January 18, 2011

Increased risk of parkinsonism among patients with cirrhosis: a 7-year follow-up study

Liver International
Early View (Articles online in advance of print)

Jiunn-Horng Kang 1,2,†, Ming-Chieh Tsai 3,4,†, Ching-Chun Lin 5, Hsiu-Li Lin 6, Herng-Ching Lin 5

Article first published online: 11 JAN 2011
DOI: 10.1111/j.1478-3231.2010.02432.x
© 2011 John Wiley & Sons A/S

Author Information
1 Neuroscience Research Center, Taipei Medical University Hospital, Taipei, Taiwan
2 School of Medicine, Taipei Medical University, Taipei, Taiwan
3 School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
4 Department of Internal Medicine, Division of Gastroenterology, General Cathay Hospital, Sijhih Branch, Taipei, Taiwan
5 School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
6 Department of Neurology, General Cathay Hospital, Sijhih Branch, Taipei, Taiwan
* Correspondence: Correspondence Herng-Ching Lin, School of Health Care Administration, Taipei Medical University, 250 Wu-Hsing St., Taipei 110, Taiwan Tel: +886 2 2736 1661x3613 Fax: +886 2 2378 9788 e-mail: henry11111@tmu.edu.tw

†* Contributed equally.

Keywords: cirrhosis;epidemiology;parkinsonism


Background/Aims: Previous studies have suggested that hepatic (toxic-metabolic) encephalopathy, the major complication of cirrhosis, is a neuropsychiatric disorder typically seen in patients with liver dysfunction after exclusion of other known brain disease. This study aims to investigate the risk for parkinsonism during a 7-year follow-up period after a diagnosis of cirrhosis.

Methods: In total, 1361 patients with cirrhosis and 6805 comparison patients without cirrhosis were included in this study. Each patient was then individually tracked for 7 years from the time of their initial diagnosis of cirrhosis to identify those who developed parkinsonism during the follow-up period. Stratified Cox proportional hazard regressions were conducted to calculate the hazard of parkinsonism for the two groups during the follow-up period, after adjusting for patient's age, monthly income, level of urbanization and geographic location.

Results: Of the total 8166 sampled patients, 141 (1.7%) developed parkinsonism during the follow-up period, 48 from the study group (3.5% of the patients with cirrhosis) and 93 from the comparison group (1.4% of patients in the comparison group). Stratified Cox proportional hazard regressions show that the hazard for parkinsonism for patients with cirrhosis was 2.65 times as high (95% confidence interval=1.85–3.80, P<0.001) as the patients in the comparison group over the 7-year follow-up period, after adjusting for patient's age, monthly income, level of urbanization and the geographic location of the community in which the patient resided.

Conclusions: We concluded that cirrhosis significantly increased the risk of parkinsonism.


Serum B12 levels predict response to treatment with interferon and ribavirin in patients with chronic HCV infection

Journal of Viral Hepatitis
Volume 18, Issue 2, pages 129–134, February 2011

P. Rosenberg 1,2, K. Hagen 2

Article first published online: 19 FEB 2010
DOI: 10.1111/j.1365-2893.2010.01288.x
© 2010 Blackwell Publishing Ltd

Author Information
1 Department of Medicine, Karolinska Institute
2 Department of Gastroenterology and Hepatology, Karolinska University Hospital, Stockholm, Sweden
* Correspondence: Peter Rosenberg, MD, PhD, Department of Gastroenterology and Hepatology, Karolinska University Hospital, S-17176 Stockholm, Sweden. E-mail: peter.rosenberg@karolinska.se


Keywords: B12;hepatitis C;infection;interferon;ribavirin;treatment

Summary. Vitamin B12 is stored in hepatocytes and inhibits hepatitis C virus (HCV) RNA translation. The implication of B12 in the setting of antiviral treatment is unknown. This study aims to retrospectively evaluate the discriminative efficacy of pretreatment B12 serum levels (s-B12) on end-of-treatment response (ETR) in patients with chronic HCV. Ninety-nine treatment naïve HCV patients, treated with interferon and ribavirin were studied. Serum B12 (s-B12) was analysed in samples collected before treatment start. Pretreatment s-B12 levels were correlated to ETR using univariate analysis. S-B12 and clinical data were evaluated in a multivariate logistic regression model. Mean pretreatment s-B12 was 331 pm in ETR and 260 pm in nonresponders (NR) (P = 0.012). In patients with s-B12 levels ≤ 360 pm, 23 (31.5%) were NR and 50 (68.5%) had ETR. In patients with s-B12 > 360 pm, one (3.8%) was NR and 25 (96.2%) had ETR (P = 0.0034). The results of the multivariate analysis were as follows: Pretreatment s-B12 > 360 vs≤360 pm: OR 28.6 CI 2.31–354, P = 0.008. Fibrosis stage 3–4 vs 0–2: OR 0.29 CI 0.074–1.12, P = 0.068. Genotype 2/3 vs 1/4/5: OR 15.5 CI 2.87–83.9, P = 0.0012. Dose reduction vs no dose reduction: OR 0.21, CI 0.048–0.91 P = 0.034. Standard interferon vs pegylated-interferon: OR 0.079, CI 0.0091–0.68 P = 0.019. Age and gender were not correlated to ETR. S-B12 > 360 pm is independently correlated to ETR in HCV patients treated with interferon and ribavirin. This suggests that B12 is involved in suppression of viral replication during anti-HCV treatment


First liver transplant patients receive experimental drug to prevent hepatitis C infection

Public release date: 18-Jan-2011

Contact: Michael Cohen
University of Massachusetts Medical School

Phase 2 clinical trial begins for a novel monoclonal antibody

Boston, Mass. — Following a successful Phase 1 study for safety, researchers at MassBiologics of the University of Massachusetts Medical School (UMMS) today announced the beginning of a Phase 2 clinical trial testing the ability of a human monoclonal antibody they developed to prevent hepatitis C virus (HCV) infection of a donor liver in transplant patients.

The first patients were enrolled in the study in December. The primary goal of this randomized, double-blind, placebo-controlled study is to test if the monoclonal antibody, designated MBL-HCV1, prevents re-infection of patients chronically infected with HCV who are undergoing liver transplantation.

MassBiologics plans to enroll 16 patients in the first part of the study. "We are hopeful that positive results from this study will meet an important public health need, and we could not take this important step without the willing and thoughtful participation of these volunteers," said Donna Ambrosino, MD, executive director of MassBiologics and a professor of pediatrics at the Medical School.

There are currently five hospitals participating in the trial—Massachusetts General Hospital, Beth Israel Deaconess Medical Center, both in Boston, Lahey Clinic in Burlington, Massachusetts, Yale-New Haven Hospital in Connecticut and Mount Sinai Hospital in New York City—and others may join in the coming months. The first six patients enrolled have come from three of these sites.

HCV damages the liver and is the leading indication for liver transplantation, diagnosed in about half of the 6,000 patients who receive liver transplants each year in the United States. According to the US Centers for Disease Control and Prevention, 3.2 million Americans are chronically infected with HCV and approximately 10,000 die annually of the disease. Globally, as many as 170 million people are estimated to suffer from HCV infection.

For patients with end-stage liver disease from HCV infection, liver transplantation is the only option. While it can be a life-saving treatment, transplantation does not cure the disease. In nearly all cases, the patient's new liver is eventually infected by HCV because the virus remains in the patient's bloodstream during surgery. The course of recurrent HCV disease is accelerated after transplantation and up to 20 percent of transplant patients develop cirrhosis within five years. Unfortunately, the standard antiviral drugs currently used to treat HCV prior to the onset of end-stage liver disease are poorly tolerated after liver transplantation, leaving these patients with few options.

To address this unmet medical need, the team at MassBiologics, working in collaboration with investigators Gyongyi Szabo, MD, PhD, professor of medicine, and Robert Finberg, MD, professor and chair of the Department of Medicine at UMMS, set out to develop a human monoclonal antibody that could clear HCV from a patient's bloodstream and protect the donated liver from infection. In pre-clinical studies, MBL-HCV1 successfully neutralized the virus in cell culture and animal models of infection. A Phase 1 study in 31 healthy volunteers completed in 2009 showed the antibody was well tolerated, with no serious side effects. The Phase 1 study also measured the levels of the antibody in the bloodstream and its ability to bind and inactivate the virus, thereby helping to establish the dosage and protocol for the Phase 2 study now under way.

In the current study, patients will be randomized to receive an infusion of either the antibody or placebo between one and four hours prior to surgery. Then, during the phase of surgery when the diseased liver is removed, but before the donor liver is implanted, patients will receive a second infusion of either the antibody or placebo. After the surgery is completed, the patients will receive a third infusion, and then daily infusions during the first week of recovery. A final infusion is administered on the 14th day after liver transplantation.

"The liver is the main reservoir for the hepatitis C virus," said Brett Leav, MD, senior director of clinical affairs at MassBiologics. "The virus circulates in the blood, but only resides and replicates in the liver. So the idea here is to clear the virus from the bloodstream before it has an opportunity to re-infect the new liver."

After transplantation, patients' blood will be tested on a regular basis to screen for reemergence of HCV, which is usually detected within the first week after transplantation. The primary goal of the Phase 2 trial is to see if the patients who received the antibody are free of HCV at 42 days after transplantation. An interim analysis is planned after the first 16 patients have been enrolled in the trial, and a Data Safety and Monitoring Board overseeing the study will assess the effectiveness and safety of MBL-HCV1.


About MassBiologics

MassBiologics, also known as the Massachusetts Biologic Laboratories, is the only non-profit FDA- licensed manufacturer of vaccines and other biologic products in the United States. MassBiologics produces 30 percent of the US tetanus/diphtheria vaccine supply. In addition to the HCV program, MassBiologics has discovered and developed human monoclonal antibodies to severe acute respiratory syndrome (SARS), and to Clostridium difficile (C. difficile), which has shown efficacy in a Phase 2 clinical trial, and to rabies which will be starting Phase 2 clinical trial soon in collaboration with the Serum Institute of India. MassBiologics traces its roots to 1894, and since then has maintained a mission to improve public health through applied research, development and production of biologic products. MassBiologics has been a part of the University of Massachusetts Medical School since 1997.

About the University of Massachusetts Medical School

The University of Massachusetts Medical School has built a reputation as a world-class research institution, consistently producing noteworthy advances in clinical and basic research. The Medical School attracts more than $255 million in research funding annually, 80 percent of which comes from federal funding sources. The work of UMMS researcher Craig Mello, PhD, an investigator of the prestigious Howard Hughes Medical Institute (HHMI), and his colleague Andrew Fire, PhD, then of the Carnegie Institution of Washington, toward the discovery of RNA interference was awarded the 2006 Nobel Prize in Physiology or Medicine and has spawned a new and promising field of research, the global impact of which may prove astounding. UMMS is the academic partner of UMass Memorial Health Care, the largest health care provider in Central Massachusetts. For more information, visit http://www.umassmed.edu/.


Studies: New treatments may increase cure rates of hepatitis C

By Jade Walker – Tue Jan 18, 9:14 am ET

The Starting Point is a snapshot of the news that occurred overnight and a preview of the stories we expect to cover today.

Featured story

People suffering from hepatitis C, a disease caused by a blood-born virus that attacks the liver, may soon have access to a cure.

Most people get the disease by using dirty needles, either to inject illegal drugs or while obtaining a tattoo or piercing. Others contracted hepatitis C from an infected blood transfusion or organ transplant that was performed before the U.S. began screening for the disease in 1992. You cannot get hepatitis C from casual contact such as hugging, kissing, sneezing, coughing or sharing food or drink.

About 3.2 million Americans, and 170 million people worldwide, have chronic hepatitis C, which is the leading cause of liver transplants. According to the Mayo Clinic, many patients may have the disease and not even realize it because they either show no symptoms (tiredness, joint and belly pain and jaundice) or the symptoms don't manifest for many years. Yet hepatitis C is a serious illness, one that kills about 12,000 Americans a year. Medical experts say that number is expected to triple over the next two decades.

The two-drug method currently used to treat the disease --ribavirin pills plus injections of interferon-alpha -- only cures about 40 percent of patients. However, new major studies show that adding a third drug, either Vertex Pharmaceuticals' telaprevir or Merck & Co.'s boceprevir, can increase cure rates by as high as 75 percent because they can block an enzyme the virus needs to reproduce. When taken in conjunction with the standard medications, these new drugs may also allow some patients to cut treatment time in half to six months.

The side effects of existing treatments include: sleeplessness, fever, muscle and body aches, anxiety, mouth sores, dehydration, irritability, headaches, depression, dry mouth, sore throat, nausea, vomiting, diarrhea and hair loss. And the new drugs may cause additional side effects, such as a rash and/or anemia. The drugmakers haven't announced what the drugs will cost either; the price of treatment can already cost $30,000 (before a liver transplant).

The Food and Drug Administration is expected to approve the drugs this summer, a move that is prompting some newly diagnosed patients to hold off on treatment until the new drug therapy is available.

"We're entering a whole new era of therapy," Dr. John Ward, hepatitis chief at the Centers for Disease Control and Prevention, told The Associated Press. "We really want to begin that clarion call for action for this population who's at risk."

Who should be tested for hepatitis C?

* Anyone who has ever injected illegal drugs
* Recipients of clotting factor concentrates made before 1987
* People who received blood transfusions or organ transplants before July 1992
* Patients who have ever received long-term hemodialysis treatment
* People who have HIV
* People with signs or symptoms of liver disease
* Children born to mothers who have hepatitis C


Also See: New Hope For Hepatitis C, An Often Hidden Disease

Review of liver injury associated with dietary supplements

Liver International
Early View (Articles online in advance of print)

Felix Stickel 1, Kerstin Kessebohm 2, Rosemarie Weimann 3, Helmut K. Seitz 4

Article first published online: 11 JAN 2011
DOI: 10.1111/j.1478-3231.2010.02439.x
© 2011 John Wiley & Sons A/S

Author Information
1 Department of Visceral Surgery and Medicine, Institute of Clinical Pharmacology and Visceral Research, Inselspital, University of Berne, Berne, Switzerland
2 Institute of Clinical Pharmacology and Visceral Research, University of Berne, Berne, Switzerland
3 Institute of Pathology, University of Berne, Berne, Switzerland
4 Department of Medicine, Center of Alcohol Research, Liver Disease and Nutrition, Salem Medical Center, University of Heidelberg, Heidelberg, Germany
* Correspondence: Correspondence Felix Stickel, MD, Department of Visceral Surgery and Medicine, Institute of Clinical Pharmacology and Visceral Research, Inselspital, University of Bern, Murtenstr. 35, 3010 Bern, Switzerland Tel: +41 31 632 87 28 Fax: +41 31 632 49 97 e-mail: felix.stickel@ikp.unibe.ch

anabolic steroids; Camellia sinensis; cholestasis; hepatitis; retinoid toxicity; toxic liver injury


Dietary supplements (DS) are easily available and increasingly used, and adverse hepatic reactions have been reported following their intake. To critically review the literature on liver injury because of DSs, delineating patterns and mechanisms of injury and to increase the awareness towards this cause of acute and chronic liver damage. Studies and case reports on liver injury specifically because of DSs published between 1990 and 2010 were searched in the PubMed and EMBASE data bases using the terms ‘dietary/nutritional supplements’, ‘adverse hepatic reactions’, ‘liver injury’; ‘hepatitis’, ‘liver failure’, ‘vitamin A’ and ‘retinoids’, and reviewed for yet unidentified publications. Significant liver injury was reported after intake of Herbalife® and Hydroxycut products, tea extracts from Camellia sinensis, products containing usnic acid and high contents of vitamin A, anabolic steroids and others. No uniform pattern of hepatotoxicity has been identified and severity may range from asymptomatic elevations of serum liver enzymes to hepatic failure and death. Exact estimates on how frequent adverse hepatic reactions occur as a result of DSs cannot be provided. Liver injury from DSs mimicking other liver diseases is increasingly recognized. Measures to reduce risk include tighter regulation of their production and distribution and increased awareness of users and professionals of the potential risks.

ALF, acute liver failure; DILI, drug-induced liver injury; DS, dietary supplements; FDA, Food and Drug Administration; HSC/MFB, hepatic stellate cells/portal myofibroblasts

The use of dietary supplements (DS) containing vitamins, anti-oxidants, fibre, trace elements, proteins, amino acids and herbal constituents has become a major health trend in affluent societies (1, 2). Consumption of DS in the USA has doubled to 18.9% of adults admitting their use only between 1999 and 2004 (3, 4); some investigations report their consumption up to 47% in certain subgroups such as among elder, non-smoking females with higher education (5). The rising popularity of DS is probably because of an increased awareness of consumers towards health in general and the desire to prevent diseases by an optimized nutritional status, and the persuasion that these treatments are safe (1, 2, 5, 6). Further, DS do not require prescriptions from health professionals allowing largely unrestricted access to relatively cheap products. Consequently, marketing such products has become a multibillion business largely unregulated by official health authorities (6–8).

In the USA, DS are expected to meet the standards outlined in the Dietary Supplement and Health Education Act published in 1994, which allows distribution without prior approval of their efficacy and safety by the Food and Drug Administration (FDA) (9). This simplified licensing practice does not ensure efficacy and safety in the same strict way as with the approval of conventional medications and treatments. Similarly, the European Union has set forth legislative measures for the distribution and marketing of DS and functional foods that are outlined in the European Commission 2000 White Paper on Food Safety (10, 11). This set of legislation pays tribute to the fact that DS may harbour specific problems because of their complex composition, particularly with respect to quality aspects, and defines guidelines for conducting premarketing in vitro and in vivo studies.

While adverse hepatic reactions from xenobiotics are well documented by pre- and post-marketing pharmacovigilance, the situation for DS is less well depicted as widespread and uncontrolled use and under-reporting prevent the determination of their true incidence. Additionally, a low awareness of users and providers towards their potential harms impedes their recognition as the causative agent in incidents of hepatotoxicity. Consequently, estimates of the frequency of DS-associated hepatic injury are likely imprecise and, possibly, too low. The proportion of hepatotoxicity ascribed to DS varies from 2% in a Spanish study (12) describing 531 cases of drug-induced liver injury (DILI) to approximately 10% in a series from the US Drug-Induced Liver Injury Network (DILIN) (13). Figures were as high as 35% in a small series of 20 patients developing acute liver failure with DS exposure as the only identifiable cause of liver damage (14).

Our article aimed to review and describe the literature on liver injury because of DS, delineate patterns and mechanisms of injury and to increase the awareness towards this possible cause of acute and chronic liver damage.

Literature search methodology

In February 2010, case reports and series thereof on liver injury specifically occurring following the consumption of DS published between 1990 and 2010 were searched in PubMed and EMBASE data bases using the terms ‘adverse hepatic reactions’, ‘anabolic steroids’, ‘Camellia sinensis’, ‘dietary/nutritional supplements’, ‘Herbalife’, ‘hepatitis’, ‘Hydroxycut’, ‘green tea’, ‘liver failure’, ‘liver injury’, ‘Noni’, ‘retinoids’, ‘vitamin A’ and critically reviewed. Retrieved publications were searched for yet unidentified publications. Remedies were considered DS if consumed as an aid to improve nutritional status, to loose weight or to treat constipation. Cases of liver injury from preparations taken for other causes than nutritional purposes were not included. No language restriction was used.

While hepatotoxicity from herbal medicines in general has been addressed in several reviews (15–18), summaries specifically devoted to liver-related risks along with DS are scarce (19). In the following, a panel of rather distinct DS preparations associated with liver injury are described (Table 1).

Specific dietary supplements associated with liver injury

Herbalife® (Los Angeles, CA, USA) sells nutritional and herbal supplements as tablets, capsules, drinks and energy bars for weight control, improvement of nutrition, ‘well-being’ and cosmetics. In 2006, the stock market quoted that Herbalife® company had a revenue of US$3.1 billion via online marketing or through independently operating sales agents.

There are so far six published reports on liver damage following the intake of Herbalife® products since 2007 describing 34 cases from five countries (Switzerland, Israel, Spain, Argentina and Iceland), although Herbalife® products are sold in at least 60 countries worldwide (20–25). Individual data of all reports are displayed in Table 2. Pattern of injury was mostly hepatocellular, but mixed and cholestatic enzyme patterns were also observed. Severity ranged from mild to severe hepatic damage including cirrhosis and acute liver failure requiring liver transplantation, which was successful in one patient while the second died because of post-operative complications. Causality between intake of Herbalife® products and the evolution of liver injury was assessed by widely used scores (26, 27) in five of the six reports and considered ‘certain’ in at least five patients by a positive rechallenge reaction and ‘probable’ in the majority of the remaining cases (20, 21).

Figure 1. Liver histology from a patient with secondary biliary cirrhosis following long-term intake of numerous Herbalife® nutritional supplements contaminated with Bacillus subtilis. (A) Enlargement of portal tracts with fibrosis, chronic inflammation and porto-lobular interface activity as well as ductular proliferation of the bile ducts with reactive changes of the epithelium (HE staining). (B) Immunohistochemistry with anticytokeratin 7 indicating bile duct such as loss of biliary lumina and significant lympho-epithelial infiltration (see arrow).

Camellia sinensis (green tea)
Green tea is among the most frequently consumed drinks in the USA and often used as a DS. The first report on liver injury following the ingestion of green tea extracts and preparations thereof was published in 1999 (31), and since then, numerous consecutive cases were reported to regulatory agencies worldwide. With effect of April 2003, the manufacturer of Exolise® (Arkopharma, Carros, France), a hydro-alcoholic extract of C. sinensis, has revocated all of their products after altogether 13 cases of acute liver damage following its intake were reported to the French pharmacovigilance authorities (Agence Francaise de Securité Sanitaire de Produits de Sanité; http://www.afssaps.sante.fr/). As a reaction to these accumulating reports, the US Pharmacopeia performed a systematic review of all cases accessible from PubMed, EMBASE and pharmacovigilance data bases in the USA, Canada, UK and Australia reporting on 34 single cases of liver injury following the ingestion of numerous different green tea preparations (32). Herein, case reports were retrospectively evaluated according to the Naranjo causality algorithm scale (33), and 27 reports pertaining to liver damage were labelled as ‘possibly’ and the remaining seven cases as ‘probably’ linked to green tea. Another Medline search review of cases on green tea liver injury from the same year also retrieved 34 published reports and described two further yet unpublished cases (34). On histological examination, livers of patients revealed inflammatory reactions, cholestasis, occasionally steatosis and necrosis. Although there was some overlap of single reports between these two review articles, collected case reports were not identical and jointly provided details on 58 cases of hepatotoxicity along with the intake of green tea extracts, powdered leaves, green tea infusions and hydro-alcoholic and aqueous extracts. In Mazzanti's summary, no causality re-evaluation was performed, but information on de- and rechallenge is provided for every case indicating a positive rechallenge response with accelerated recurrence of liver injury in seven of 36 incidents, which strongly suggests a causal relationship between the observed liver injury and green tea consumption. Of concern is that there was one reported death. However, a note of caution is warranted in many of the cases regarding an exclusive assignment of causality to green tea, because many patients who experienced adverse hepatic reactions also took numerous other products with a published record of hepatotoxicity, such as Cassia angustifolia, Hydroxycut and Ephedra sinica (for all three, please see below). Since these two review articles, additional cases have been published from Belgium reporting on a 42-year-old female patient who developed cholestatic hepatitis 6 months after starting Densitive® (Kerastase Nutritients, L'Oréal, Paris), which contains C. sinensis (35). Upon dechallenge, a full recovery was recorded. Other causes of liver injury were carefully excluded, but formal causality assessment using an established score was not performed. In the second case, jaundice, weight loss and subacute hepatitis developed in a 76-year-old man who regularly drank green tea infusions (36). Histology showed marked necro-inflammation, and transiently elevated antismooth muscle auto-antibodies were suggestive of autoimmunity induced by green tea constituents.

The mode of toxicity derived from green tea still remains incompletely understood but could be because of (−)-epigallocatechin gallate or its metabolite (−)-epicatechin gallate, which, under certain conditions such as fasting, can induce oxidative stress-related liver damage (37). Interestingly, in vitro and in vivo experimental studies have demonstrated both hepatoprotective as well as hepatotoxic properties (37–40). Along this line, support for potentially hepatoprotective activity from green tea extracts comes from clinical studies studying its therapeutic effects in humans with liver diseases including liver cancer, cirrhosis and steatosis. Four randomized-controlled clinical trials, two cohort, one case–control and three cross-sectional studies from China, Japan and the USA were recently subjected to a systematic review and found overall favourable effects from green tea as reflected by reduced mortality, attenuated steatosis and reduced incidence of primary liver cancer (41).

Whether the risks from green tea consumption outweigh their benefits remains open, but current evidence as outlined above suggests a causal relationship between intake of green tea-containing products and hepatotoxicity. Consequently, in their systematic review, the US Pharmacopeia included a cautionary statement on green tea indicating this possibility (32).

Usnic acid

Some years ago, several cases of acute liver failure requiring liver transplantation following the intake of LipoKinetix®, a product extracted from lichens and fungi and sold as DS capsules, were reported (42–45). Onset of liver injury was usually acute with a maximum latency of 3 months and the injury pattern hepatocellular with massive elevations of ALT and AST. Lipokinetix contained usnic acid and was marketed as a weight-loss remedy. Efficacy for this indication was postulated based on its function as an uncoupler of the respiratory chain, which in principle can augment weight loss (46). Apart from usnic acid, LipoKinetix® contained norephedrine hydrochloride, diiodothyronine, yohimbine hydrochloride and caffeine, which were confirmed by analysing the used LipoKinetix® lots. None of the ingredients were associated previously with liver damage and inadvertent contamination was excluded. These serious events caused the withdrawal of LipoKinetix® from the market.


Only recently, several Hydroxycut products were retracted by the manufacturer following a warning posted by the FDA in May 2009 because of 23 reports of liver injury including cases with acute hepatic failure and subsequent liver transplantation (47–49). Hydroxycut preparations were sold as powder, capsules and tablets by conventional retailers, through Internet sources and via direct television marketing. Hydroxycut was used to support weight loss and by body builders. The manufacturer had been charged previously with several lawsuits for unfounded health claims. Before May 2009, its primary ingredients included Garcinia cambogia, Gymnema sylvestre, chromium polynicotinate, caffeine and green tea. Published cases were recently reviewed and showed acute onset after several weeks of intake with high levels of serum aminotransferases in the majority of cases, while others presented with a more insidious, usually cholestatic course (50).


Various other DS have been associated with acute and subacute liver damage such as Senna (C. angustifolia), which is used as a powder, tea or suppository to treat constipation. According to our search, a total of five reports with altogether five individual cases describe the evolution of variable liver pathologies including acute cytolytic hepatitis, subacute cholestatic hepatitis, acute liver failure and portal vein thrombosis upon consumption of Senna products (51–55). In some reports, Senna preparations were self-made or ingested excessively such as in a young woman taking approximately 10 times the recommended dose who developed cytolytic hepatitis, which completely subsided after stopping Senna (51). The causal relationship between the preparation and hepatitis was confirmed through a positive rechallenge in two cases (51, 52). Senna is biotransformed via intestinal bacteria to rhein anthrone, which is highly reactive and requires binding to glucuronide and sulphate via phase I oxidation for renal excretion (56). Rhein anthrone is suspected to function as an uncoupler of the respiratory chain, and can therefore possibly affect hepatocyte integrity under certain circumstances, such as in genetically predisposed individuals. Seybold et al. (52) describe a case of increased toxicity of Senna tea in a homozygous carrier of a genetic cytochrome P450 2D6 variant rendering the individual a poor metabolizer for phase I hepatic detoxification reactions.

Noni juice (Morinda citrifolia) has become increasingly popular in Western countries as a health tonic. Consumption of Noni was the presumed cause of acute hepatitis in a 45-year-old man who drank a glass of this tropical fruit over several weeks for preventive reasons and for ‘strengthening the immune system’ (57). Other possible aetiologies of acute hepatitis were ruled out and liver tests rapidly turned normal after the cessation of Noni intake. Since this first report in 2005, five additional cases have been published from Austria, Germany and Spain (58–61). Remarkably, two patients experienced liver failure of which one required liver transplantation. The pattern of liver injury was hepatocellular in all cases and occurred rapidly within a few weeks of exposure. Causality was formally assessed in two publications, but not considered ‘certain’ in any of the cases because no rechallenge was used. Also, at least two of totally six patients had concomitant medication with known hepatotoxic potential, such as interferon-β (62) and a Chinese herbal mixture (63) respectively. Responsibility of Noni preparations as the cause of liver injury in these cases is challenged by one of the manufacturers of Noni products (64, 65) by demonstrating experimental evidence of no dose-dependent hepatotoxicity and even hepatoprotective properties in some animal models of chronic liver injury (66, 67). However, a lack of dose-dependent hepatotoxicity does not exclude idiosyncratic drug toxicity, e.g. by inducing autoimmune reaction as shown by Yuce et al. (59) who found excessively high liver–kidney microsomal antibodies of 1:3840 in a patient drinking Noni juice for 4 weeks. Nevertheless, the true underlying pathophysiology of Noni-associated liver injury remains elusive because active components within Noni extracts such as flavonoids, glycosides, vitamins, anthraquinones and polyunsaturated fatty acids are not known to be hepatotoxic.

Chinese herbs have become highly popular among consumers in Western countries because of a prevailing belief in their efficacy and safety. Among many others, Ma huang (E. sinica) is marketed in the USA as a nasal decongestant and bronchodilator, and more recently as a weight-loss remedy. The first report of Ma huang-associated liver injury was about a woman developing acute hepatitis together with elevated antinuclear antibodies (ANA) and smooth muscle antibodies (SMA) after only 3 weeks of intake of Ma huang, but liver abnormalities resolved after its discontinuation (68). Another report suggested that intake of Ma huang was the cause of acute liver failure in a 58-year-old patient initiating her listing for high-urgency liver transplantation who also presented with elevated titres of SMA (69). Another report suggested an association of Ma huang-related liver injury with compound heterozygosity for the C282Y and H63D mutation in the haemochromatosis gene, proposing that excess hepatic iron could aggravate hepatotoxicity, possibly via enhancing oxidative stress (70). The largest series on severe liver injury because of the intake of Ma huang by Neff et al. (71) describes 10 cases of acute cytolytic hepatitis of which two subjects required liver transplantation and one died, while the remaining seven patients recovered spontaneously. These cases of severe liver damage and others referring to cardiac toxicity have prompted a warning by the FDA for the use of Epedra-containing DS such as Ma huang (72).

In 1986, Germander (Teucrium chamaedrys) was approved as a drug for the supportive treatment of obesity in France. Its subsequent widespread use precipitated numerous reports on acute, chronic and even fulminant hepatitis to the French pharmacovigilance authorities in 1992 (73–75). Within a median of 2 months, intake of daily doses between 600 and 1600 mg/day precipitated acute cytolytic hepatitis or chronic hepatitis with fibrosis and even cirrhosis (74, 76). All patients recovered after the discontinuation of treatment, but some relapsed under re-exposure. Germander contains saponins, glycosides, flavonoids and neoclerodane diterpenoids, which were shown to be converted into diterpenoid toxic metabolites by cytochrome P450 3A in mice (77). In conditions of glutathione depletion – such as during fasting – or after induction of cytochrome P450 3A, toxic diterpenoids are potent inducers of hepatocyte apoptosis (78, 79). Hence, in 1992, the license for Germander-containing products was withdrawn.

‘Onshidou-Genbi-Kounou’, another herbal marketed for weight loss, seemed the likely cause of chronic hepatitis in a 52-year-old Japanese woman who took this preparation for 2 months (80). Serum levels of liver enzymes were elevated to >1500 IU/l and ANA were positive with 1:160. All other possible causes for chronic hepatitis were excluded, and liver histology was compatible with drug-induced autoimmune hepatitis. The patient recovered completely without intervention on cessation of ‘Onshidou-Genbi-Kounou’ intake. In a larger series from Japan describing 12 patients with acute hepatitis after taking ‘Onshidou-Genbi-Kounou’ and ‘Chaso’ for weight loss, two patients developed liver failure of which one survived after successful liver transplantation and the other one died (81). ‘Onshidou-Genbi-Kounou’ contains several natural compounds (amachazuru, tea leaf, barbaloin, total saponin and polyphenols) and N-nitroso-fenfluramine. The latter demonstrated induction of mitochondrial permeability transition and hepatocyte apoptosis following uncoupling of oxidative phosphorylation and intracellular ATP depletion (82, 83).

Vitamin A-associated liver injury

DS fortified with vitamin A are used to prevent night blindness, to increase immune function and to promote health in general. Liver injury related to hypervitaminosis A is well known for many decades and comprises mild elevations of serum liver enzymes, cholestatic hepatitis, non-cirrhotic portal hypertension, progressive fibrosis and cirrhosis (84–87). Toxicity does not usually occur with standard doses below 50 000 IU/day as contained in common multivitamin preparations, but individual tolerability may vary (88). Pre-existing liver lesions including steatosis, chronic alcohol consumption, comedication with other potentially hepatotoxic drugs and young age may predispose certain individuals to develop vitamin A hepatotoxicity (89, 90). Several case reports have demonstrated significant hepatotoxicity with vitamin A doses as low as 20 000 IU/day (91), and upper limits of tolerability may even be lower in regular alcohol consumers (92).

Toxicity is mediated to the dose-dependent effect of retinoids on hepatic stellate cells/portal myofibroblasts (HSC/MFB), which are the key effector cells in the evolution of fibrosis and cirrhosis (93). Upon excessive vitamin A exposure, HSC/MFB start to produce collagens, downregulate collagenase activity and acquire the ability of contraction leading to elevation of blood pressure in the portal vein. In addition to this direct impact on HSC/MFB function and activity, retinoids can be transformed into metabolites that affect mitochondrial function and hepatocyte viability with resulting liver cell apoptosis (94, 95). This was shown to occur particularly when co-administered with alcohol. Dan and colleagues showed that retinoids can be transformed via alcohol-induced cytochrome P450 2E1 into highly reactive and toxic polar metabolites, which cause hepatocyte apoptosis upon caspase 3 activation (Fig. 2). Hence, health professionals should consult users carefully about the potential dangers of vitamin A, particularly when intended for longer period, in children and regular alcohol consumers.

Figure 2. Retinoids are substrates of cytochrome P450 2E1 and may be transformed into toxic polar retinoid metabolites. These can damage mitochondria by disrupting the mitochondrial membrane potential, releasing pro-apoptotic factors (e.g. cytochrome C) and initiating caspase activation and hepatocellular apoptosis.

Anabolic steroids

Anabolic steroids are an integral part of the nutritional concept of many athletes to improve fitness, muscle gain and exercise performance. Their use is widespread although anabolics are classified as class III substances and therefore subdued to strict rules (96). However, access via inofficial and sometimes illegal sources is easy, and therefore, in spite of tight rules, further adverse hepatic reactions following the consumption of anabolic steroids can be expected. Hepatotoxicity has been frequently described and patterns of injury delineated. Liver lesions include intrahepatic cholestasis, hepatitis, adenoma and hepatocellular carcinoma and rare malformations such as peliosis hepatis, a rare pathological entity characterized by the gross appearance of multiple cyst-like, blood-filled cavities within the liver (97, 98). A recent case series demonstrated the evolution of cholestasis 2 weeks after the intake of anabolic steroids had been stopped. All patients recovered fully after intake had been terminated (99). Even more worrisome is the observation that some DS may contain anabolic steroids sufficient to precipitate liver injury, as demonstrated by a recent case report showing cholestasis in two young men who took DS to enhance their body-building performance (100). Another case presented with a less favourable course as prolonged intrahepatic cholestasis and subsequent kidney failure developed (101). The precise mechanism underlying toxicity is yet unclear, but experimental data indicate direct hepatocellular toxicity from steroids via increased oxidative stress and subsequent impairment of function of the canalicular bile salt export pump (100).

A recent case–control study from Brazil suggested that anabolic steroids could be a cause of toxicant-associated non-alcoholic fatty liver disease (TAFLD) by comparing 95 recreational body builders using anabolic steroids with 85 non-users. In those consuming anabolic steroids, 12.6% of subjects revealed criteria compatible with TAFLD such as steatosis on ultrasound imaging, elevated serum transaminases and exclusion of relevant alcohol intake or concomitant medication, but no overweight or insulin resistance suggestive of metabolic NAFLD. In turn, 2.4% of body builders not using anabolic steroids showed clinical signs and findings suggestive of NAFLD. The authors concluded that the intake of anabolic steroids could be a cause of non-metabolic, but toxicant-associated NAFLD (102).


Hepatic injury secondary to consumption of DS is recognized, although its exact frequency remains unclear, mostly because evidence relies exclusively on case reports. Lack of stringent diagnostic criteria, poor awareness of consumers and prescribers, easy and uncontrolled access and under-reporting account for this epidemiological gap of knowledge. Diagnostic assessment of DS-associated should be made more consistent, and customized specifically to DS. Although causality categories reached in many of the published reports suggest a causal relationship between liver injury and the intake of certain DS products, pitfalls exist related to the used diagnostic scales, which have all been criticized for variable reasons and of which none is unequivocally accepted as being suitable for the evaluation of DS as a cause of liver injury. While the WHO score is not specifically designed to evaluate DILI (103), the Naranjo adverse drug reaction probability scale (33) was recently found to have low sensitivity (54%), poor negative predictive value (29%) and to lack reproducibility in a large series of cases of suspected hepatotoxicity (104) when compared with the Roussel Uclaf Causality Assessment Method (RUCAM) (26, 105). A clinical diagnostic scale has been suggested as a simple tool to assess adverse hepatic drug reactions and showed good correlation with RUCAM in one study (106), but not in another (107). To conclude, all used scores reveal merits and limitations, but a common consensus on which one is the best to apply in causality assessment of DS-associated liver damage has never been reached. In an approach to compensate for this lack of common agreement, recently, the DILIN was established to advance our understanding and research into DILI by initiating a prospective registry of patients with DILI for future studies into host clinical, genetic, environmental and immunological risk factors, and to develop standardized nomenclature, terminology and causality assessment instruments (108). Patients with liver injury because of herbal products are also eligible to be included. Herein, a causality score ranging from 1 (definite) to 5 (unlikely) as well as a severity score ranging from 1 (mild) to 5 (fatal) is applied by three hepatologists of the DILIN study group, thereby minimizing individual biases. In addition to accounting for the input of the reporting investigator who took the history, performed the physical examination and supervised the data collection, a prospective evaluation of other potential causes of liver injury and serial laboratory data through at least 6 months of follow-up are offered. However, the DILIN expert opinion is limited by its lack of generalizability and a low level of agreement between the three hepatologists (109). Hence, a certain degree of inaccuracy in assigning causality remains until better diagnostic measures are established.

Apart from diagnostic measures, better regulatory measures to assure safety and timely recognition of potentially harmful products require improvement and, thus, efforts of pharmacovigilance authorities and healthcare providers must jointly act to minimize risks and protect consumers. Manufactures must spend utmost care in providing users with clean and unadulterated products and should be held liable if this accidentally or carelessly fails. Finally, consumers should develop a more critical attitude towards the expectations and hopes associated with DS use in largely healthy individuals, and turn to measures for which safety data are known, and efficacy is proven.


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Genentech Informs Customers of Important Information About Triad Group's Alcohol Prep Pads

January 13, 2011 07:55 PM Eastern Time

-- Consumers Alerted to Discontinue Use of Alcohol Prep Pads Packaged with Boniva® Injection, Fuzeon®, Nutropin A.Q. Pen®, Pegasys®, TNKase® Medicines --

SOUTH SAN FRANCISCO, Calif.--(BUSINESS WIRE)--Genentech, Inc., a member of the Roche Group (SIX: RO, ROG; OTCQX: RHHBY), has become aware of the market recall of Triad Group’s alcohol prep pads, alcohol swabs, and alcohol swabsticks manufactured by Triad in the United States and marketed under various brand names, (http://www.fda.gov/Safety/Recalls/ucm239219.htm). The Triad Group alcohol prep pads are co-packaged and distributed with Genentech medicines, Boniva Injection, Fuzeon, Nutropin A.Q. Pen, Pegasys, and TNKase to customers in the United States.

According to the Food and Drug Administration’s (FDA) Medwatch communication, the recall was initiated due to concerns about potential contamination of the Triad Group’s products with the bacteria, Bacillus cereus. This recall involves those products marked as sterile as well as non-sterile. Use of contaminated alcohol prep pads, alcohol swabs, and alcohol swabsticks could lead to life-threatening infections, especially in at-risk populations, including immune suppressed and surgical patients.

It is important to note, that Genentech medicines are not contaminated and may continue to be used in accordance with the package insert. Patients and healthcare providers should not use the alcohol prep pads packaged with these medicines and should instead use an alternate alcohol prep pad that is not involved with the Triad Group recall, or alternatively use a sterile gauze pad in conjunction with isopropyl alcohol for disinfecting the injection site prior to administration.

Genentech is in discussion with the FDA and is currently assessing alternatives to address the situation. The company plans to issue a Dear Healthcare Provider letter to potential prescribers and pharmacists to make them aware of the Triad product recall and the need to discontinue use of the alcohol prep pads packaged with Boniva Injection, Fuzeon, Nutropin A.Q. Pen, Pegasys, and TNKase.

Further information about the Triad Group recall can be found on the FDA website at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm239319.htm.
Patients should consult their healthcare provider for further information. Healthcare providers with questions may contact the Patient Resource Center at 1-877-436-3683 between the hours of 6 a.m. and 5 p.m. Pacific Time.

For the Boniva indication, full prescribing information, and important safety information, please visit http://www.boniva.com/.

For the Fuzeon indication, full prescribing information, and important safety information, please visit http://www.fuzeon.com/.

For the Nutropin A.Q. Pen indication, full prescribing information, and important safety information, please visit http://www.nutropin.com/.

For the Pegasys indication, full prescribing information, and important safety information including Boxed WARNING and Medication Guide, please visit http://www.pegasys.com/.

For the TNKase indication, full prescribing information, and important safety information, please visit http://www.tnkase.com/.

About Genentech

Founded more than 30 years ago, Genentech is a leading biotechnology company that discovers, develops, manufactures and commercializes medicines to treat patients with serious or life-threatening medical conditions. The company, a member of the Roche Group, has headquarters in South San Francisco, California. For additional information about the company, please visit http://www.gene.com/.

Genentech, Inc.
Tara Iannuccillo, 650-467-6800 (Media)
Investor Relations North America, 650-225-4150


Hepatitis C Cases Appearing More In Vietnam Veterans

Hepatitis C & Veterans (Added: January 18, 2011)
A growing problem for aging Vietnam-era veterans is showing up at
a rate five times the general public. (more)
Published: January 17, 2011

BEXLEY, Ohio -- It is becoming a battle that doesn't end for Vietnam veterans.

Medical writers researching VA medical centers claim that between 10 and 20 percent of veterans from the Vietnam era have hepatitis c.

"It can remain undetected, usually remains undetected for 20 to 30 years and then all of a sudden things start to show up with you," said Dennis Agin, who has the virus.

Agin is a navy veteran and was a doctor in Vietnam.

"I did unprotected surgery in Vietnam," said Agin.

In fact, that's where the disease is showing up: among medics from Vietnam.

"If they were medics and they went to a wounded person, they're going to get that person's blood on them and if they had a cut on their body or it went in their eyes they're going to pick up the disease," Agin said.

It is believed that the disease could have also been passed with air injection inoculations, but it is among the medical veterans where it is showing up more frequently.

Agin has started his own organization, the Coalition For Veterans from his home in Bexley.

What started as a personal battle after being denied most of a VA benefit for hepatitis c is gaining attention from around the country.

He spends much of his time trying to help other veterans who at this stage of their lives are being reminded of another time in their life.

"With hepatitis c, people are dying from this all the time," Agin said.

To contact Dr. Agin, call 877-OHIO-VET or email n8iln@att.net.