Outcomes and Toxicology of Herbal Drugs in Alcoholic Hepatitis - A Single Center Experience from India

Cyriac Abby Philips; Sasidharan Rajesh; Tom George; Rizwan Ahamed; Sandeep Kumbar; Philip Augustine

doi:10.14218/JCTH.2019.00043

Outcomes and Toxicology of Herbal Drugs in Alcoholic Hepatitis - A Single Center Experience from India

J Clin Transl Hepatol. 2019 Dec 28;7(4):329-340. doi: 10.14218/JCTH.2019.00043. Epub 2019 Nov 27.

Authors

Cyriac Abby Philips¹, Sasidharan Rajesh², Tom George², Rizwan Ahamed³, Sandeep Kumbar³, Philip Augustine³

Affiliations

¹ The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, India.
² Interventional Radiology, Department of Gastroenterology and Hepatology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, India.
³ Gastroenterology and Advanced G.I. Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, Kerala, India.

Abstract

Background and Aims: We aimed to study clinical outcomes and liver biopsy features of alcoholic hepatitis (AH) patients on complementary and alternative medicines (CAMs) and to analyze the retrieved drugs for chemical and toxic components linked to drug-induced liver injury. Methods: We retrospectively assessed clinical, biochemical and liver biopsy features of AH patients on CAM with drug-induced liver injury (AH-CAM, n = 27) and compared them to a control group (classical AH, n = 29) on standard of care. Patients without liver biopsy evaluation and other causes for liver disease were excluded. Samples of the CAMs (n = 42) from patients were retrieved and assessed for chemical and toxins. Results: All were males, and significantly worse clinical presentation, biochemical severity, and liver disease scores were notable in patients with AH-CAM. Traditional Ayurvedic-polyherbal formulations were the most commonly used CAM. On liver histology, varying grades of severe-necrosis, severe hepatocellular, canalicular, cholangiolar cholestasis with predominant lymphocytic-portal-inflammation and varying grades of interface-hepatitis were noted in AH-CAM. Analysis of CAMs revealed presence of heavy metals up to 100,000 times above detectable range and adulterants, such as antibiotics, chemotherapy agents, nonsteroidal anti-inflammatory drugs, alcohols, antidepressants, anxiolytics, and recreational drugs. On follow up, a significantly higher number of patients with AH on CAM died at end of 1, 3- and-6-months compared to controls (37% vs. 83%, 29% vs. 62%, 18% vs. 52% respectively; p < 0.001). Conclusions: Patients with AH and CAM-related drug-induced liver injury have extremely poor short-term survival in the absence of liver transplantation compared to those patients with AH on evidence-based management. Early transplant referral and educating on and curbing of CAM use in severe liver disease through strict monitoring of unregulated traditional health practices can help ease the burden of liver-related death.

Keywords: Alcohol; Ayurveda; CAM; DILI; Hepatitis.