1
|
Björnsson ES, Medina-Caliz I, Andrade RJ, Lucena MI. Setting up criteria for drug-induced autoimmune-like hepatitis through a systematic analysis of published reports. Hepatol Commun 2022; 6:1895-1909. [PMID: 35596597 PMCID: PMC9315110 DOI: 10.1002/hep4.1959] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 12/11/2022] Open
Abstract
Nitrofurantoin, minocycline, methyldopa and infliximab, have been found to induce autoimmune-like hepatitis (DI-AILH). Evidence for other drugs and herbal and dietary supplements (HDS) is unclear. The aims of the study were to establish criteria to define and review the published evidence of suspected DI-AILH. Search was undertaken in Pubmed using search terms "drug-induced liver injury," "autoimmune hepatitis," and "drug-induced autoimmune hepatitis." DI-AILH was defined as (1) drug as a potential trigger of liver injury with autoimmune features and histological findings compatible with AIH; (2) no or incomplete recovery or worsening of liver tests after discontinuation of the drug; (3) corticosteroids requirement or spontaneous recovery; (4) follow-up without immunosuppression (IS) and no relapse of AIH at least 6 months after discontinuation of IS; and (5) drugs potentially inducing AILH with a chronic course. Cases fulfilling the first four criteria were considered probable DI-AILH with three possible DI-AILH. A total of 186 case reports were identified for conventional drugs (n = 148; females 79%; latency 2.6 months) and HDS (n = 38; females 50%). The most commonly reported agents of DI-AILH were interferons (n = 37), statins (n = 24), methylprednisolone (MPS) (n = 16), adalimumab (n = 10), imatinib (n = 8), and diclofenac (n = 7). Tinospora cordifolia and Khat were the only HDS with probable DI-AILH cases. No relapses of AIH were observed when IS was stopped after interferons, imatinib, diclofenac, and methylprednisolone. Conclusion: Beyond well-recognized nitrofurantoin, methyldopa, hydralazine, minocycline, and infliximab as causes of DI-AILH, interferons, imatinib, adalimumab, and MPS were the best-documented agents leading to probable DI-AILH. Khat and Tinospora cordifolia were the only HDS found to be able to induce DI-AILH. Long-term immunosuppression appears to be rarely required in patients with DI-AILH due to these drugs.
Collapse
Affiliation(s)
- Einar S Björnsson
- Faculty of MedicineUniversity of IcelandReykjavikIceland.,Division of Gastroenterology and HepatologyDepartment of Internal MedicineThe National University Hospital of IcelandReykjavikIceland
| | - Inmaculada Medina-Caliz
- UGC Aparato Digestivo and Servicio de Farmacología ClínicaInstituto de Investigación Biomédica de Málaga-IBIMAHospital Universitario Virgen de la VictoriaUniversidad de MálagaMálagaSpain
| | - Raul J Andrade
- UGC Aparato Digestivo and Servicio de Farmacología ClínicaInstituto de Investigación Biomédica de Málaga-IBIMAHospital Universitario Virgen de la VictoriaUniversidad de MálagaMálagaSpain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y DigestivasMadridSpain
| | - M Isabel Lucena
- UGC Aparato Digestivo and Servicio de Farmacología ClínicaInstituto de Investigación Biomédica de Málaga-IBIMAHospital Universitario Virgen de la VictoriaUniversidad de MálagaMálagaSpain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y DigestivasMadridSpain
| |
Collapse
|
2
|
Le Y, Li X, Chen S, Ning KG, Guo X, Wu CG, Manjanatha MG, Mei N. Actein contributes to black cohosh extract-induced genotoxicity in human TK6 cells. J Appl Toxicol 2022; 42:1491-1502. [PMID: 35261072 DOI: 10.1002/jat.4313] [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: 01/29/2022] [Revised: 02/27/2022] [Accepted: 02/27/2022] [Indexed: 11/06/2022]
Abstract
Black cohosh extract (BCE) is one of the most popular botanical products for relieving menopausal symptoms. However, recent studies indicate that BCE is not only ineffective for menopausal therapy, but also induces genotoxicity through an aneugenic mode of action (MoA). In this study, the cytotoxicity of five constituents of BCE was evaluated in human lymphoblastoid TK6 cells. Among the five constituents, actein (up to 50 μM) showed the highest cytotoxicity and was thus selected for further genotoxicity evaluations. Actein caused DNA damage proportionally to concentration as evidenced by the phosphorylation of the histone protein H2A.X (γH2A.X) and resulted in chromosomal damage as measured by the increased percentage of micronuclei (MN) in cells. In addition, actein activated DNA damage response (DDR) pathway through induction of p-ATM, p-Chk1, and p-Chk2, which subsequently induced cell cycle changes and apoptosis. Moreover, both BCE and actein increased intracellular reactive oxygen species (ROS) production, decreased glutathione levels, and activated the mitogen-activated protein kinases (MAPK) signaling pathway. N-acetylcysteine, a ROS scavenger, attenuated BCE- and actein-induced ROS production, apoptosis, and DNA damage. These findings indicate that BCE- and actein-induced genotoxicity is mediated through oxidative stress. Taken together, our data show that actein is likely one of the major contributors to BCE-induced genotoxicity.
Collapse
Affiliation(s)
- Yuan Le
- Division of Genetic and Molecular Toxicology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, AR, USA
| | - Xilin Li
- Division of Genetic and Molecular Toxicology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, AR, USA
| | - Si Chen
- Division of Biochemical Toxicology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, AR, USA
| | - Kylie G Ning
- Division of Genetic and Molecular Toxicology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, AR, USA
| | - Xiaoqing Guo
- Division of Genetic and Molecular Toxicology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, AR, USA
| | - Charles G Wu
- Botanical Review Team, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Mugimane G Manjanatha
- Division of Genetic and Molecular Toxicology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, AR, USA
| | - Nan Mei
- Division of Genetic and Molecular Toxicology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, AR, USA
| |
Collapse
|
3
|
Björnsson ES, Navarro VJ, Chalasani N. Liver Injury Following Tinospora Cordifolia Consumption: Drug-Induced AIH, or de novo AIH? J Clin Exp Hepatol 2022; 12:6-9. [PMID: 35068778 PMCID: PMC8766689 DOI: 10.1016/j.jceh.2021.11.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Einar S Björnsson
- Department of Gastroenterology, Landspitali University Hospital, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Victor J Navarro
- Department of Medicine, Einstein Health Care Network, Jefferson Health, Philadelphia, PA, USA
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indianapolis, IN, USA
| |
Collapse
|
4
|
Seo JE, Guo X, Petibone DM, Shelton SD, Chen Y, Li X, Tryndyak V, Smith-Roe SL, Witt KL, Mei N, Manjanatha MG. Mechanistic Evaluation of Black Cohosh Extract-Induced Genotoxicity in Human Cells. Toxicol Sci 2021; 182:96-106. [PMID: 33856461 DOI: 10.1093/toxsci/kfab044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Black cohosh extract (BCE) is marketed to women as an alternative to hormone replacement therapy for alleviating menopausal symptoms. Previous studies by the National Toxicology Program revealed that BCE induced micronuclei (MN) and a nonregenerative macrocytic anemia in rats and mice, likely caused by disruption of the folate metabolism pathway. Additional work using TK6 cells showed that BCE induced aneugenicity by destabilizing microtubules. In the present study, BCE-induced MN were confirmed in TK6 and HepG2 cells. We then evaluated BCE-induced DNA damage using the comet assay at multiple time points (0.5-24 h). Following a 0.5-h exposure, BCE induced significant, concentration-dependent increases in %tail DNA in TK6 cells only. Although DNA damage decreased in TK6 cells over time, likely due to repair, small but statistically significant levels of DNA damage were observed after 2 and 4 h exposures to 250 µg/ml BCE. A G1/S arrest in TK6 cells exposed to 125 µg/ml BCE (24 h) was accompanied by apoptosis and increased expression of γH2A.X, p-Chk1, p-Chk2, p53, and p21. Conditioning TK6 cells to physiological levels of folic acid (120 nM) did not increase the sensitivity of cells to BCE-induced DNA damage. BCE did not alter global DNA methylation in TK6 and HepG2 cells cultured in standard medium. Our results suggest that BCE induces acute DNA strand breaks which are quickly repaired in TK6 cells, whereas DNA damage seen at 4 and 24 h may reflect apoptosis. The present study supports that BCE is genotoxic mainly by inducing MN with an aneugenic mode of action.
Collapse
Affiliation(s)
- Ji-Eun Seo
- Division of Genetic and Molecular Toxicology, National Center for Toxicological Research, Jefferson, Arkansas 72079, USA
| | - Xiaoqing Guo
- Division of Genetic and Molecular Toxicology, National Center for Toxicological Research, Jefferson, Arkansas 72079, USA
| | - Dayton M Petibone
- Division of Genetic and Molecular Toxicology, National Center for Toxicological Research, Jefferson, Arkansas 72079, USA
| | - Sharon D Shelton
- Division of Genetic and Molecular Toxicology, National Center for Toxicological Research, Jefferson, Arkansas 72079, USA
| | - Ying Chen
- Division of Genetic and Molecular Toxicology, National Center for Toxicological Research, Jefferson, Arkansas 72079, USA
| | - Xilin Li
- Division of Genetic and Molecular Toxicology, National Center for Toxicological Research, Jefferson, Arkansas 72079, USA
| | - Volodymyr Tryndyak
- Division of Biochemical Toxicology, National Center for Toxicological Research, Jefferson, Arkansas 72079, USA
| | - Stephanie L Smith-Roe
- Division of the National Toxicology Program, National Institute of Environmental Health Sciences (NIEHS), Research Triangle Park, North Carolina 27709, USA
| | - Kristine L Witt
- Division of the National Toxicology Program, National Institute of Environmental Health Sciences (NIEHS), Research Triangle Park, North Carolina 27709, USA
| | - Nan Mei
- Division of Genetic and Molecular Toxicology, National Center for Toxicological Research, Jefferson, Arkansas 72079, USA
| | - Mugimane G Manjanatha
- Division of Genetic and Molecular Toxicology, National Center for Toxicological Research, Jefferson, Arkansas 72079, USA
| |
Collapse
|
5
|
Mack CL, Adams D, Assis DN, Kerkar N, Manns MP, Mayo MJ, Vierling JM, Alsawas M, Murad MH, Czaja AJ. Diagnosis and Management of Autoimmune Hepatitis in Adults and Children: 2019 Practice Guidance and Guidelines From the American Association for the Study of Liver Diseases. Hepatology 2020; 72:671-722. [PMID: 31863477 DOI: 10.1002/hep.31065] [Citation(s) in RCA: 446] [Impact Index Per Article: 111.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Cara L Mack
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - David Adams
- Centre for Liver Research, University of Birmingham, Birmingham, UK
| | - David N Assis
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Nanda Kerkar
- Golisano Children's Hospital at Strong, University of Rochester Medical Center, New York, NY
| | - Michael P Manns
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Marlyn J Mayo
- Division of Digestive and Liver Diseases, University of Texas SW Medical Center, Dallas, TX
| | - John M Vierling
- Medicine and Surgery, Baylor College of Medicine, Houston, TX
| | | | - Mohammad H Murad
- Mayo Knowledge and Encounter Research Unit, Mayo Clinic College of Medicine, Rochester, MN
| | - Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
| |
Collapse
|
6
|
Santos G, Gasca J, Parana R, Nunes V, Schinnoni M, Medina-Caliz I, Cabello MR, Lucena MI, Andrade RJ. Profile of herbal and dietary supplements induced liver injury in Latin America: A systematic review of published reports. Phytother Res 2020; 35:6-19. [PMID: 32525269 DOI: 10.1002/ptr.6746] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/05/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023]
Abstract
Hepatotoxicity related to HDS is a growing global health issue. We have undertaken a systematic review of published case reports and case series from LA from 1976 to 2020 to describe the clinical features of HDS related hepatotoxicity in this region. We search in PubMed, Web of Science, Scopus and specific LA databases according to PRISMA guidelines. Only HILI cases published in LA that met criteria for DILI definition were included. Duplicate records or reports that lacked relevant data that precluded establishing causality were excluded. Finally, 17 records (23 cases) were included in this review. Centella asiatica, Carthamus tinctorius, and Herbalife® were the most reported HDS culprit products, the main reason for HDS consumption was weight loss. The clinical characteristics of HDS hepatotoxicity in our study were compared to those of other studies in the USA, Europe and China showing a similar signature with predominance of young females, hepatocellular damage, a high rate of ALF and mortality, more frequent inadvertent re-challenge and chronic damage. This study underscores the challenge in causality assessment when multi-ingredients HDS are taken and the need for consistent publication practice when reporting hepatotoxicity cases due to HDS, to foster HDS liver safety particularly in LA.
Collapse
Affiliation(s)
- Genario Santos
- Núcleo de Hepatologia, Hospital Universitário Prof. Edgard Santos - UFBA, Salvador, Brazil
| | - Jessica Gasca
- UICEC IBIMA, Plataforma SCReN (Spanish Clinical Research Network), Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Raymundo Parana
- Núcleo de Hepatologia, Hospital Universitário Prof. Edgard Santos - UFBA, Salvador, Brazil
| | - Vinicius Nunes
- Núcleo de Hepatologia, Hospital Universitário Prof. Edgard Santos - UFBA, Salvador, Brazil
| | - Maria Schinnoni
- Núcleo de Hepatologia, Hospital Universitário Prof. Edgard Santos - UFBA, Salvador, Brazil
| | - Inmaculada Medina-Caliz
- Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga - IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Spain
| | - Maria Rosario Cabello
- Núcleo de Hepatologia, Hospital Universitário Prof. Edgard Santos - UFBA, Salvador, Brazil.,CIBERehd, Madrid, Spain
| | - Maria Isabel Lucena
- Núcleo de Hepatologia, Hospital Universitário Prof. Edgard Santos - UFBA, Salvador, Brazil.,UICEC IBIMA, Plataforma SCReN (Spanish Clinical Research Network), Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,CIBERehd, Madrid, Spain
| | - Raul J Andrade
- Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga - IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Spain.,CIBERehd, Madrid, Spain
| |
Collapse
|
7
|
Czaja AJ. Examining pathogenic concepts of autoimmune hepatitis for cues to future investigations and interventions. World J Gastroenterol 2019; 25:6579-6606. [PMID: 31832000 PMCID: PMC6906207 DOI: 10.3748/wjg.v25.i45.6579] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/25/2019] [Accepted: 11/29/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Multiple pathogenic mechanisms have been implicated in autoimmune hepatitis, but they have not fully explained susceptibility, triggering events, and maintenance or escalation of the disease. Furthermore, they have not identified a critical defect that can be targeted. The goals of this review are to examine the diverse pathogenic mechanisms that have been considered in autoimmune hepatitis, indicate investigational opportunities to validate their contribution, and suggest interventions that might evolve to modify their impact. English abstracts were identified in PubMed by multiple search terms. Full length articles were selected for review, and secondary and tertiary bibliographies were developed. Genetic and epigenetic factors can affect susceptibility by influencing the expression of immune regulatory genes. Thymic dysfunction, possibly related to deficient production of programmed cell death protein-1, can allow autoreactive T cells to escape deletion, and alterations in the intestinal microbiome may help overcome immune tolerance and affect gender bias. Environmental factors may trigger the disease or induce epigenetic changes in gene function. Molecular mimicry, epitope spread, bystander activation, neo-antigen production, lymphocytic polyspecificity, and disturbances in immune inhibitory mechanisms may maintain or escalate the disease. Interventions that modify epigenetic effects on gene expression, alter intestinal dysbiosis, eliminate deleterious environmental factors, and target critical pathogenic mechanisms are therapeutic possibilities that might reduce risk, individualize management, and improve outcome. In conclusion, diverse pathogenic mechanisms have been implicated in autoimmune hepatitis, and they may identify a critical factor or sequence that can be validated and used to direct future management and preventive strategies.
Collapse
Affiliation(s)
- Albert J Czaja
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN 55905, United States
| |
Collapse
|
8
|
Terziroli Beretta-Piccoli B, Mieli-Vergani G, Bertoli R, Mazzucchelli L, Nofziger C, Paulmichl M, Vergani D. Atovaquone/proguanil-induced autoimmune-like hepatitis. Hepatol Commun 2017; 1:293-298. [PMID: 29404460 PMCID: PMC5721398 DOI: 10.1002/hep4.1039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 04/04/2017] [Accepted: 04/08/2017] [Indexed: 01/18/2023] Open
Abstract
We report a novel association between the commonly used antimalarial medication atovaquone/proguanil and drug‐induced autoimmune‐like hepatitis. The patient developed severe liver disease fulfilling biochemical, immunologic, and histologic criteria for the diagnosis of autoimmune hepatitis after the inadvertent rechallenge with the offending drug, which had caused self‐limited hepatitic symptoms a year previously. Over a period of 18 months, the patient underwent two follow‐up liver biopsies showing progressive resolution of the liver inflammation and achieved complete biochemical and immunologic remission on steroids. This remission persisted for 20 months following treatment withdrawal. Conclusion: This well documented case raises awareness of the potential hepatotoxicity of atovaquone/proguanil. (Hepatology Communications 2017;1:293–298)
Collapse
Affiliation(s)
| | | | - Raffaela Bertoli
- Regional Pharmacovigilance Center, Division of Clinical Pharmacology and Toxicology Ente Ospedaliero Cantonale Lugano Switzerland
| | | | - Charity Nofziger
- Institute of Pharmacology and Toxicology Paracelsus Medical University Salzburg Austria
| | - Markus Paulmichl
- Center for Health and Bioresources Austrian Institute of Technology Vienna Austria
| | - Diego Vergani
- Institute of Liver Studies King's College Hospital London United Kingdom
| |
Collapse
|
9
|
Franco DL, Kale S, Lam-Himlin DM, Harrison ME. Black Cohosh Hepatotoxicity with Autoimmune Hepatitis Presentation. Case Rep Gastroenterol 2017; 11:23-28. [PMID: 28203134 PMCID: PMC5301124 DOI: 10.1159/000452735] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 10/17/2016] [Indexed: 11/29/2022] Open
Abstract
Herbal medicines have been used for the treatment of various ailments since time immemorial. Black cohosh (BC) is well known for the treatment of postmenopausal symptoms, with conflicting evidence supporting its safety and benefits. We present a rare case of BC-induced autoimmune hepatitis (AIH) with hepatotoxicity in a 69-year-old female. To our knowledge, this represents the third case of BC-induced AIH.
Collapse
Affiliation(s)
- Diana L Franco
- Gastroenterology Fellow, Mayo Clinic, Scottsdale, AZ, USA
| | - Santosh Kale
- Gastroenterology Fellow, Mayo Clinic, Scottsdale, AZ, USA
| | | | | |
Collapse
|
10
|
Brown AC. Liver toxicity related to herbs and dietary supplements: Online table of case reports. Part 2 of 5 series. Food Chem Toxicol 2016; 107:472-501. [PMID: 27402097 DOI: 10.1016/j.fct.2016.07.001] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND No online current list of potentially life-threatening, hepatotoxic herbs and dietary supplements based on PubMed case reports exists in a summarized tabular form. METHODS Documented case reports of herbs or dietary supplements (DS; includes herbs) appearing to contribute to liver injury were used to create an online "DS Toxic Table" of potentially hepatotoxic herbs and dietary supplements (PubMed, 1966 to June, 2016, and cross-referencing). The spectrum of DS induced liver injuries (DSILI) included elevated liver enzymes, hepatitis, steatosis, cholestasis, hepatic necrosis, hepatic fibrosis, hepatic cirrhosis, veno-occlusive disease, acute liver failure requiring a liver transplant, and death. RESULTS Over the past 50 years, approximately 21 herbs (minus germander and usnic acid that are no longer sold) and 12 dietary supplements (minus the nine no longer sold and vitamin A & niacin due to excess intake) posed a possible risk for liver injures in certain individuals. The herbs with the most number of reported publications (but not cases studies) in descending order, were germander, black cohosh, kava extract, and green tea extract. CONCLUSION These online DS Toxic Tables will contribute to continued Phase IV post marketing surveillance to detect possible liver toxicity cases and serve to forewarn consumers, clinicians, and corporations.
Collapse
Affiliation(s)
- Amy Christine Brown
- Department of Complementary and Alternative Medicine, John A. Burns School of Medicine, 651 Ilalo Street, MEB 223, University of Hawaii at Manoa, Honolulu, HI, 96813, USA.
| |
Collapse
|
11
|
Calitz C, du Plessis L, Gouws C, Steyn D, Steenekamp J, Muller C, Hamman S. Herbal hepatotoxicity: current status, examples, and challenges. Expert Opin Drug Metab Toxicol 2015; 11:1551-65. [PMID: 26149408 DOI: 10.1517/17425255.2015.1064110] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Herbal medicines have commonly been considered safe by the general public due to their natural origin and long history of traditional uses. In contrast to this belief, many plants produce toxic substances as secondary metabolites that are sometimes not easily distinguishable from the pharmacological active compounds. Some herbal medicines have been associated with adverse effects and toxic effects, including hepatotoxicity, which have been reversed upon discontinuation of the herbal medicine by the patient. AREAS COVERED This review reflects on selected herbal medicines that are associated with hepatotoxic effects including a description of the phytochemicals that have been linked to liver injury where available. Although case studies are discussed where patients presented with hepatotoxicity due to use of herbal medicines, results from both in vitro and in vivo studies that have been undertaken to confirm liver injury are also included. EXPERT OPINION Increasing evidence of herbal hepatotoxicity has become available through case reports; however, several factors contribute to challenges associated with causality assessment and pre-emptive testing as well as diagnosis of herb-induced liver injury.
Collapse
Affiliation(s)
- Carlemi Calitz
- a 1 North-West University, Centre of Excellence for Pharmaceutical Sciences , Private Bag X6001, Potchefstroom, 2520, South Africa +27 18 299 4035 ; +27 87 231 5432 ;
| | - Lissinda du Plessis
- a 1 North-West University, Centre of Excellence for Pharmaceutical Sciences , Private Bag X6001, Potchefstroom, 2520, South Africa +27 18 299 4035 ; +27 87 231 5432 ;
| | - Chrisna Gouws
- a 1 North-West University, Centre of Excellence for Pharmaceutical Sciences , Private Bag X6001, Potchefstroom, 2520, South Africa +27 18 299 4035 ; +27 87 231 5432 ;
| | - Dewald Steyn
- a 1 North-West University, Centre of Excellence for Pharmaceutical Sciences , Private Bag X6001, Potchefstroom, 2520, South Africa +27 18 299 4035 ; +27 87 231 5432 ;
| | - Jan Steenekamp
- a 1 North-West University, Centre of Excellence for Pharmaceutical Sciences , Private Bag X6001, Potchefstroom, 2520, South Africa +27 18 299 4035 ; +27 87 231 5432 ;
| | - Christo Muller
- b 2 Diabetes Discovery Platform, South African Medical Research Council , P.O. Box 19070, Tygerberg, 7505, South Africa
| | - Sias Hamman
- a 1 North-West University, Centre of Excellence for Pharmaceutical Sciences , Private Bag X6001, Potchefstroom, 2520, South Africa +27 18 299 4035 ; +27 87 231 5432 ;
| |
Collapse
|
12
|
Enbom ET, Le MD, Oesterich L, Rutgers J, French SW. Mechanism of hepatotoxicity due to black cohosh (Cimicifuga racemosa): histological, immunohistochemical and electron microscopy analysis of two liver biopsies with clinical correlation. Exp Mol Pathol 2014; 96:279-83. [PMID: 24657312 DOI: 10.1016/j.yexmp.2014.03.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 03/12/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND Consumption of herbal supplements in the developed world remains high. Cimicifuga racemosa (C. racemosa) extract, or black cohosh, is widely used as a hormone replacing and an anti-inflammatory agent, and has been shown to cause idiosyncratic hepatitis. The mechanism of acute liver injury in those cases is unclear. To date, hepatotoxic effects of C. racemosa have been studied mostly in vitro and in animal models. Data on human tissue is extremely limited, and mostly confined to histological findings of explanted livers. METHODS We evaluated clinical data and examined surgical diagnostic liver biopsy specimens obtained from two female patients, who developed acute submassive liver necrosis, following consumption of C. racemosa. Both patients presented with acute elevation of liver enzymes, cholestasis, absence of reactivity to hepatitis A, B and C antibodies, and weak non-specific positivity for autoimmune serological markers. Initial histological interpretation of the biopsies, with focus on hepatic parenchyma and portal tracts, was done by light microscopy, followed by special stain series and immunohistochemical studies, including Cam 5.2, AE1/AE3, reticulin, α-actin, sirius red, and PAS with diastase. Areas of prominent lymphocytic infiltration of the periportal liver plate, observed microscopically, were further evaluated by electron microscopy (EM). 4HNE adduction study, an immunofluorescent assay, was performed to detect products of the oxidative damage and their localization in the liver parenchyma. RESULTS Oxidative damage was evident by accumulation of 4HNE protein adducts in the cytoplasm of hepatocytes, secondary lysosomes and macrophages. We hypothesize that the adducted proteins, accumulated in the liver parenchyma, serve as autoantigens, which provoke an autoimmune response, and cause migration of lymphocytes to the affected regions. The formation of immunological synapses between hepatocytes and lymphocytes, predominantly T-lymphocytes, is demonstrated by electron microscopy. The autoimmune response induces piecemeal, or troxis necrosis of hepatocytes, a well described biological phenomenon, where lymphocytes gradually remove hepatocytes in a piecemeal fashion, slowly consuming them and leaving fragments of liver cells, or nubbins of anuclear cytoplasm of liver cell, at the interface between lymphocytes and hepatocytes. CONCLUSION The pattern of pathological injury of liver cells in both patients, following consumption of black cohosh, is identical to troxis necrosis, seen during autoimmune hepatitis. Recognition of the possibility of the acute hepatic injury by the herbal supplement black cohosh is essential for early accurate diagnosis, and timely patient management.
Collapse
Affiliation(s)
- Elena T Enbom
- Department of Pathology and Laboratory Medicine, Harbor-UCLA Medical Center, Torrance, CA, United States.
| | - Mary D Le
- Department of Pathology and Laboratory Medicine, Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Leslie Oesterich
- Department of Internal Medicine, Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Joanne Rutgers
- Department of Pathology Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles CA, United States
| | - Samuel W French
- Department of Pathology and Laboratory Medicine, Harbor-UCLA Medical Center, Torrance, CA, United States
| |
Collapse
|
13
|
Navarro VJ, Seeff LB. Liver injury induced by herbal complementary and alternative medicine. Clin Liver Dis 2013; 17:715-35, x. [PMID: 24099027 DOI: 10.1016/j.cld.2013.07.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Herbal and dietary supplement use is common. Most marketed products consist of complex mixtures. Although they are perceived as safe, instances of hepatotoxicity attributable to these products underscore their potential for injury, but the exact component that is responsible for injury is difficult to discern. The lenient regulatory environment in the United States, which opens the possibility of adulteration and contamination, adds to the challenge of disease attribution. Although many different herbal and dietary supplements have been reported to cause liver injury, in the United States, products used for bodybuilding and weight loss are the most commonly implicated.
Collapse
Affiliation(s)
- Victor J Navarro
- Division of Hepatology, Einstein Healthcare Network, 5401 Old York Road, Klein Building, Suite 505, Philadelphia, PA 19141, USA.
| | | |
Collapse
|
14
|
Smith MJ, Germolec DR, Frawley RP, White KL. Immunomodulatory effects of black cohosh (Actaea racemosa) extract in female B6C3F1/N mice. Toxicology 2013; 308:146-57. [PMID: 23571075 DOI: 10.1016/j.tox.2013.03.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 01/30/2013] [Accepted: 03/31/2013] [Indexed: 10/27/2022]
Abstract
Black cohosh extracts (BCE; Actaea racemosa) are being used worldwide as an alternative to hormone replacement therapy for the management of menstrual and menopausal symptoms, yet the effects of BCE on the immune system are largely unknown. Female B6C3F1/N mice were treated daily with BCE (0, 62.5, 125, 250, 500, or 1000mg/kg) for 28 days by oral gavage. Liver weights were significantly increased (26-32%) at the 1000mg/kg dose. Dose-related increases in mean corpuscular volume and mean corpuscular hemoglobin were observed. Decreasing trends were observed in all thymic T cell populations, with the most notable dose-responsive effects on immature thymocytes. In the spleen, dose-related decreases were observed in all cell phenotypes evaluated, reaching the level of statistical significance at the 1000mg/kg BCE dose. Splenic natural killer (NK) cell numbers were significantly decreased at all BCE doses, with the exception of absolute NK numbers at the 125mg/kg dose. No effects were observed on T-dependent antibody responses of the humoral immune system, including the antibody-forming cell response to sheep erythrocytes (sRBC) and IgM antibody levels to both sRBC and keyhole limpet hemocyanin. Cytotoxic T cell (TCTL) activity was increased, as was the mixed leukocyte response in one of two studies. Anti-CD3 mediated proliferation and the delayed-type hypersensitivity response were unaffected. No effects were observed on innate immunity or on bone marrow cellularity and colony-forming units. Overall, BCE exposure in B6C3F1/N mice for 28 days at doses up to 1000mg/kg had minimal immune effects, with the exception of an increased TCTL response.
Collapse
Affiliation(s)
- Matthew J Smith
- Department of Pharmacology and Toxicology, Virginia Commonwealth University, 527 N. 12th Street, Room 2-009, Richmond, VA 23298, USA.
| | | | | | | |
Collapse
|
15
|
Mercado-Feliciano M, Cora MC, Witt KL, Granville CA, Hejtmancik MR, Fomby L, Knostman KA, Ryan MJ, Newbold R, Smith C, Foster PM, Vallant MK, Stout MD. An ethanolic extract of black cohosh causes hematological changes but not estrogenic effects in female rodents. Toxicol Appl Pharmacol 2012; 263:138-47. [PMID: 22687605 DOI: 10.1016/j.taap.2012.05.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 05/30/2012] [Accepted: 05/31/2012] [Indexed: 10/28/2022]
Abstract
Black cohosh rhizome (Actaea racemosa) is used as a remedy for pain and gynecological ailments; modern preparations are commonly sold as ethanolic extracts available as dietary supplements. Black cohosh was nominated to the National Toxicology Program (NTP) for toxicity testing due to its widespread use and lack of safety data. Several commercially available black cohosh extracts (BCE) were characterized by the NTP, and one with chemical composition closest to formulations available to consumers was used for all studies. Female B6C3F1/N mice and Wistar Han rats were given 0, 15 (rats only), 62.5 (mice only), 125, 250, 500, or 1000 mg/kg/day BCE by gavage for 90 days starting at weaning. BCE induced dose-dependent hematological changes consistent with a non-regenerative macrocytic anemia and increased frequencies of peripheral micronucleated red blood cells (RBC) in both species. Effects were more severe in mice, which had decreased RBC counts in all treatment groups and increased micronucleated RBC at doses above 125 mg/kg. Dose-dependent thymus and liver toxicity was observed in rats but not mice. No biologically significant effects were observed in other organs. Puberty was delayed 2.9 days at the highest treatment dose in rats; a similar magnitude delay in mice occurred in the 125 and 250 mg/kg groups but not at the higher doses. An additional uterotrophic assay conducted in mice exposed for 3 days to 0.001, 0.01, 0.1, 1, 10, 100 and 500 mg/kg found no estrogenic or anti-estrogenic activity. These are the first studies to observe adverse effects of BCE in rodents.
Collapse
Affiliation(s)
- Minerva Mercado-Feliciano
- National Toxicology Program, National Institute of Environmental Health Sciences, National Institutes of Health, 111 Alexander Drive, Research Triangle Park, NC, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Guttuso T. Effective and clinically meaningful non-hormonal hot flash therapies. Maturitas 2012; 72:6-12. [PMID: 22377187 DOI: 10.1016/j.maturitas.2012.01.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 01/30/2012] [Accepted: 01/31/2012] [Indexed: 11/19/2022]
Abstract
Although many non-hormonal compounds have shown statistically significant benefit over placebo in hot flash randomized controlled trials (RCTs), these studies have varied considerably in basic methodology making it challenging to deduce which compounds have the greatest potential to provide clinically meaningful benefit. This review used evidence-based methodology closely mirroring the FDA and EMEA guidelines as a template to identify "well-designed" RCTs from which effective and clinically meaningful non-hormonal hot flash therapies could be identified. In addition, pertinent safety information was reviewed. Out of 3548 MEDLINE citations and abstracts, 51 well-designed hot flash RCTs were identified. From these trials, gabapentin, oxybutynin ER, desvenlafaxine, soy-derived isoflavones and black cohosh each showed a clinically meaningful treatment effect in at least 1 RCT. Among these 5 compounds, only gabapentin demonstrated consistent and statistically significant benefit over placebo in all of its well-designed RCTs. Desvenlafaxine, soy-derived isoflavones, and black cohosh demonstrated statistically significant benefit over placebo in 75%, 21%, and 17% of the well-designed RCTs for each compound, respectively. There was only 1 well-designed RCT using oxybutynin ER, which showed it to have a robust and clinically meaningful benefit. In terms of safety, there have been cardiovascular risks associated with desvenlafaxine use in postmenopausal women with hot flashes. The use of anticonvulsants, in general, has been associated with an absolute 0.21% increase in suicidal thoughts and behavior. Further research is needed with several of these nonhormonal compounds to replicate these findings and to also directly compare their efficacy and tolerability with those of hormone replacement therapy.
Collapse
Affiliation(s)
- Thomas Guttuso
- University at Buffalo, Buffalo, NY 14214, United States.
| |
Collapse
|
17
|
Herb induced liver injury presumably caused by black cohosh: A survey of initially purported cases and herbal quality specifications. Ann Hepatol 2011. [DOI: 10.1016/s1665-2681(19)31536-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
|
18
|
Abstract
The clinical phenotype of classical autoimmune hepatitis can be mimicked by idiosyncratic drug-induced liver injury, and differentiation can be difficult. The goals of this review are to enumerate the major agents of drug-induced autoimmune-like hepatitis, describe the clinical findings and risk factors associated with it, detail the clinical tools by which to assess causality, discuss putative pathogenic mechanisms, and describe treatment and outcome. The frequency of drug-induced autoimmune-like hepatitis among patients with classical features of autoimmune hepatitis is 9%. Minocycline and nitrofurantoin are implicated in 90% of cases. Female predominance, acute onset, and absence of cirrhosis at presentation are important clinical manifestations. Genetic factors affecting phase I and phase II transformations of the drug, polymorphisms that protect against cellular oxidative stress, and human leukocyte antigens that modulate the immune response may be important pathogenic components. Clinical judgment is the mainstay of diagnosis as structured diagnostic methods for drug-induced liver injury are imperfect. The covalent binding of a reactive drug metabolite to a hepatocyte surface protein (commonly a phase I or phase II enzyme), formation of a neoantigen, activation of CD8 T lymphocytes with nonselective antigen receptors, and deficient immune regulatory mechanisms are the main bases for a transient loss of self-tolerance. Discontinuation of the offending drug is the essential treatment. Spontaneous improvement usually ensues within 1 month. Corticosteroid therapy is warranted for symptomatic severe disease, and it is almost invariably effective. Relapse after corticosteroid withdrawal probably does not occur, and its absence distinguishes drug-induced disease from classical autoimmune hepatitis.
Collapse
|
19
|
Gertz MA. Herbs for hematology. Leuk Lymphoma 2010; 51:1389-90. [DOI: 10.3109/10428194.2010.486880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|