine, Guangzhou Higher Education Mega Center, Guangzhou 510006, China
| | - Shao-Zhen Hou
- Guangdong Provincial Key Laboratory of New Chinese Medicinals Development and Research, Guangzhou University of Chinese Medicine, Guangzhou Higher Education Mega Center, Guangzhou 510006, China.
| | - Xiao-Ping Lai
- Guangdong Provincial Key Laboratory of New Chinese Medicinals Development and Research, Guangzhou University of Chinese Medicine, Guangzhou Higher Education Mega Center, Guangzhou 510006, China.
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Research Advances on Hepatotoxicity of Herbal Medicines in China. BIOMED RESEARCH INTERNATIONAL 2016; 2016:7150391. [PMID: 28078299 PMCID: PMC5203888 DOI: 10.1155/2016/7150391] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 07/31/2016] [Indexed: 02/07/2023]
Abstract
In general, herbal medicines have been considered as safe by the general public, since they are naturally occurring and have been applied in treatment for over thousands of years. As the use of herbal medicine is rapidly increasing globally, the potential toxicity of herbal drugs, in particular drug-induced liver injury (DILI), has now become a serious medical issue. According to the literature, the authors analyzed and discussed the hepatotoxicity problem of Chinese herbal medicines (CHM), including global overview on herbal-induced liver injury (HILI), current research progress on toxic CHM, diagnosis and treatment of HILI, and modern approaches and technologies of study of hepatotoxicity. As to promote the recognition of HILI and tackle the issue, a guideline for the diagnosis and treatment of HILI has recently been drafted by Chinese scientists. As suggested by the guideline, the hepatotoxicity issue of CHM, as a matter of fact, is overestimated. Up to date, the investigation of hepatotoxicity of CHM is now booming with worldwide application of CHM. This review therefore provides useful information for investigating hepatotoxicity of herbal medicine and characterizing DILI caused by CHM. In addition, authors describe in which way further efforts should be made to study the rationale of CHM and liver injury.
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The Honolulu Liver Disease Cluster at the Medical Center: Its Mysteries and Challenges. Int J Mol Sci 2016; 17:476. [PMID: 27043544 PMCID: PMC4848932 DOI: 10.3390/ijms17040476] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 03/18/2016] [Accepted: 03/21/2016] [Indexed: 12/16/2022] Open
Abstract
In 2013, physicians at the Honolulu Queen’s Medical Center (QMC) noticed that seven liver disease patients reported the use of OxyELITE Pro (OEP), a widely consumed dietary supplement (DS). Assuming a temporal association between OEP use and disease, they argued that OEP was the cause of this mysterious cluster. Subsequent reexamination, however, has revealed that this QMC cohort is heterogeneous and not a cluster with a single agent causing a single disease. It is heterogeneous because patients used multiple DS’s and drugs and because patients appeared to have suffered from multiple liver diseases: liver cirrhosis, liver failure by acetaminophen, hepatotoxicity by non-steroidal antiinflammatory drugs (NSAIDs), resolving acute viral hepatitis by hepatitis B virus (HBV), herpes simplex virus (HSV), and varicella zoster virus (VZV), and suspected hepatitis E virus (HEV). Failing to exclude these confounders and to consider more viable diagnoses, the QMC physicians may have missed specific treatment options in some of their patients. The QMC physicians unjustifiably upgraded their Roussel Uclaf Causality Assessment Method (RUCAM) causality scores so that all patients would appear to be “probable” for OEP. However, subsequent RUCAM reassessments by our group demonstrated a lack of causality for OEP in the evaluated QMC cases. The QMC’s questionable approaches explain the extraordinary accumulation of suspected OEP cases at the QMC in Hawaii as single place, whereas similar cohorts were not published by any larger US liver center, substantiating that the problem is with the QMC. In this review article, we present and discuss new case data and critically evaluate upcoming developments of problematic regulatory assessments by the US Centers for Disease Control and Prevention (CDC), the Hawaii Department of Health (HDOH), and the Food and Drug Administration (FDA), as based on invalid QMC conclusions, clarifying now also basic facts and facilitating constructive discussions.
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Danan G, Teschke R. RUCAM in Drug and Herb Induced Liver Injury: The Update. Int J Mol Sci 2015; 17:E14. [PMID: 26712744 PMCID: PMC4730261 DOI: 10.3390/ijms17010014] [Citation(s) in RCA: 440] [Impact Index Per Article: 48.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 12/07/2015] [Accepted: 12/09/2015] [Indexed: 12/12/2022] Open
Abstract
RUCAM (Roussel Uclaf Causality Assessment Method) or its previous synonym CIOMS (Council for International Organizations of Medical Sciences) is a well established tool in common use to quantitatively assess causality in cases of suspected drug induced liver injury (DILI) and herb induced liver injury (HILI). Historical background and the original work confirm the use of RUCAM as single term for future cases, dismissing now the term CIOMS for reasons of simplicity and clarity. RUCAM represents a structured, standardized, validated, and hepatotoxicity specific diagnostic approach that attributes scores to individual key items, providing final quantitative gradings of causality for each suspect drug/herb in a case report. Experts from Europe and the United States had previously established in consensus meetings the first criteria of RUCAM to meet the requirements of clinicians and practitioners in care for their patients with suspected DILI and HILI. RUCAM was completed by additional criteria and validated, assisting to establish the timely diagnosis with a high degree of certainty. In many countries and for more than two decades, physicians, regulatory agencies, case report authors, and pharmaceutical companies successfully applied RUCAM for suspected DILI and HILI. Their practical experience, emerging new data on DILI and HILI characteristics, and few ambiguous questions in domains such alcohol use and exclusions of non-drug causes led to the present update of RUCAM. The aim was to reduce interobserver and intraobserver variability, to provide accurately defined, objective core elements, and to simplify the handling of the items. We now present the update of the well accepted original RUCAM scale and recommend its use for clinical, regulatory, publication, and expert purposes to validly establish causality in cases of suspected DILI and HILI, facilitating a straightforward application and an internationally harmonized approach of causality assessment as a common basic tool.
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Affiliation(s)
- Gaby Danan
- Pharmacovigilance Consultancy, rue des Ormeaux, 75020 Paris, France.
| | - Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Academic Teaching Hospital of the Medical Faculty, Goethe University Frankfurt/Main, Frankfurt am Main, D-63450 Hanau, Germany.
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Zambrone FAD, Corrêa CL, Amaral LMSD. A critical analysis of the hepatotoxicity cases described in the literature related to Herbalife (r) products. BRAZ J PHARM SCI 2015. [DOI: 10.1590/s1984-82502015000400004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract The aim of this study was to assess the hepatotoxicity cases described in the literature, attributed to the consumption of Herbalife(r) products, and to determine whether a causal relationship exists between the reported cases of liver injury and the use of these products. A literature search was performed on the PubMed, LILACS and PAHO databases. Seven publications reporting a total of 53 cases of hepatotoxicity linked to the use of Herbalife(r) products were retrieved. All of the studies lacked sufficient information to some degree, whether related to patients' history, concomitant use of medication and/or other compounds (including alcohol), observations on interrupted use (dechallenge), results found with markers, viral serology and autoantibodies or observations concerning re-exposure to the products. In addition to these items, the lack of clear information on the type of products evaluated and their respective composition is an important factor to be considered. Furthermore, data quality was also questionable due to the presence of confounding factors, absence of proper exclusion of alternative explanations, and the use of questionable methods for attributing causality. Hence, an association between hepatotoxicity and consumption of these products cannot be proven based on the data collected and rigorous scientific analysis.
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Evidence chain-based causality identification in herb-induced liver injury: exemplification of a well-known liver-restorative herb Polygonum multiflorum. Front Med 2015; 9:457-67. [PMID: 26459430 DOI: 10.1007/s11684-015-0417-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 07/07/2015] [Indexed: 12/12/2022]
Abstract
Herbal medicines have recently been recognized as the second most common cause of drug-induced liver injury (DILI) in the United States. However, reliable methods to identify the DILI causality of some herbs, such as Heshouwu (dried root of Polygonum multiflorum), remain lacking. In this study, a total of 12 307 inpatients with liver dysfunction and 147 literature-reported cases of Heshouwu DILI were screened. A general algorithm indicated that only 22.5% (9/40) and 30.6% (45/147) of all hospitalization and literature case reports, respectively, demonstrate the high probability of DILI causality of Heshouwu. By contrast, 95% (19/20) of all cases prospectively investigated by pharmacognosy, phytochemistry, and metabolomic tests exhibited highly probable causality, including a patient who was previously incorrectly attributed and a case that was excluded from Heshouwu causality by pharmacognostic evidence. Toxin (heavy metals, pesticides, and mycotoxins) contamination was also excluded from Heshouwu DILI causality. The objectivity of these screening methods for Heshouwu DILI diagnosis addresses safety concerns regarding stilbene-containing herbal medicines and dietary supplements.
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Chalhoub WM, Sliman KD, Arumuganathan M, Lewis JH. Drug-induced liver injury: what was new in 2013? Expert Opin Drug Metab Toxicol 2014; 10:959-80. [PMID: 24746272 DOI: 10.1517/17425255.2014.909408] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION The year 2013 continued to highlight numerous aspects of drug-induced liver injury (DILI), with new information communicated via > 1500 publications. New reports of DILI were described and FDA warnings and alerts were issued for a number of products, emphasizing the risks related to hepatotoxicity. AREAS COVERED We provide a summary of the year's published reports of new causes of DILI, along with reviews and reports of established hepatotoxins, new and expanded DILI registries and the continuing emphasis placed on genetic and other risk factors. Several new analyses of data generated from the US DILI Network are included. EXPERT OPINION The clinical usefulness of pharmacogenetic testing remains to be determined; the number of patients who must be tested is large and the overall risk of DILI is quite small. The role that dose and hepatic metabolism play in causing idiosyncratic DILI was reviewed; daily doses > 50 - 100 mg of medications with high lipophilicity appear to be most predictive of severe DILI, but not in all cases. Restricting access to paracetamol in certain parts of the UK continues to demonstrate a successful reduction in the number of acute liver failure cases and patients listed for liver transplant.
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Affiliation(s)
- Walid M Chalhoub
- Georgetown University Hospital, Department of Medicine, Division of Gastroenterology, Hepatology Section , 3800 Reservoir Road, NW, Washington, DC 20007 , USA
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Abstract
BACKGROUND AND OBJECTIVES Alternative explanations are common in suspected drug-induced liver injury (DILI) and account for up to 47.1% of analyzed cases. This raised the question of whether a similar frequency may prevail in cases of assumed herb-induced liver injury (HILI). METHODS We searched the Medline database for the following terms: herbs, herbal drugs, herbal dietary supplements, hepatotoxic herbs, herbal hepatotoxicity, and herb-induced liver injury. Additional terms specifically addressed single herbs and herbal products: black cohosh, Greater Celandine, green tea, Herbalife products, Hydroxycut, kava, and Pelargonium sidoides. We retrieved 23 published case series and regulatory assessments related to hepatotoxicity by herbs and herbal dietary supplements with alternative causes. RESULTS The 23 publications comprised 573 cases of initially suspected HILI; alternative causes were evident in 278/573 cases (48.5%). Among them were hepatitis by various viruses (9.7%), autoimmune diseases (10.4%), nonalcoholic and alcoholic liver diseases (5.4%), liver injury by comedication (DILI and other HILI) (43.9%), and liver involvement in infectious diseases (4.7%). Biliary and pancreatic diseases were frequent alternative diagnoses (11.5%), raising therapeutic problems if specific treatment is withheld; pre-existing liver diseases including cirrhosis (9.7%) were additional confounding variables. Other diagnoses were rare, but possibly relevant for the individual patient. CONCLUSION In 573 cases of initially assumed HILI, 48.5% showed alternative causes unrelated to the initially incriminated herb, herbal drug, or herbal dietary supplement, calling for thorough clinical evaluations and appropriate causality assessments in future cases of suspected HILI.
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Teschke R, Schwarzenboeck A, Eickhoff A, Frenzel C, Wolff A, Schulze J. Clinical and causality assessment in herbal hepatotoxicity. Expert Opin Drug Saf 2013; 12:339-66. [PMID: 23458441 DOI: 10.1517/14740338.2013.774371] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Herbal hepatotoxicity represents a poorly understood, neglected and multifaceted disease with numerous confounding variables and missing established causality in the majority of cases. This review discusses overt shortcomings in its clinical and causality assessment and suggests improvements. AREAS COVERED A selective literature search of PubMed using the terms herbal hepatotoxicity, herb-induced liver injury, drug hepatotoxicity and drug-induced liver injury was performed to identify published case reports, spontaneous case reports, case series and review articles regarding hepatotoxicity due to herbs, herbal drugs and herbal dietary supplements. Covered areas focused on confounding variables related to the documentation of the herbal product and the clinical course, hepatotoxicity and reexposure criteria, temporal association, comedication and alternative causes with special attention to preexisting diseases of the liver, bile ducts and the pancreas. Of particular interest were recent discussions of approaches designed and validated for hepatotoxicity causality, such as the scale of CIOMS (Council for International Organizations of Medical Sciences). EXPERT OPINION The authors call for substantial improvements in data quality of herbal products and case characteristics and strongly recommend using the CIOMS scale to assess causality in suspected herbal hepatotoxicity.
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Affiliation(s)
- Rolf Teschke
- Academic Teaching Hospital of Goethe University of Frankfurt/Main, Department of Internal Medicine II, Klinikum Hanau, Leimenstrasse 20, D-63450 Hanau, Germany.
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