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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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Patel S, Tareen K, Patel C, Rosinski A. Herbal and Non-Herbal Dietary Supplements for Psychiatric Indications: Considerations in Liver Transplantation. Curr Psychiatry Rep 2024; 26:436-446. [PMID: 38941032 DOI: 10.1007/s11920-024-01517-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 06/29/2024]
Abstract
PURPOSE OF REVIEW Traditional, complementary, and integrative medicine (TCIM) modalities are widely employed. However, TCIM, specifically herbal and non-herbal dietary supplements, can pose challenges in the context of organ transplantation. In this review, we discuss common supplements used for psychiatric purposes and highlight important considerations for candidates and recipients of liver transplants. RECENT FINDINGS Ashwagandha, kava kava, green tea extract, skullcap, turmeric, and valerian have known idiosyncratic hepatotoxic potential and may complicate the liver transplantation course. Multiple supplements reportedly carry a lower risk of hepatotoxicity, though evidence for widespread use in those at risk for or with hepatic impairment is limited. Psychiatrists caring for candidates and recipients of liver transplants must recognize that patients may find supplements helpful in alleviating psychiatric symptoms, despite an overall limited evidence base. Evaluating benefit versus risk ratios and reviewing drug-drug interactions is essential to promote transplant candidacy and mitigate the possibility of native or graft liver dysfunction.
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Affiliation(s)
- Shivali Patel
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.
- Department of Psychiatry, Henry Ford Health, 2799 W Grand Blvd., Detroit, MI, 48202, USA.
| | - Kinza Tareen
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Chandni Patel
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Amy Rosinski
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Kołodziejska R, Tafelska-Kaczmarek A, Pawluk M, Sergot K, Pisarska L, Woźniak A, Pawluk H. Ashwagandha-Induced Programmed Cell Death in the Treatment of Breast Cancer. Curr Issues Mol Biol 2024; 46:7668-7685. [PMID: 39057095 PMCID: PMC11275341 DOI: 10.3390/cimb46070454] [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: 06/21/2024] [Revised: 07/15/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
The aim of this review is to provide experimental evidence for the programmed-death activity of Ashwagandha (Withania somnifera) in the anti-cancer therapy of breast cancer. The literature search was conducted using online electronic databases (Google Scholar, PubMed, Scopus). Collection schedule data for the review article covered the years 2004-2024. Ashwagandha active substances, especially Withaferin A (WA), are the most promising anti-cancer compounds. WS exerts its effect on breast cancer cells by inducing programmed cell death, especially apoptosis, at the molecular level. Ashwagandha has been found to possess a potential for treating breast cancer, especially estrogen receptor/progesterone receptor (ER/PR)-positive and triple-negative breast cancer.
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Affiliation(s)
- Renata Kołodziejska
- Department of Medical Biology and Biochemistry, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Karłowicza 24, 85-092 Bydgoszcz, Poland; (M.P.); (L.P.); (H.P.)
| | - Agnieszka Tafelska-Kaczmarek
- Department of Organic Chemistry, Faculty of Chemistry, Nicolaus Copernicus University, Gagarina 7, 87-100 Toruń, Poland;
| | - Mateusz Pawluk
- Department of Medical Biology and Biochemistry, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Karłowicza 24, 85-092 Bydgoszcz, Poland; (M.P.); (L.P.); (H.P.)
| | - Krzysztof Sergot
- Laboratory of Laser Molecular Spectroscopy, Institute of Applied Radiation Chemistry, Faculty of Chemistry, Lodz University of Technology, Wroblewskiego 15, 93-590 Lodz, Poland;
| | - Lucyna Pisarska
- Department of Medical Biology and Biochemistry, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Karłowicza 24, 85-092 Bydgoszcz, Poland; (M.P.); (L.P.); (H.P.)
| | - Alina Woźniak
- Department of Medical Biology and Biochemistry, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Karłowicza 24, 85-092 Bydgoszcz, Poland; (M.P.); (L.P.); (H.P.)
| | - Hanna Pawluk
- Department of Medical Biology and Biochemistry, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Karłowicza 24, 85-092 Bydgoszcz, Poland; (M.P.); (L.P.); (H.P.)
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Xu W, Yang T, Zhang J, Li H, Guo M. Rhodiola rosea: a review in the context of PPPM approach. EPMA J 2024; 15:233-259. [PMID: 38841616 PMCID: PMC11147995 DOI: 10.1007/s13167-024-00367-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 05/08/2024] [Indexed: 06/07/2024]
Abstract
A natural "medicine and food" plant, Rhodiola rosea (RR) is primarily made up of organic acids, phenolic compounds, sterols, glycosides, vitamins, lipids, proteins, amino acids, trace elements, and other physiologically active substances. In vitro, non-clinical and clinical studies confirmed that it exerts anti-inflammatory, antioxidant, and immune regulatory effects, balances the gut microbiota, and alleviates vascular circulatory disorders. RR can prolong life and has great application potential in preventing and treating suboptimal health, non-communicable diseases, and COVID-19. This narrative review discusses the effects of RR in preventing organ damage (such as the liver, lung, heart, brain, kidneys, intestines, and blood vessels) in non-communicable diseases from the perspective of predictive, preventive, and personalised medicine (PPPM/3PM). In conclusion, as an adaptogen, RR can provide personalised health strategies to improve the quality of life and overall health status.
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Affiliation(s)
- Wenqian Xu
- Henan University of Traditional Chinese Medicine, Zhengzhou, China
| | | | - Jinyuan Zhang
- The Third People’s Hospital of Henan Province, Zhengzhou, China
| | - Heguo Li
- Department of Spleen, Stomach, Liver and Gallbladder, The First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou, China
| | - Min Guo
- Department of Spleen, Stomach, Liver and Gallbladder, The First Affiliated Hospital of Henan University of Traditional Chinese Medicine, Zhengzhou, China
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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, Theruvath AH. A comprehensive review on the hepatotoxicity of herbs used in the Indian (Ayush) systems of alternative medicine. Medicine (Baltimore) 2024; 103:e37903. [PMID: 38640296 PMCID: PMC11029936 DOI: 10.1097/md.0000000000037903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/21/2024] Open
Abstract
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.
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Affiliation(s)
- Cyriac Abby Philips
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, India
- Department of Clinical Research, Division of Complementary and Alternative Medicine and the Liver, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, India
| | - Arif Hussain Theruvath
- Department of Clinical Research, Division of Complementary and Alternative Medicine and the Liver, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, India
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Philips CA, Theruvath AH, Ravindran R, Chopra P. Citizens protein project: A self-funded, transparent, and concerning report on analysis of popular protein supplements sold in the Indian market. Medicine (Baltimore) 2024; 103:e37724. [PMID: 38579036 PMCID: PMC10994440 DOI: 10.1097/md.0000000000037724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/05/2024] [Indexed: 04/07/2024] Open
Abstract
Protein powders, including those containing herbal and dietary supplements such as vitamins, minerals, and other natural or synthetic ingredients, can be associated with hepatotoxicity. Protein supplements are often mislabeled and deceptive in their contents. In this self-funded transparent study, we extensively analyzed popular protein supplements in India to identify potential hepatotoxic substances based on industrial standards. All products underwent extensive analysis, including total protein content, fungal aflatoxin detection, pesticide residue estimation, heavy metal quantification, steroid detection, and complete organic and inorganic profiling, according to industry standards. Most protein supplements did not meet the labeled and advertised protein content, while certain brands surpassed the stated levels, raising concerns about potential "protein/amino-spiking." In addition, the major brands contained detectable fungal toxins and pesticide residues. Furthermore, many major formulations contained harmful heavy metals such as lead and arsenic, and some featured hepatoxic herbal extracts, particularly green tea extract, turmeric, Garcinia cambogia, and Ashwagandha. Indian-made products were inferior to those manufactured by multinational companies. The presence of various potentially toxic compounds, such as cycloheptatriene, benzene derivatives, toluene, and isopropyl alcohol, within a nonstandardized and unregulated diverse ingredient mix added to the overall concern. We demonstrate that the protein-based herbal and dietary supplement industry requires stringent scrutiny, regulation, and basic safety studies before being marketed. Manufacturers must consider reducing "ingredient complexities" of their protein powders to prevent adverse interactions between herbal and nonherbal components in consumers. Manufacturers must avoid using known toxic ingredients to reduce the avoidable disease burden within the public community.
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Affiliation(s)
- Cyriac Abby Philips
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
- Division of Complementary and Alternative Medicine, Department of Clinical Research, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Arif Hussain Theruvath
- Division of Complementary and Alternative Medicine, Department of Clinical Research, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Resmi Ravindran
- Division of Complementary and Alternative Medicine, Department of Clinical Research, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Paras Chopra
- Human Behaviour and Change, Nintee, San Francisco, CA, United States
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Philips CA, Theruvath AH, Ravindran R, Augustine P. Complementary and alternative medicines and liver disease. Hepatol Commun 2024; 8:e0417. [PMID: 38563584 PMCID: PMC10990366 DOI: 10.1097/hc9.0000000000000417] [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: 01/13/2024] [Accepted: 01/25/2024] [Indexed: 04/04/2024] Open
Abstract
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.
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Affiliation(s)
- Cyriac Abby Philips
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
- Department of Clinical Research, Division of Complementary and Alternative Medicine (AYUSH) and the Liver, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Arif Hussain Theruvath
- Department of Clinical Research, Division of Complementary and Alternative Medicine (AYUSH) and the Liver, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Resmi Ravindran
- Department of Clinical Research, Division of Complementary and Alternative Medicine (AYUSH) and the Liver, The Liver Institute, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I Endoscopy, Center of Excellence in Gastrointestinal Sciences, Rajagiri Hospital, Aluva, Kerala, India
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Goldin D, Salani D. Let's Get to the Root of Ashwagandha: What Health Care Professionals Need to Know. J Psychosoc Nurs Ment Health Serv 2024; 62:33-40. [PMID: 37751577 DOI: 10.3928/02793695-20230919-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
The prevalence of stress- and anxiety-related disorders is increasing along with widespread demand for anxiolytics. Due to drug supply shortages and access restrictions, nonprescription remedies have gained popularity. In addition, the marketing of herbals and botanicals as low-cost and all-natural products with fewer access restrictions has increased their use. The current article explores the evidence to provide an overview of the current understanding of Ashwagandha (Withania somnifera), an anxiolytic and apoptogenic herb with therapeutic and health-promoting potentials to help the body reduce stress and maintain a homeostatic state. Due to poor quality controls and diversity of Ashwagandha products, clinical trials on Ashwagandha's effectiveness in anxiety-related conditions reveal conflicting results, although many show favorable findings. Furthermore, health care professionals, such as nurses, advanced practice nurses, physicians, physician assistants, and pharmacists, need to be aware of variability in Ashwagandha products, quality controls, reported evidence regarding use, safety profile, and clinical implications in stress reduction. [Journal of Psychosocial Nursing and Mental Health Services, 62(4), 33-40.].
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Carty J, Navarro VJ. Dietary Supplement-Induced Hepatotoxicity: A Clinical Perspective. J Diet Suppl 2024:1-20. [PMID: 38528750 DOI: 10.1080/19390211.2024.2327546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
The consumption of dietary supplements (DS) has resulted in a significant and escalating number of cases involving liver injury. It is crucial for clinicians and consumers to be well informed about the adverse effects of such products, leading to their discontinuation and timely reporting of any harmful cases. This article delves into the clinical perspective of DS-related hepatotoxicity, highlighting key concepts such as a systematic diagnostic approach. The discussion extends to notable examples of both currently popular and potential future dietary supplements, such as garcinia cambogia, turmeric, and ashwagandha, accompanied by an overview of recent findings. Causality assessment tools play a crucial role in establishing a connection between these products and instances of liver injury, with consideration of the advantages and disadvantages associated with their use. Fostering a comprehensive understanding of regulatory standards, coupled with a solid foundation of knowledge of DS, will prove instrumental in preventing DS-related hepatotoxicity. Achieving this goal requires collaborative efforts from both consumers and clinicians.
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Affiliation(s)
- Jordan Carty
- Department of Medicine, Jefferson Einstein Medical Center, Philadelphia, PA, USA
| | - Victor J Navarro
- Department of Medicine, Jefferson Einstein Medical Center, Philadelphia, PA, USA
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Rani J, Dhull SB, Rose PK, Kidwai MK. Drug-induced liver injury and anti-hepatotoxic effect of herbal compounds: a metabolic mechanism perspective. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2024; 122:155142. [PMID: 37913641 DOI: 10.1016/j.phymed.2023.155142] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/27/2023] [Accepted: 10/10/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Drug-induced liver injury (DILI) is the most challenging and thought-provoking liver problem for hepatologists owing to unregulated medication usage in medical practices, nutritional supplements, and botanicals. Due to underreporting, analysis, and identification issues, clinically evaluated medication hepatotoxicity is prevalent yet hard to quantify. PURPOSE This review's primary objective is to thoroughly compare pharmaceutical drugs and herbal compounds that have undergone clinical trials, focusing on their metabolic mechanisms contributing to the onset of liver illnesses and their hepatoprotective effects. METHODS The data was gathered from several online sources, such as PubMed, Scopus, Google Scholar, and Web of Science, using appropriate keywords. RESULTS The prevalence of conventional and herbal medicine is rising. A comprehensive understanding of the metabolic mechanism is necessary to mitigate the hepatotoxicity induced by drugs and facilitate the incorporation or substitution of herbal medicine instead of pharmaceuticals. Moreover, pre-clinical pharmacological research has the potential to facilitate the development of natural products as therapeutic agents, displaying promising possibilities for their eventual clinical implementation. CONCLUSIONS Acetaminophen, isoniazid, rifampicin, diclofenac, and pyrogallol have been identified as the most often reported synthetic drugs that produce hepatotoxicity by oxidative stress, inflammation, apoptosis, and fibrosis during the last several decades. Due to their ability to downregulate many factors (such as cytokines) and activate several enzyme/enzyme systems, herbal substances (such as Gingko biloba extract, curcumin, resveratrol, and silymarin) provide superior protection against harmful mechanisms which induce hepatotoxicity with fewer adverse effects than their synthetic counterparts.
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Affiliation(s)
- Jyoti Rani
- Department of Botany, Chaudhary Devi Lal University, Sirsa 125055, Haryana, India
| | - Sanju Bala Dhull
- Department of Food Science and Technology, Chaudhary Devi Lal University, Sirsa 125055, Haryana, India.
| | - Pawan Kumar Rose
- Department of Energy and Environmental Sciences, Chaudhary Devi Lal University, Sirsa 125055, Haryana, India.
| | - Mohd Kashif Kidwai
- Department of Energy and Environmental Sciences, Chaudhary Devi Lal University, Sirsa 125055, Haryana, India
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Della Porta M, Maier JA, Cazzola R. Effects of Withania somnifera on Cortisol Levels in Stressed Human Subjects: A Systematic Review. Nutrients 2023; 15:5015. [PMID: 38140274 PMCID: PMC10745833 DOI: 10.3390/nu15245015] [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: 10/23/2023] [Revised: 11/30/2023] [Accepted: 12/02/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Withania somnifera (WS), a popular medicinal plant of the Solanaceae family, contains active ingredients with antioxidant, anti-inflammatory, immunomodulatory, and anti-stress activities. However, its precise mechanisms of action and optimal use as a supplement are not yet fully understood. The objective of this systematic review is to assess the impact of WS supplementation on cortisol levels in stressed humans by analyzing clinical trials conducted prior to May 2023. METHODS The assessment was carried out following the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) by exploring the databases of EMBASE, PubMed, Google Scholar, CENTRAL, and Scopus. RESULTS Of the 4788 articles identified, only 9 studies met the selection criteria. The selected studies varied in terms of design, results, formulations, dosages, and treatment duration (30-112 days), and involved subjects with varying degrees of stress. WS supplementation decreases cortisol secretion with no significant adverse effects. Nonetheless, none of the studies evaluated the potential impact of cortisol reduction on adrenal function and long-term effects. CONCLUSIONS Brief-term supplementation with WS appears to have a stress-reducing effect in stressed individuals. However, since the long-term effects of WS supplementation are not yet fully understood, WS supplements should be used under medical supervision.
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Affiliation(s)
- Matteo Della Porta
- Department of Biomedical and Clinical Sciences, University of Milano, 20157 Milan, Italy; (J.A.M.); (R.C.)
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Casiano-Manzano S, Torres-Larrubia M, Masa-Caballero A, Jiménez-Colmenarez Z, Martín-Noguerol E, Fernández-Bermejo M, Solís-Muñoz P. Changing perspectives: unveiling the risks of ashwagandha-induced hepatotoxicity. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023. [PMID: 37982556 DOI: 10.17235/reed.2023.10080/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
Ashwagandha, an herb popular in Ayurvedic medicine, is renowned for its health-enhancing properties. However, its association with liver damage in recent years has raised significant concerns, necessitating careful assessment and management. This case underscores the dangers of Ashwagandha, particularly for individuals with preexisting liver conditions, where it can lead to life-threatening acute-on-chronic liver failure. The lack of solid clinical evidence supporting Ashwagandha's health claims emphasizes the need for an evidence-based approach. Public education is essential to raise awareness of the risks associated with herbal supplements and prevent liver diseases.
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Wiciński M, Fajkiel-Madajczyk A, Kurant Z, Kurant D, Gryczka K, Falkowski M, Wiśniewska M, Słupski M, Ohla J, Zabrzyński J. Can Ashwagandha Benefit the Endocrine System?-A Review. Int J Mol Sci 2023; 24:16513. [PMID: 38003702 PMCID: PMC10671406 DOI: 10.3390/ijms242216513] [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: 10/03/2023] [Revised: 11/10/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023] Open
Abstract
Withania somnifera, also known as Ashwagandha, has been used in traditional medicine for thousands of years. Due to the wide range of its activities, there has been interest in its possible beneficial effects on the human body. It is proved that, among others, Ashwagandha has anti-stress, anti-inflammatory, antimicrobial, anti-cancer, anti-diabetic, anti-obesity, cardioprotective, and hypolipidemic properties. Particularly interesting are its properties reported in the field of psychiatry and neurology: in Alzheimer's disease, Parkinson's disease, multiple sclerosis, depression, bipolar disorder, insomnia, anxiety disorders and many others. The aim of this review is to find and summarize the effect that Ashwagandha root extract has on the endocrine system and hormones. The multitude of active substances and the wide hormonal problems faced by modern society sparked our interest in the topic of Ashwagandha's impact on this system. In this work, we also attempted to draw conclusions as to whether W. somnifera can help normalize the functions of the human endocrine system in the future. The search mainly included research published in the years 2010-2023. The results of the research show that Ashwagandha can have a positive effect on the functioning of the endocrine system, including improving the secretory function of the thyroid gland, normalizing adrenal activity, and multidirectional improvement on functioning of the reproductive system. The main mechanism of action in the latter appears to be based on the hypothalamus-pituitary-adrenal (HPA) axis, as a decrease in cortisol levels and an increase in hormones such as luteinizing hormone (LH) and follicle-stimulating hormone (FSH) in men were found, which results in stress level reduction and improvement in fertility. In turn, other studies prove that active substances from W. somnifera, acting on the body, cause an increase in the secretion of triiodothyronine (T3) and thyroxine (T4) by the thyroid gland and a subsequent decrease in the level of thyroid-stimulating hormone (TSH) in accordance with the hypothalamus-pituitary-thyroid (HPT) axis. In light of these findings, it is clear that Ashwagandha holds significant promise as a natural remedy for various health concerns, especially those related to the endocrine system. Future research may provide new insights into its mechanisms of action and expand its applications in both traditional and modern medicine. The safety and toxicity of Ashwagandha also remain important issues, which may affect its potential use in specific patient groups.
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Affiliation(s)
- Michał Wiciński
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, M. Curie Skłodowskiej 9, 85-094 Bydgoszcz, Poland; (A.F.-M.); (Z.K.); (D.K.); (K.G.)
| | - Anna Fajkiel-Madajczyk
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, M. Curie Skłodowskiej 9, 85-094 Bydgoszcz, Poland; (A.F.-M.); (Z.K.); (D.K.); (K.G.)
| | - Zuzanna Kurant
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, M. Curie Skłodowskiej 9, 85-094 Bydgoszcz, Poland; (A.F.-M.); (Z.K.); (D.K.); (K.G.)
| | - Dominik Kurant
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, M. Curie Skłodowskiej 9, 85-094 Bydgoszcz, Poland; (A.F.-M.); (Z.K.); (D.K.); (K.G.)
| | - Karol Gryczka
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, M. Curie Skłodowskiej 9, 85-094 Bydgoszcz, Poland; (A.F.-M.); (Z.K.); (D.K.); (K.G.)
| | - Michal Falkowski
- Department of Medicinal Chemistry, Faculty of Pharmacy, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Dr. A. Jurasza 2, 85-089 Bydgoszcz, Poland;
| | - Magdalena Wiśniewska
- Department of Oncology and Brachytherapy, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Dr I. Romanowskiej 2, 85-796 Bydgoszcz, Poland;
- Department of Clinical Oncology, Professor Franciszek Lukaszczyk Oncology Center, Dr I. Romanowskiej 2, 85-796 Bydgoszcz, Poland
| | - Maciej Słupski
- Department of Hepatobiliary and General Surgery, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, M. Curie Skłodowskiej 9, 85-094 Bydgoszcz, Poland;
| | - Jakub Ohla
- Department of Orthopedics and Traumatology, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, M. Curie Skłodowskiej 9, 85-094 Bydgoszcz, Poland; (J.O.); (J.Z.)
| | - Jan Zabrzyński
- Department of Orthopedics and Traumatology, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, M. Curie Skłodowskiej 9, 85-094 Bydgoszcz, Poland; (J.O.); (J.Z.)
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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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Vazirani S, Kothari A, Fujimoto J, Gomez M. Supplements Are Not a Synonym for Safe: Suspected Liver Injury From Ashwagandha. Fed Pract 2023; 40:315-319. [PMID: 38562158 PMCID: PMC10984693 DOI: 10.12788/fp.0409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background As patients look more to alternative herbal and dietary supplements to boost energy and mood, reports are increasing of unintended adverse effects, particularly to the liver. Case Presentation We report a case of a 48-year-old man with a history of severe alcohol use disorder who presented to the emergency department with a cholestatic pattern of liver injury in the setting of alcohol and use of a testosterone-boosting supplement containing ashwagandha. Conclusions Drug-induced liver damage should be considered in patients with alcohol use disorder who present with a cholestatic pattern of liver injury. Although many natural substances are well tolerated, others can have unanticipated and harmful adverse effects and drug interactions. Future research should identify not only potentially harmful substances, but also which patients may be at greatest risk.
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Affiliation(s)
- Sondra Vazirani
- Veterans Affairs Greater Los Angeles Healthcare System, California
| | - Amit Kothari
- Veterans Affairs Greater Los Angeles Healthcare System, California
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18
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Mallock-Ohnesorg N, Rinaldi S, Malke S, Dreiack N, Pieper E, Laux P, Schulz T, Zimmermann R, Luch A. Oral nicotine pouches with an aftertaste? Part 1: screening and initial toxicological assessment of flavorings and other ingredients. Arch Toxicol 2023; 97:2357-2369. [PMID: 37389646 PMCID: PMC10404176 DOI: 10.1007/s00204-023-03538-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/06/2023] [Indexed: 07/01/2023]
Abstract
Nicotine pouches are oral products that deliver nicotine without containing tobacco. Previous studies mainly focused on the determination of known tobacco toxicants, while yet no untargeted analysis has been published on unknown constituents, possibly contributing to toxicity. Furthermore, additives might enhance product attractiveness. We therefore performed an aroma screening with 48 different nicotine-containing and two nicotine-free pouches using gas chromatography coupled to mass spectrometry, following acidic and basic liquid-liquid extraction. For toxicological assessment of identified substances, European and international classifications for chemical and food safety were consulted. Further, ingredients listed on product packages were counted and grouped by function. Most abundant ingredients comprised sweeteners, aroma substances, humectants, fillers, and acidity regulators. 186 substances were identified. For some substances, acceptable daily intake limits set by European Food Safety Agency (EFSA) and Joint FAO/WHO Expert Committee on Food Additives are likely exceeded by moderate pouch consumption. Eight hazardous substances are classified according to the European CLP regulation. Thirteen substances were not authorized as food flavorings by EFSA, among them impurities such as myosmine and ledol. Three substances were classified by International Agency for Research on Cancer as possibly carcinogenic to humans. The two nicotine-free pouches contain pharmacologically active ingredients such as ashwagandha extract and caffeine. The presence of potentially harmful substances may point to the need for regulation of additives in nicotine-containing and nicotine-free pouches that could be based on provisions for food additives. For sure, additives may not pretend positive health effects in case the product is used.
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Affiliation(s)
- Nadja Mallock-Ohnesorg
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany.
| | - Selina Rinaldi
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
- Chair of Analytical Chemistry, Joint Mass Spectrometry Centre, University of Rostock, 18059, Rostock, Germany
| | - Sebastian Malke
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Nadine Dreiack
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Elke Pieper
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Peter Laux
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Thomas Schulz
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
| | - Ralf Zimmermann
- Chair of Analytical Chemistry, Joint Mass Spectrometry Centre, University of Rostock, 18059, Rostock, Germany
| | - Andreas Luch
- Department of Chemical and Product Safety, German Federal Institute for Risk Assessment (BfR), Berlin, Germany
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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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Fontana RJ, Bjornsson ES, Reddy R, Andrade RJ. The Evolving Profile of Idiosyncratic Drug-Induced Liver Injury. Clin Gastroenterol Hepatol 2023; 21:2088-2099. [PMID: 36868489 DOI: 10.1016/j.cgh.2022.12.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/02/2022] [Accepted: 12/19/2022] [Indexed: 03/05/2023]
Abstract
Idiosyncratic drug-induced liver injury (DILI) is an infrequent but important cause of liver disease. Newly identified causes of DILI include the COVID vaccines, turmeric, green tea extract, and immune checkpoint inhibitors. DILI is largely a clinical diagnosis of exclusion that requires evaluation for more common causes of liver injury and a compatible temporal association with the suspect drug. Recent progress in DILI causality assessment includes the development of the semi-automated revised electronic causality assessment method (RECAM) instrument. In addition, several drug-specific HLA associations have been identified that can help with the confirmation or exclusion of DILI in individual patients. Various prognostic models can help identify the 5%-10% of patients at highest risk of death. Following suspect drug cessation, 80% of patients with DILI fully recover, whereas 10%-15% have persistently abnormal laboratory studies at 6 months of follow-up. Hospitalized patients with DILI with an elevated international normalized ratio or mental status changes should be considered for N-acetylcysteine therapy and urgent liver transplant evaluation. Selected patients with moderate to severe drug reaction with eosinophilia and systemic symptoms or autoimmune features on liver biopsy may benefit from short-term corticosteroids. However, prospective studies are needed to determine the optimal patients and dose and duration of steroids to use. LiverTox is a comprehensive, freely accessible Web site with important information regarding the hepatotoxicity profile of more than 1000 approved medications and 60 herbal and dietary supplement products. It is hoped that ongoing "omics" studies will lead to additional insight into DILI pathogenesis, improved diagnostic and prognostic biomarkers, and mechanism-based treatments.
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Affiliation(s)
- Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan.
| | - Einar S Bjornsson
- Deparment of Internal Medicine, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raul J Andrade
- Division of Gastroenterology and Hepatology, University Hospital-IBIMA Platform BIONAND, University of Malaga, CIBERehd, Spain
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Mikulska P, Malinowska M, Ignacyk M, Szustowski P, Nowak J, Pesta K, Szeląg M, Szklanny D, Judasz E, Kaczmarek G, Ejiohuo OP, Paczkowska-Walendowska M, Gościniak A, Cielecka-Piontek J. Ashwagandha (Withania somnifera)—Current Research on the Health-Promoting Activities: A Narrative Review. Pharmaceutics 2023; 15:pharmaceutics15041057. [PMID: 37111543 PMCID: PMC10147008 DOI: 10.3390/pharmaceutics15041057] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/12/2023] [Accepted: 03/20/2023] [Indexed: 03/28/2023] Open
Abstract
In recent years, there has been a significant surge in reports on the health-promoting benefits of winter cherry (Withania somnifera), also known as Ashwagandha. Its current research covers many aspects of human health, including neuroprotective, sedative and adaptogenic effects and effects on sleep. There are also reports of anti-inflammatory, antimicrobial, cardioprotective and anti-diabetic properties. Furthermore, there are reports of reproductive outcomes and tarcicidal hormone action. This growing body of research on Ashwagandha highlights its potential as a valuable natural remedy for many health concerns. This narrative review delves into the most recent findings and provides a comprehensive overview of the current understanding of ashwagandha’s potential uses and any known safety concerns and contraindications.
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22
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Philips CA, Theruvath AH, Raveendran R, Ahamed R, Rajesh S, Abduljaleel JK, Tharakan A, Augustine P. Clinical outcomes associated with complementary and alternative medicine-related "immunity-boosting" practices in patients with cirrhosis during the COVID-19 pandemic - an observational study. Medicine (Baltimore) 2023; 102:e33365. [PMID: 36961176 PMCID: PMC10035553 DOI: 10.1097/md.0000000000033365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/06/2023] [Indexed: 03/25/2023] Open
Abstract
During the coronavirus disease 2019 pandemic, Ayurvedic herbal supplements and homeopathic immune boosters (IBs) were promoted as disease-preventive agents. The present study examined the clinical outcomes among patients with chronic liver disease who presented with complications of portal hypertension or liver dysfunction temporally associated with the use of IBs in the absence of other competing causes. This single-center retrospective observational cohort study included patients with chronic liver disease admitted for the evaluation and management of jaundice, ascites, or hepatic encephalopathy temporally associated with the consumption of IBs and followed up for 180 days. Chemical analysis was performed on the retrieved IBs. From April 2020 to May 2021, 1022 patients with cirrhosis were screened, and 178 (19.8%) were found to have consumed complementary and alternative medicines. Nineteen patients with cirrhosis (10.7%), jaundice, ascites, hepatic encephalopathy, or their combination related to IBs use were included. The patients were predominantly male (89.5%). At admission, 14 (73.75%) patients had jaundice, 9 (47.4%) had ascites, 2 (10.5%) presented with acute kidney injury, and 1 (5.3%) had overt encephalopathy. Eight patients (42.1%) died at the end of the follow up period. Hepatic necrosis and portal-based neutrophilic inflammation were the predominant features of liver biopsies. IB analysis revealed detectable levels of (heavy metals) As (40%), Pb (60%), Hg (60%), and various hepatotoxic phytochemicals. Ayurvedic and Homeopathic supplements sold as IBs potentially cause the worsening of preexisting liver disease. Responsible dissemination of scientifically validated, evidence-based medical health information from regulatory bodies and media may help ameliorate this modifiable liver health burden.
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Affiliation(s)
- Cyriac Abby Philips
- Clinical and Translational Hepatology, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Arif Hussain Theruvath
- Complementary and Alternative Medicine (Homeopathy), Department of Clinical Research, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala
| | - Resmi Raveendran
- Complementary and Alternative Medicine (Ayurveda), Department of Clinical Research, The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Sasidharan Rajesh
- Interventional Radiology, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Jinsha K Abduljaleel
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Ajit Tharakan
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
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Tóth M, Benedek AE, Longerich T, Seitz H. Ashwagandha-induced acute liver injury: A case report. Clin Case Rep 2023; 11:e7078. [PMID: 36937644 PMCID: PMC10014511 DOI: 10.1002/ccr3.7078] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/19/2023] [Accepted: 02/26/2023] [Indexed: 03/17/2023] Open
Abstract
Drug-induced liver injury became one of the most important liver disorders and diagnostic challenge for clinicians and pathologists. Here, we report a rare case of ashwagandha-induced acute liver injury. The patient developed jaundice 2 weeks after starting ashwagandha intake and recovered within 5 months after withdrawal without any specific treatment.
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Affiliation(s)
- Marcell Tóth
- Institute of PathologyUniversity Hospital HeidelbergHeidelbergGermany
| | | | - Thomas Longerich
- Institute of PathologyUniversity Hospital HeidelbergHeidelbergGermany
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Fontana RJ, Liou I, Reuben A, Suzuki A, Fiel MI, Lee W, Navarro V. AASLD practice guidance on drug, herbal, and dietary supplement-induced liver injury. Hepatology 2023; 77:1036-1065. [PMID: 35899384 PMCID: PMC9936988 DOI: 10.1002/hep.32689] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Robert J. Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Iris Liou
- University of Washington, Seattle, Washington, USA
| | - Adrian Reuben
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ayako Suzuki
- Division of Gastroenterology, Duke University, Durham, North Carolina, USA
| | - M. Isabel Fiel
- Department of Pathology, Mount Sinai School of Medicine, New York City, New York, USA
| | - William Lee
- Division of Gastroenterology, University of Texas Southwestern, Dallas, Texas, USA
| | - Victor Navarro
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
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Lubarska M, Hałasiński P, Hryhorowicz S, Mahadea DS, Łykowska-Szuber L, Eder P, Dobrowolska A, Krela-Kaźmierczak I. Liver Dangers of Herbal Products: A Case Report of Ashwagandha-Induced Liver Injury. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3921. [PMID: 36900932 PMCID: PMC10002162 DOI: 10.3390/ijerph20053921] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 06/18/2023]
Abstract
In recent years, cases of liver damage caused by ashwagandha herbal supplements have been reported from different parts of the world (Japan, Iceland, India, and the USA). Here, we describe the clinical phenotype of suspected ashwagandha-induced liver injury and the potential causative mechanism. The patient was admitted to the hospital because of jaundice. In the interview, it was reported that he had been taking ashwagandha for a year. Laboratory results showed an increase in total bilirubin, alanine transaminase (ALT), aspartate transaminase (AST), (gamma-glutamyl transpherase (GGT), alkaline phosphatase (ALP), total cholesterol, triglycerides, and ferritin. Based on clinical symptoms and additional tests, the patient was diagnosed with acute hepatitis and referred to a facility with a higher reference rate to exclude drug-induced liver injury. An R-value was assessed, indicative of hepatocellular injury. The result of the 24 h urine collection exceeded the upper limit of normal for copper excretion in urine twice. The clinical condition improved after intensive pharmacological treatment and four plasmapheresis treatments. This case is another showing the hepatotoxic potential of ashwagandha to cause cholestatic liver damage mixed with severe jaundice. In view of several documented cases of liver damage caused by ashwagandha and the unknown metabolic molecular mechanisms of substances contained in it, attention should be paid to patients reporting the use of these products in the past and presenting symptoms of liver damage.
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Affiliation(s)
- Marta Lubarska
- Department of Gastroenterology, Dietetics and Internal Diseases, University of Medical Sciences Poznan, Przybyszewskiego 49, 60-355 Poznan, Poland
| | - Przemysław Hałasiński
- Department of Gastroenterology, Dietetics and Internal Diseases, University of Medical Sciences Poznan, Przybyszewskiego 49, 60-355 Poznan, Poland
| | - Szymon Hryhorowicz
- Institute of Human Genetics, Polish Academy of Sciences, Strzeszynska 32, 60-479 Poznan, Poland
| | - Dagmara Santabye Mahadea
- Department of Gastroenterology, Dietetics and Internal Diseases, University of Medical Sciences Poznan, Przybyszewskiego 49, 60-355 Poznan, Poland
| | - Liliana Łykowska-Szuber
- Department of Gastroenterology, Dietetics and Internal Diseases, University of Medical Sciences Poznan, Przybyszewskiego 49, 60-355 Poznan, Poland
| | - Piotr Eder
- Department of Gastroenterology, Dietetics and Internal Diseases, University of Medical Sciences Poznan, Przybyszewskiego 49, 60-355 Poznan, Poland
| | - Agnieszka Dobrowolska
- Department of Gastroenterology, Dietetics and Internal Diseases, University of Medical Sciences Poznan, Przybyszewskiego 49, 60-355 Poznan, Poland
| | - Iwona Krela-Kaźmierczak
- Department of Gastroenterology, Dietetics and Internal Diseases, University of Medical Sciences Poznan, Przybyszewskiego 49, 60-355 Poznan, Poland
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Ashwagandha-Associated Acute Liver Failure Requiring Liver Transplantation. Am J Ther 2023; 30:e80-e83. [PMID: 36321995 DOI: 10.1097/mjt.0000000000001466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Vuppalanchi R, Ghabril M. Review article: clinical assessment of suspected drug-induced liver injury and its management. Aliment Pharmacol Ther 2022; 56:1516-1531. [PMID: 36282208 DOI: 10.1111/apt.17246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/10/2022] [Accepted: 09/25/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Idisyncratic drug-induced liver injury (DILI) is a rare instance of liver injury after exposure to an otherwise safe drug or herbal or dietary supplement. DILI can be associated with significant morbidity and mortality. Furthermore, it is an important consideration in drug development due to safety concerns. AIMS AND METHODS To highlight pearls and pitfalls to aid clinicians in diagnosing DILI and surmising the management options. We also share the best practices from personal insights developed from decades long participation in the causality assessment committee meetings of the DILI Network. RESULTS DILI lacks a diagnostic test and is currently diagnosed through a process of exclusion of competing aetiologies of liver injury. This requires a high degree of suspicion to consider the possibility of DILI, skill in ruling out the obvious and less obvious competing liver insults, and an understanding of the expected phenotypes of DILI. The facets of DILI cover multiple aspects, including the latency, liver injury pattern, course of injury, and associated autoimmune or immuno-allergic features. Care for patients with DILI is geared towards stopping the offending drug and symptom management that include the use of corticosteroids in select cases. CONCLUSION The diagnosis of DILI is challenging and is primarily made through a carefully crafted patient interview, temporal relationship with the implicated drug or supplement, and exclusion of competing aetiology. LiverTox is a useful resource for clinicians to review the literature and recognise the likelihood of the implicated agent in causing DILI.
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Affiliation(s)
- Raj Vuppalanchi
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Pusec CM, Wolsky R, Llerena C, Sura P. A Case of Supplement-Induced Hepatitis. Cureus 2022; 14:e30433. [DOI: 10.7759/cureus.30433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
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Gurley BJ, McGill MR, Koturbash I. Hepatotoxicity due to herbal dietary supplements: Past, present and the future. Food Chem Toxicol 2022; 169:113445. [PMID: 36183923 DOI: 10.1016/j.fct.2022.113445] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/20/2022] [Accepted: 09/23/2022] [Indexed: 11/26/2022]
Abstract
Dietary supplements (DS) constitute a widely used group of products comprising vitamin, mineral, and botanical extract formulations. DS of botanical or herbal origins (HDS) comprise nearly 30% of all DS and are presented on the market either as single plant extracts or multi-extract-containing products. Despite generally safe toxicological profiles of most products currently present on the market, rising cases of liver injury caused by HDS - mostly by multi-ingredient and adulterated products - are of particular concern. Here we discuss the most prominent historical cases of HDS-induced hepatotoxicty - from Ephedra to Hydroxycut and OxyELITE Pro-NF, as well as products with suspected hepatotoxicity that are either currently on or are entering the market. We further provide discussion on overcoming the existing challenges with HDS-linked hepatotoxicity by introduction of advanced in silico, in vitro, in vivo, and microphysiological system approaches to address the matter of safety of those products before they reach the market.
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Affiliation(s)
- Bill J Gurley
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA; Center for Dietary Supplement Research, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
| | - Mitchell R McGill
- Department of Environmental Health Sciences, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA; Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA; Center for Dietary Supplement Research, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
| | - Igor Koturbash
- Department of Environmental Health Sciences, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA; Center for Dietary Supplement Research, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA.
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A Comprehensive Review on the Use of Herbal Dietary Supplements in the USA, Reasons for Their Use, and Review of Potential Hepatotoxicity. LIVERS 2022. [DOI: 10.3390/livers2030011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Herbal and dietary supplement (HDS) use has grown exponentially in the United States. Unfortunately, the incidence of HDS-related liver injury has proportionally increased. Despite the potential for certain HDSs to cause clinically significant liver injury, they are not regulated by the Food and Drug Administration. Recent efforts have been made to regulate HDSs but are far removed from the scrutiny of prescription medications. Scant literature exists on HDSs and their risks of causing liver injury. In this comprehensive review, we examine trends of HDS use in the United States and the pathophysiologic mechanisms of drug-induced liver injury (DILI) of certain HDSs. Finally, we review usage rates; benefits, if any; purported pathophysiology of DILI; and propensity for progression to fulminant hepatic failure of nine HDSs linked to clinically significant DILI.
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Li X, Tang J, Mao Y. Incidence and risk factors of drug-induced liver injury. Liver Int 2022; 42:1999-2014. [PMID: 35353431 DOI: 10.1111/liv.15262] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 03/08/2022] [Accepted: 03/26/2022] [Indexed: 12/17/2022]
Abstract
The epidemiology and aetiology of drug-induced liver injury (DILI) vary across different countries and populations. Overall, DILI is rare in the general population but has become more prevalent in hospitalized patients, especially among patients with unexplained liver conditions. In addition, drugs implicated in DILI differ between Western and Eastern countries. Antibiotics are the leading drugs implicated in DILI in the West, whereas traditional Chinese medicine is the primary cause implicated in DILI in the East. The incidence of herbal and dietary supplements-induced hepatotoxicity is increasing globally. Several genetic and nongenetic risk factors associated with DILI have been described in the literature; however, there are no confirmed risk factors for all-cause DILI. Some factors may contribute to the risk of DILI in a drug-specific manner.
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Affiliation(s)
- Xiaoyun Li
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Jieting Tang
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Yimin Mao
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
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Patel AD, Pinsker BL, Wall A, Arbogast M, King LY, Sherzoy S. Itching to find a diagnosis. Clin Liver Dis (Hoboken) 2022; 20:77-80. [PMID: 36187371 PMCID: PMC9512456 DOI: 10.1002/cld.1230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/22/2022] [Accepted: 04/03/2022] [Indexed: 02/04/2023] Open
Abstract
Content available: Audio Recording.
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Affiliation(s)
- Akash D. Patel
- School of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | | | - April Wall
- Division of GastroenterologyDepartment of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | | | - Lindsay Y. King
- Division of GastroenterologyDepartment of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Sheila Sherzoy
- School of MedicineDuke UniversityDurhamNorth CarolinaUSA,Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
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Kumar P, Sharma R, Garg N. Withania somnifera - a magic plant targeting multiple pathways in cancer related inflammation. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2022; 101:154137. [PMID: 35533610 DOI: 10.1016/j.phymed.2022.154137] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 03/31/2022] [Accepted: 04/28/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Deregulated inflammatory responses are known to play a pivotal role in cancer initiation and progression. Tumor microenvironment is associated with the presence of a diverse array of inflammatory reactions, which further help tumor growth, metastasis and drug resistance. Withania somnifera is known to curb proliferation of cancer cells and lower inflammatory responses. PURPOSE In order to minimize the inflammation, cancer treatments often include immunomodulatory drugs. However, given the side effects of both of the cytotoxic cancer drugs and synthetic immunomodulatory agents, there is a need to develop novel anti-inflammatory agents for improved cancer therapy. A number of reports indicate that bioactive phytochemicals derived from W. somnifera exhibit anti-inflammatory capabilities in cancer. A deeper look into the underlying molecular mechanisms implicated in W. somnifera mediated anti inflammation is lacking, which is essential to fully understand the potential of this magical plant in cancer. Therefore, in the present review we are summarizing various reports, which describe mechanistic understanding of W. somnifera in cancer related inflammation. STUDY DESIGN AND METHODOLOGY In order to gather information on the molecular pathways affected by W. somnifera in cancer related inflammation, 'PubMed' and 'Science Direct' databases were searched using keywords Withania, cancer inflammation, and Withaferin A. Selected literature was analyzed to cover the role of inflammation in cancer, usage and side effects of anti-inflammatory drugs, W. somnifera as an immunomodulatory agent in cancer, molecular pathways modulated by W. somnifera in various preclinical models, and clinical trials using W. somnifera as an anti-inflammatory agent. RESULTS Upon literature survey we found that both W. somnifera extracts and Withaferin-A, exhibit anti inflammatory activities in various preclinical cancer models. W. somnifera modulates a number of signaling pathways such as NF-kB, JAK-STAT and AP1 to reduce cancer related inflammation. Anti inflammatory properties of W. somnifera might be effective in the treatment of drug resistance in cancers. Based on its promising effects against cancer associated inflammation in preclinical studies, W. somnifera derived products are being tested in clinical trials. CONCLUSION Several preclinical studies demonstrated anti-inflammatory potential of W. somnifera in a variety of cancers. While a few clinical trials are investigating the role of W. somnifera in various diseases, focused studies on its role in cancer related inflammation are lacking. Additionally, its anti-inflammatory effects offer targeting of senescence associated secretory phenotype (SASP), which is speculated to play a critical role in chemoresistance. Apart from targeting cancer cell proliferation, anti-inflammatory effects of Withania provide double advantage in cancer management. Therefore, clinical trials to target cancer related inflammation using W. somnifera as a drug, should be performed to validate its advantages in cancer therapy.
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Affiliation(s)
- Praveen Kumar
- Department of Medicinal Chemistry, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh 221005, India; Department of Rasa Shastra & Bhaishajya Kalpana, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh 221005, India
| | - Rohit Sharma
- Department of Rasa Shastra & Bhaishajya Kalpana, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh 221005, India
| | - Neha Garg
- Department of Medicinal Chemistry, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh 221005, India.
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Tewari D, Chander V, Dhyani A, Sahu S, Gupta P, Patni P, Kalick LS, Bishayee A. Withania somnifera (L.) Dunal: Phytochemistry, structure-activity relationship, and anticancer potential. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2022; 98:153949. [PMID: 35151215 DOI: 10.1016/j.phymed.2022.153949] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/08/2022] [Accepted: 01/15/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Ayurveda is a highly recognized, well-documented, and well-accepted traditional medicine system. This system utilizes many natural products in various forms for therapeutic purposes. Thousands of plants mentioned in the Ayurvedic system are useful in disease mitigation and health preservation. One potential plant of the Ayurvedic system is "Ashwagandha" [Withania somnifera (L.) Dunal], commonly regarded as Indian Ginseng. It possesses various therapeutic activities, such as neuroprotective, hypoglycemic, hepatoprotective, antiarthritic, and anticancer effects. PURPOSE Here we present a comprehensive insight on the anticancer effects of W. somnifera and mechanistic attributes of its bioactive phytocompounds. This review also provides updated information on the clinical studies pertaining to cancer, safety evaluation and opportunities for chemical modifications of withanolides, a group of specialized phytochemicals of W. somnifera. METHODS The present study was performed in accordance with the guidelines of the Preferred Reporting Items for Systemic Reviews and Meta-Analysis. Various scientific databases, such as PubMed, Science Direct, Scopus, Google Scholar, were explored for related studies published up to May 2021. RESULTS An updated review on the anticancer potential and mechanisms of action of the major bioactive components of W. somnifera, including withanolides, withaferin A and withanone, is presented. Comprehensive information on clinical attributes of W. somnifera and its active components are presented with the structure-activity relationship (SAR) and toxicity evaluation. CONCLUSION The outcome of the work clearly indicates that W. somnifera has a significant potential for cancer therapy. The SAR revealed that various withanolides in general and withaferin A in particular have binding energies against various proteins and tremendous potential to serve as the lead for new chemical entities. Nevertheless, additional studies, particularly well-designed clinical trials are required before therapeutic application of withanolides for cancer treatment.
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Affiliation(s)
- Devesh Tewari
- Department of Pharmacognosy, School of Pharmaceutical Sciences, Lovely Professional University, Phagwara 144411, Punjab, India.
| | - Vikas Chander
- Department of Pharmacy, Uttarakhand Technical University, Dehradun 248007, Uttarakhand, India
| | - Archana Dhyani
- Department of Pharmaceutics, School of Pharmacy, Graphic Era Hill University, Dehradun 248001, Uttarakhand, India
| | - Sanjeev Sahu
- Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Lovely Professional University, Phagwara 144411, Punjab, India
| | - Pawan Gupta
- Shree SK Patel College of Pharmaceutical Education and Research, Ganpat University, Mehsana 384012, Gujarat, India
| | - Pooja Patni
- Department of Pharmaceutics, School of Pharmaceutical Sciences, Lovely Professional University, Phagwara 144411, Punjab, India
| | - Lindsay S Kalick
- College of Osteopathic Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, FL 34211, USA
| | - Anupam Bishayee
- College of Osteopathic Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, FL 34211, USA.
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Behl A, Mishra A, Sharma GP. A Critical Scientific Review on Withania somnifera, Garcinia cambogia and
Curcumin Supplements: Food Forensics Perspective. CURRENT NUTRITION & FOOD SCIENCE 2022. [DOI: 10.2174/1573401317666210910114721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Abstract:
Food forensics is an emerging branch that applies scientific knowledge for the verification
and authentication of food supplements. The term “dietary supplement” refers to a diverse
set of preparations that are deemed to be essential for the well-being of the human body.
These supplements consist of various physiologically active substances that produce effects on
the body. However, a major issue with these supplements is that they are neither considered as
medicines nor as a food products. Due to this, such food supplements are prone to adulteration
and counterfeiting. In this review, three widely used supplements, namely Curcuma longa,
Withania somnifera, and Garcinia cambogia supplements, are considered. Chemistry, pharmacology,
and benefits of three are being discussed along with the analytical techniques for their
analysis. Chromatographic techniques are popular for the examination of dietary supplements.
Several such analytical techniques are being used to detect and identify the physiologically active
constituents as well as adulterants in dietary products. This review intends to demonstrate
the overall issues regarding dietary supplements.
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Affiliation(s)
- Akanksha Behl
- Amity Institute of Forensic Sciences, Amity University Uttar Pradesh, Noida, India
| | - Amarnath Mishra
- Amity Institute of Forensic Sciences, Amity University Uttar Pradesh, Noida, India
| | - G. P. Sharma
- National Food Laboratory,
Ghaziabad, Uttar Pradesh, India
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Analysis of Clinical Characteristics and Chronic Factors of Drug-induced Liver Injury in Chronic Hepatitis B Infection: A Retrospective Study. HEPATITIS MONTHLY 2021. [DOI: 10.5812/hepatmon.119328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Background: This study investigated clinical characteristics and chronic factors of drug-induced liver injury (DILI) among patients with chronic hepatitis B virus (HBV) infection. Methods: DILI patients were enrolled and divided into a DILI group and an HBV+DILI group. Laboratory indicators were recorded and analyzed. Multivariate logistic regression and the receiver operating characteristic (ROC) curve were used to determine risk factors and the predictive value for chronic DILI. Results: Of all the 114 patients, 87 were in the DILI group and 27 were in the HBV+DILI group. Baseline total bilirubin (TBIL), direct bilirubin (DBIL), and incidence of chronicity were significantly higher in the HBV+DILI group than in the DILI group (P = 0.017, P = 0.037, P = 0.045, respectively). However, platelet (PLT) and prothrombin activity (PTA) were significantly lower in the HBV+DILI group than in the DILI group (P = 0.022, P = 0.013, respectively). HBV infection, baseline aspartate aminotransferase (AST) > 200 U/L, and TBIL > 34.2 μmol/L were predictors of chronic DILI (OR = 4.481 [95% CI, 1.298 - 15.470], P = 0.018; OR = 8.478 [95% CI, 2.079 - 34.566], P = 0.003; OR = 7.358 [95% CI, 2.215 - 24.446], P = 0.001). The area under ROC curve (AUC) of joint diagnosis for chronic DILI was 0.814 (95% CI, 0.704 - 0.925, P < 0.001), which was significantly higher than that of single parameter prediction. Also, the sensitivity, specificity, positive predictive value, and negative predictive value of joint diagnosis were 81.0%, 73.1%, 40.5%, and 94.4%, respectively. Conclusions: HBV infection aggravated liver injury. HBV infection, baseline AST > 200 U/L, and TBIL > 34.2 μmol/L were predictors of chronic DILI, and their joint diagnosis could be used to predict chronic DILI effectively.
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Ireland PJ, Hardy T, Burt AD, Donnelly MC. Drug-induced hepatocellular injury due to herbal supplement ashwagandha. J R Coll Physicians Edinb 2021; 51:363-365. [PMID: 34882134 DOI: 10.4997/jrcpe.2021.409] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A 39-year-old female presented with a one-week history of jaundice and nausea after taking an over-the-counter herbal supplement containing ashwagandha root extract. Initial investigations revealed a hepatocellular pattern of liver enzyme abnormality with jaundice. Investigations, including viral serology, liver specific autoantibodies and an ultrasound scan of the abdomen, were unremarkable. Liver biopsy showed an acute cholestatic hepatitis with confluent necrosis but no features of chronicity. These histopathological findings differ to that of a previously reported case. Review of recent literature revealed that some clinical features and the time course of liver injury were similar to previous reports of ashwagandha drug-induced liver injury (DILI). The patient received treatment with ursodeoxycholic acid. We compare this case to previous reported cases of ashwagandha DILI and discuss the biochemical and histopathological features of ashwagandha DILI, therapeutic strategies and the importance of recognising herbal supplements as a possible cause of DILI.
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Affiliation(s)
| | | | | | - Mhairi C Donnelly
- Ward 16, Liver Unit, Freeman Hospital, Newcastle upon Tyne, NE7 7DN, UK,
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Ashwagandha-Induced Liver Injury: Self-Reports on Commercial Websites as Useful Adjunct Tools for Causality Assessment. Am J Gastroenterol 2021; 116:2151-2152. [PMID: 34187981 DOI: 10.14309/ajg.0000000000001369] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Woo SM, Davis WD, Aggarwal S, Clinton JW, Kiparizoska S, Lewis JH. Herbal and dietary supplement induced liver injury: Highlights from the recent literature. World J Hepatol 2021; 13:1019-1041. [PMID: 34630872 PMCID: PMC8473494 DOI: 10.4254/wjh.v13.i9.1019] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/08/2021] [Accepted: 08/09/2021] [Indexed: 02/06/2023] Open
Abstract
Herbal-induced liver injury (HILI) is an important and increasingly concerning cause of liver toxicity, and this study presents recent updates to the literature. An extensive literature review was conducted encompassing September 2019 through March 2021. Studies with clinically significant findings were analyzed and included in this review. We emphasized those studies that provided a causality assessment methodology, such as Roussel Uclaf Causality Assessment Method scores. Our review includes reports of individual herbals, including Garcinia cambogia, green tea extract, kratom as well as classes such as performance enhancing supplements, Traditional Chinese medicine, Ayurvedic medicine and herbal contamination. Newly described herbals include ashwagandha, boldo, skyfruit, and 'Thermo gun'. Several studies discussing data from national registries, including the United States Drug-Induced Liver Injury (DILI) Network, Spanish DILI Registry, and Latin American DILI Network were incorporated. There has also been a continued interest in hepatoprotection, with promising use of herbals to counter hepatotoxicity from anti-tubercular medications. We also elucidated the current legal conversation surrounding use of herbals by presenting updates from the Federal Drug Administration. The highlights of the literature over the past year indicate interest in HILI that will continue as the supplement industry in the United States grows.
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Affiliation(s)
- Stephanie M Woo
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC 20007, United States.
| | - William D Davis
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC 20007, United States
| | - Soorya Aggarwal
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC 20007, United States
| | - Joseph W Clinton
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC 20007, United States
| | - Sara Kiparizoska
- Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC 20007, United States
| | - James H Lewis
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC 20007, United States
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Prasad S, Kulshreshtha A, Lall R, Gupta SC. Inflammation and ROS in arthritis: management by Ayurvedic medicinal plants. Food Funct 2021; 12:8227-8247. [PMID: 34302162 DOI: 10.1039/d1fo01078f] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Chronic joint inflammatory disorders like osteoarthritis and rheumatoid arthritis, which are manifested by joint dysfunction, show an upsurge in inflammation and oxidative stress. Although conventional anti-arthritic drugs are being used to relieve pain from arthritic symptoms, they usually cause severe side effects. Traditionally used Ayurvedic medicinal plants are a promising alternative for the management of arthritic symptoms, as they are safe and effective. Ayurvedic medicinal plants improve arthritic symptoms by reducing joint tenderness, joint pain, swelling, bone and cartilage damage, and increasing knee flexion, walking distance and sports activities. These beneficial effects of Ayurvedic medicinal plants on arthritis are mediated through various cellular mechanisms including inhibition of the inflammatory markers NF-κB, cytokines, adipokines, PGE2, NO, iNOS, COX-2, and MMPs and induction of antioxidant status by decreasing free radicals, lipid peroxidation, and myeloperoxidase, and increasing antioxidant enzymes, Nrf2, and HO-1. Thus, a strategy requires using these Ayurvedic medicinal plants to treat arthritis. This article describes the status of inflammation and oxidative stress in arthritic conditions. We also provide evidence that Ayurvedic medicinal plants and their bioactive components are highly effective in improving arthritic symptoms.
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Affiliation(s)
- Sahdeo Prasad
- Noble Pharma, LLC, Research and Development, Menomonie, WI, 54751 USA.
| | - Alok Kulshreshtha
- Noble Pharma, LLC, Research and Development, Menomonie, WI, 54751 USA.
| | - Rajiv Lall
- Noble Pharma, LLC, Research and Development, Menomonie, WI, 54751 USA.
| | - Subash C Gupta
- Department of Biochemistry, Institute of Science, Banaras Hindu University, Varanasi, India
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Acharya SK. Acute Liver Failure: Indian Perspective. Clin Liver Dis (Hoboken) 2021; 18:143-149. [PMID: 34691401 PMCID: PMC8518349 DOI: 10.1002/cld.1135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/26/2021] [Accepted: 05/05/2021] [Indexed: 02/04/2023] Open
Affiliation(s)
- Subrat Kumar Acharya
- Pro chancellorKIIT UniversityBhubaneswarIndia,Emeritus Professor in GastroenterologyAll India Institute of Medical SciencesNew DelhiIndia
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Case series and review of Ayurvedic medication induced liver injury. BMC Complement Med Ther 2021; 21:91. [PMID: 33714265 PMCID: PMC7956115 DOI: 10.1186/s12906-021-03251-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 02/16/2021] [Indexed: 02/08/2023] Open
Abstract
Background Complementary and alternative medicine use among Americans is prevalent. Originating in India, Ayurvedic medicine use in the United States has grown 57% since 2002. CAM accounts for a significant proportion of drug induced liver injury in India and China, but there have been only three reports of drug induced liver injury from Ayurvedic medications in the U.S. We report three cases of suspected Ayurvedic medication associated liver injury seen at a Southern California community hospital and review literature of Ayurvedic medication induced liver injury. Case presentations Three patients presented with acute hepatocellular injury and jaundice after taking Ayurvedic supplements for 90–120 days. First patient took Giloy Kwath consisting solely of Tinospora cordifolia. Second patient took Manjishthadi Kwatham and Aragwadhi Kwatham, which contained 52 and 10 individual plant extracts, respectively. Third patient took Kanchnar Guggulu, containing 10 individual plant extracts. Aminotransferase activities decreased 50% in < 30 days and all 3 patients made a full recovery. Roussel Uclaf Causality Assessment Method (RUCAM) scores were 7–8, indicating probable causality. These products all contained ingredients in other Ayurvedic and traditional Chinese medicines with previously reported associations with drug induced liver injury. Conclusions These patients highlight the risk of drug induced liver injury from Ayurvedic medications and the complexity of determining causality. There is a need for a platform like LiverTox.gov to catalog Ayurvedic ingredients causing liver damage. Supplementary Information The online version contains supplementary material available at 10.1186/s12906-021-03251-z.
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Devarbhavi H, Aithal G, Treeprasertsuk S, Takikawa H, Mao Y, Shasthry SM, Hamid S, Tan SS, Philips CA, George J, Jafri W, Sarin SK. Drug-induced liver injury: Asia Pacific Association of Study of Liver consensus guidelines. Hepatol Int 2021; 15:258-282. [PMID: 33641080 DOI: 10.1007/s12072-021-10144-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/16/2021] [Indexed: 02/06/2023]
Abstract
Idiosyncratic drug-induced liver injury mimics acute and chronic liver disease. It is under recognized and underrecognised because of the lack of pathognomonic diagnostic serological markers. Its consequences may vary from being asymptomatic to self-limiting illness to severe liver injury leading to acute liver failure. Its incidence is likely to be more common in Asia than other parts of the world, mainly because of hepatotoxicity resulting from the treatment of tuberculosis disease and the ubiquitous use of traditional and complimentary medicines in Asian countries. This APASL consensus guidelines on DILI is a concise account of the various aspects including current evidence-based information on DILI with special emphasis on DILI due to antituberculosis agents and traditional and complementary medicine use in Asia.
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Affiliation(s)
- Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St John's Medical College Hospital, Bangalore, India.
| | - Guruprasad Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK
| | | | - Hajime Takikawa
- Faculty of Medical Technology, Emeritus Professor, School of Medicine, Tokyo, Japan
| | - Yimin Mao
- Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, and Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Saggere M Shasthry
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Saeed Hamid
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Soek Siam Tan
- Department of Medicine, Hospital Selayang, Bata Caves, Selangor, Malaysia
| | - Cyriac Abby Philips
- The Liver Institute, Center of Excellence in GI Sciences, Rajagiri Hospital, Aluva, Kerala, India
| | - Jacob George
- Department of Gastroenterology and Hepatology, Westmead Hospital and Sydney West Local Health District, Sydney, Australia
| | - Wasim Jafri
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
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Siddiqui S, Ahmed N, Goswami M, Chakrabarty A, Chowdhury G. DNA damage by Withanone as a potential cause of liver toxicity observed for herbal products of Withania somnifera (Ashwagandha). Curr Res Toxicol 2021; 2:72-81. [PMID: 34345852 PMCID: PMC8320610 DOI: 10.1016/j.crtox.2021.02.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 01/30/2021] [Accepted: 02/06/2021] [Indexed: 12/14/2022] Open
Abstract
The widely used medicinal herb Withania somnifera (Ashwagandha) has been recently reported to cause liver damage. Withanone is a major metabolite of Ashwagandha. Withanone was found to cause DNA damage. Withanone forms adducts with amines and thiols. Withanone-mediated DNA damage has serious biological consequences.
Withania somnifera, commonly known as Ashwagandha, is a medicinal plant used for thousands of years for various remedies. Extracts of Ashwagandha contain more than 200 metabolites, with withanone (win) being one of the major ones responsible for many of its medicinal properties. Recently, several cases of liver toxicity resulting from commercially available Ashwagandha products have been reported. The first report of Ashwagandha-related liver damage was from Japan, which was quickly resolved after drug-withdrawal. Later, similar cases of liver toxicity due to Ashwagandha consumption were reported from the USA and Iceland. Towards understanding the liver toxicity of Ashwagandha extracts, we studied win, a representative withanolide having toxicophores or structural alerts that are commonly associated with adverse drug reactions. We found that win can form non-labile adducts with the nucleosides dG, dA, and dC. Using various biochemical assays, we showed that win forms adducts in DNA and interfere with its biological property. Win also forms adducts with amines and this process is reversible. Based on the data presented here we concluded that win is detoxified by GSH but under limiting GSH levels it can cause DNA damage. The work presented here provides a potential mechanism for the reported Ashwagandha-mediated liver damage.
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Affiliation(s)
- Shazia Siddiqui
- Department of Life Sciences, Shiv Nadar University, Greater Noida, UP 201314, India
| | - Nabeel Ahmed
- Department of Life Sciences, Shiv Nadar University, Greater Noida, UP 201314, India
| | - Mausumi Goswami
- Department of Chemistry, School of Advanced Sciences, Vellore Institute of Technology, Vellore, TN 632014, India
| | - Anindita Chakrabarty
- Department of Life Sciences, Shiv Nadar University, Greater Noida, UP 201314, India
| | - Goutam Chowdhury
- Department of Chemistry, Shiv Nadar University, Greater Noida, UP 201314, India
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Devarbhavi H, Joseph T, Sunil Kumar N, Rathi C, Thomas V, Prasad Singh S, Sawant P, Goel A, Eapen CE, Rai P, Arora A, Leelakrishnan V, Gopalakrishnan G, Vardhan Reddy V, Singh R, Goswami B, Venkataraman J, Balaraju G, Patil M, Patel R, Taneja S, Koshy A, Nagaraja Rao P, Kumar Sarin S, Rathi P, Dhiman R, Duseja AK, Vargese J, Kumar Jain A, Wadhawan M, Ranjan P, Karanth D, Ganesh P, Nijhawan S, Krishna Dhali G, Adarsh CK, Jhaveri A, Nagral A, Rao P, Shalimar. The Indian Network of Drug-Induced Liver Injury: Etiology, Clinical Features, Outcome and Prognostic Markers in 1288 Patients. J Clin Exp Hepatol 2021; 11:288-298. [PMID: 33994711 PMCID: PMC8103312 DOI: 10.1016/j.jceh.2020.11.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 11/09/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Etiology of and outcomes following idiosyncratic drug-induced liver injury (DILI) vary geographically. We conducted a prospective study of DILI in India, from 2013 to 2018 and summarize the causes, clinical features, outcomes and predictors of mortality. METHODS We enrolled patients with DILI using international DILI expert working group criteria and Roussel Uclaf causality assessment method. Follow-up was up to 3 months from onset of DILI or until death. Multivariate logistics regression was carried out to determine predictors of non-survival. RESULTS Among 1288 patients with idiosyncratic DILI, 51.4% were male, 68% developed jaundice, 68% required hospitalization and 8.2% had co-existing HIV infection. Concomitant features of skin reaction, ascites, and encephalopathy (HE) were seen in 19.5%, 16.4%, and 10% respectively. 32.4% had severe disease. Mean MELD score at presentation was 18.8 ± 8.8. Overall mortality was 12.3%; 65% in those with HE, 17.6% in patients who fulfilled Hy's law, and 16.6% in those that developed jaundice. Combination anti-TB drugs (ATD) 46.4%, complementary and alternative medicines (CAM) 13.9%, anti-epileptic drugs (AED) 8.1%, non-ATD antimicrobials 6.5%, anti-metabolites 3.8%, anti-retroviral drugs (ART)3.5%, NSAID2.6%, hormones 2.5%, and statins 1.4% were the top 9 causes. Univariate analysis identified, ascites, HE, serum albumin, bilirubin, creatinine, INR, MELD score (p < 0.001), transaminases (p < 0.04), and anti-TB drugs (p = 0.02) as predictors of non-survival. Only serum creatinine (p = 0.017), INR (p < 0.001), HE (p < 0.001), and ascites (p = 0.008), were significantly associated with mortality on multivariate analysis. ROC yielded a C-statistic of 0.811 for MELD and 0.892 for combination of serum creatinine, INR, ascites and HE. More than 50 different agents were associated with DILI. Mortality varied by drug class: 15% with ATD, 13.6% with CAM, 15.5% with AED, 5.8% with antibiotics. CONCLUSION In India, ATD, CAM, AED, anti-metabolites and ART account for the majority of cases of DILI. The 3-month mortality was approximately 12%. Hy's law, presence of jaundice or MELD were predictors of mortality.
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Key Words
- AED, Anti-epileptic drugs
- ALF, Acute liver failure
- ALT, Alanine aminotransferase
- ART, Anti-retroviral drugs
- AST, Aspartate aminotransferase
- ATD, Anti- tuberculosis drugs
- Anti-tuberculosis drugs
- C.I, Confidence interval
- CAM, Complementary and alternative medicine
- Complimentary medicines
- DILI, Drug-induced liver injury
- DILIN, Drug induced liver injury network
- HE, Hepatic encephalopathy
- HIV, Human immunodeficiency virus
- INR, International normalised ratio
- Isoniazid
- Jaundice
- MELD, Model for end stage liver disease
- Mortality
- NSAID, Nonsteroidal anti-inflammatory drugs
- OR, Odds ratio
- Prognosis
- Pyrazinamide
- ROC, Receiver operating characteristic
- RUCAM, Roussel uclaf causality assessment method
- Rifampicin
- TB, Tuberculosis.
- TCM, Traditional chinese medicines.
- Traditional medicines
- ULN, Upper limit of normal
- USA, United states of america
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Affiliation(s)
- Harshad Devarbhavi
- Department of Gastroenterology, St. John's Medical College Hospital, Bangalore, India,Address for correspondence. Harshad Devarbhavi, Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India.
| | - Tarun Joseph
- Department of Gastroenterology, St. John's Medical College Hospital, Bangalore, India
| | | | - Chetan Rathi
- Department of Gastroenterology, LTM Medical College Hospital, Mumbai, India
| | - Varghese Thomas
- Department of Gastroenterology, Government Medical College, Kozhikode, India
| | | | - Prabha Sawant
- Department of Gastroenterology, LTM Medical College Hospital, Mumbai, India
| | - Ashish Goel
- Department of Gastroenterology, Christian Medical College, Vellore, India
| | | | - Prakash Rai
- Department of General Medicine, Holy Spirit Hospital, Mumbai, India
| | - Anil Arora
- Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India
| | | | | | - Vishnu Vardhan Reddy
- Department of Gastroenterology, St. John's Medical College Hospital, Bangalore, India
| | - Rajvir Singh
- Acute Care Surgery, HGH, Hamad Medical Corporation, Doha, Qatar
| | - Bhabadev Goswami
- Department of Gastroenterology, Dispur Hospitals, Guwahati, India
| | | | - Girisha Balaraju
- Department of Gastroenterology, Kasturba Medical College Hospital, Manipal, India
| | - Mallikarjun Patil
- Department of Gastroenterology, St. John's Medical College Hospital, Bangalore, India
| | - Rakesh Patel
- Department of Gastroenterology, Suyash Endoscopy Centre, Thane, India
| | - Sunil Taneja
- Department of Hepatology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Abraham Koshy
- Department of Gastroenterology, Lakeshore Hospital, Kochi, India
| | - Padaki Nagaraja Rao
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Pravin Rathi
- Department of Gastroenterology, B.Y.L. Nair Hospital, Mumbai, India
| | - Radhakrishna Dhiman
- Department of Hepatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ajay K. Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Joy Vargese
- Department of Hepatology, Gleneagles Global Health City, Chennai, India
| | - Ajay Kumar Jain
- Department of Gastroenterology, Choithram Hospital and Research Centre, Indore, India
| | - Manav Wadhawan
- Department of Gastroenterology, BLK Super Speciality Hospital, New Delhi, India
| | - Piyush Ranjan
- Department of Gastroenterology, Sir Ganga Ram Hospital, New Delhi, India
| | - Dheeraj Karanth
- Department of Gastroenterology, Vikram Hospital, Bangalore, India
| | | | - Sandeep Nijhawan
- Department of Gastroenterology, Sawai Man Singh Medical College, Jaipur, India
| | - Gopal Krishna Dhali
- School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Channagiri K. Adarsh
- Department of Gastroenterology, BGS Gleneagles Global Hospitals, Bangalore, India
| | - Ajay Jhaveri
- Department of Gastroenterology, Jaslok Hospital and Research Center, Mumbai, India
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital and Research Center, Mumbai, India
| | - Prasanna Rao
- Department of Gastroenterology, Apollo Hospitals, Bangalore, India
| | - Shalimar
- Department of Gastroenterology and Hepatology, AIIMS, New Delhi, India
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Complementary and alternative medicine. SIDE EFFECTS OF DRUGS ANNUAL 2021. [PMCID: PMC8488687 DOI: 10.1016/bs.seda.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Complementary and alternative medicine is used worldwide. The use of plant-based medicines for the prevention or treatment of disease is prevalent but not regulated or studied. Multiple countries are implementing pharmacovigilance systems to monitor the use and safety of dietary supplements. Reporting mechanisms continue to be sporadic and inconsistent, based mainly on consumer or healthcare provider reports outlining individual adverse effects (AEs) from dietary supplements. Supplement product ingredient lists may be inaccurate, claims biased, and Evidence-Based information regarding risks and benefits lacking. Healthcare providers should familiarize themselves with complementary medicine practices, the benefits and associated risks to best care for their patient populations. A global pandemic marked 2020 with the emergence of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A short review of vitamin and plant-based prevention, treatment, and associated ramifications with use of these products for coronavirus disease 2019 (COVID-19) is provided. Another world-wide dilemma is food security. Nutrieconomics and the socioeconomic ramifications of food are reviewed from a wider timeframe. Reports and reviews from 2020 describe AEs of complementary and alternative medicine and herbal dietary supplements. These are listed alphabetically by plant or supplement name.
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Philips CA, Ahamed R, Rajesh S, George T, Mohanan M, Augustine P. Comprehensive review of hepatotoxicity associated with traditional Indian Ayurvedic herbs. World J Hepatol 2020; 12:574-595. [PMID: 33033566 PMCID: PMC7522561 DOI: 10.4254/wjh.v12.i9.574] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/16/2020] [Accepted: 08/15/2020] [Indexed: 02/06/2023] Open
Abstract
With growing antipathy toward conventional prescription drugs due to the fear of adverse events, the general and patient populations have been increasingly using complementary and alternative medications (CAMs) for managing acute and chronic diseases. The general misconception is that natural herbal-based preparations are devoid of toxicity, and hence short- and long-term use remain justified among people as well as the CAM practitioners who prescribe these medicines. In this regard, Ayurvedic herbal medications have become one of the most utilized in the East, specifically the Indian sub-continent, with increasing use in the West. Recent well-performed observational studies have confirmed the hepatotoxic potential of Ayurvedic drugs. Toxicity stems from direct effects or from indirect effects through herbal metabolites, unknown herb-herb and herb-drug interactions, adulteration of Ayurvedic drugs with other prescription medicines, and contamination due to poor manufacturing practices. In this exhaustive review, we present details on their hepatotoxic potential, discuss the mechanisms, clinical presentation, liver histology and patient outcomes of certain commonly used Ayurvedic herbs which will serve as a knowledge bank for physicians caring for liver disease patients, to support early identification and treatment of those who present with CAM-induced liver injury.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India.
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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Björnsson HK, Björnsson ES, Avula B, Khan IA, Jonasson JG, Ghabril M, Hayashi PH, Navarro V. Ashwagandha as a cause for liver injury. Liver Int 2020; 40:2035-2036. [PMID: 32475004 DOI: 10.1111/liv.14551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | | | - Bharathi Avula
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, Mississippi, USA
| | - Ikhlas A Khan
- National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, Mississippi, USA
| | | | - Marwan Ghabril
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Paul H Hayashi
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Victor Navarro
- Einstein Healthcare Network, Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
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