herbal and complementary and alternative medicine therapies for liver disease

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CURRENT AND FUTURE TREATMENT THERAPIES FOR LIVER DISEASE 1089-3261/01 $15.00 + .OO HERBAL AND COMPLEMENTARY AND ALTERNATIVE MEDICINE THERAPIES FOR LIVER DISEASE A Focus on Chinese Traditional Medicine in Hepatitis C Virus Misha Ruth Cohen, OMD, LAC This article presents herbal and alternative therapies used in the treatment of liver disease both as adjunctive or complementary treatment to Western pharmaceutical strategies and as an alternative treatment in liver disease, particularly for hepatitis C Virus (HCV). There is a special emphasis on traditional Chinese herbal medicine. The author also dis- cusses several other contemporary and alternative medicine (CAM) ther- apies currently used to treat liver disease. CHINESE TRADITIONAL MEDICINE FOR LIVER DISEASE AND CHRONIC VIRAL HEPATITIS Hepatitis B-and increasingly, hepatitis C-is prevalent throughout China, accounting for the increased risk of hepatocellular carcinoma (HCC) in the mainland Chinese population. Fortunately, Chinese tradi- tional medicine has a rich history in the treatment of chronic viral hepatitis and other liver diseases. Therefore, throughout the world today, many people with HCV and other liver diseases are turning to Chinese traditional medicine. From the Cancer Research Institute, School of Medicine, University of California San Francisco, San Francisco; Institute for Health and Aging, University of California San Francisco, San Francisco; and Department of Research and Education, Quan Yin Healing Arts Center, San Francisco, California CLINICS IN LIVER DISEASE VOLUME 5 * NUMBER 2 . MAY 2001 461

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Page 1: HERBAL AND COMPLEMENTARY AND ALTERNATIVE MEDICINE THERAPIES FOR LIVER DISEASE

CURRENT AND FUTURE TREATMENT THERAPIES FOR LIVER DISEASE 1089-3261/01 $15.00 + .OO

HERBAL AND COMPLEMENTARY AND ALTERNATIVE MEDICINE

THERAPIES FOR LIVER DISEASE A Focus on Chinese Traditional Medicine in

Hepatitis C Virus

Misha Ruth Cohen, OMD, LAC

This article presents herbal and alternative therapies used in the treatment of liver disease both as adjunctive or complementary treatment to Western pharmaceutical strategies and as an alternative treatment in liver disease, particularly for hepatitis C Virus (HCV). There is a special emphasis on traditional Chinese herbal medicine. The author also dis- cusses several other contemporary and alternative medicine (CAM) ther- apies currently used to treat liver disease.

CHINESE TRADITIONAL MEDICINE FOR LIVER DISEASE AND CHRONIC VIRAL HEPATITIS

Hepatitis B-and increasingly, hepatitis C-is prevalent throughout China, accounting for the increased risk of hepatocellular carcinoma (HCC) in the mainland Chinese population. Fortunately, Chinese tradi- tional medicine has a rich history in the treatment of chronic viral hepatitis and other liver diseases. Therefore, throughout the world today, many people with HCV and other liver diseases are turning to Chinese traditional medicine.

From the Cancer Research Institute, School of Medicine, University of California San Francisco, San Francisco; Institute for Health and Aging, University of California San Francisco, San Francisco; and Department of Research and Education, Quan Yin Healing Arts Center, San Francisco, California

CLINICS IN LIVER DISEASE

VOLUME 5 * NUMBER 2 . MAY 2001 461

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462 COHEN

At the International Symposium on Viral Hepatitis and AIDS held in April, 1991, in Beijing, China, more than 100 papers on viral hepatitis were presented, several of which documented the results of studies of Chinese herbal medicine in the treatment of hepatitis. Studies of Chinese herbal antiviral agents and Xue (Blood)-cooling and Xue-circulating herbs for repairing liver damage supported the hundreds of years of practical experience with Chinese herbs used to treat the symptoms of hepatitis and other disease of the liver.2, 19, 24 A literature review by Dr. Kevin Ergil in 19959 found that at least 55 Chinese herbal formulas are used clinically to treat liver disease and hepatitis. Some recent herbal studies in China and Australia have also show positive results in HCV using formulas similar to those used widely in clinics in the United States.1, 7, 14.20.21

CHINESE TRADITIONAL MEDICINE FOR LIVER DISEASE IN THE UNITED STATES TODAY

In the United States Chinese traditional medicine is a popular com- plementary or alternative therapy among people with chronic liver dis- ease. An anecdotal report in 1996 from one of the largest clinical hepatol- ogy practices in San Francisco suggests that at least 20% to 30% of patients in this practice report use of Chinese herbal interventions for hepatitis (Robert Gishm, MD, personal communication). The level of use is probably underestimated, because patients often choose not to divulge the use of complementary and alternative medicine therapies to their Western primary care physician.8 For example, surveys have estimated that 40% or more of all HIV-positive patients are using some form of Chinese medicine and more than 66% are using alternative and complementary therapies in conjunction with highly active antiretroviral therapy (HAART).

In the last several years, Chinese traditional medicine protocols have been developed that have successfully helped HCV-infected people to decrease symptoms, normalize or lower liver enzyme levels, and apparently slow the progression of liver disease. A small pilot study conducted in 1995 among people co-infected with HIV and hepatitis B or C viruses at the Quan Yin Healing Arts Center in San Francisco indicates that acupuncture alone may have an effect in lowering and normalizing liver enzyme levels.25

CHINESE MEDICINE PHILOSOPHY

The primary goal of Chinese traditional medicine is to create whole- ness and harmony within a person, allowing the mind/body/spirit to heal itself. Chinese philosophy states that there are two polar principles of life, Yin and Yang, that are dialectically opposed to each other. Imbal- ances of Yin and Yang within an individual may be reflected as illness, because the body is considered a microcosm of the world.

Chinese traditional medicine defines the physiologic components of

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illness using the concepts Qi (Vital Energy), Xue (Blood), Jin-Ye (Body Fluids), Jing (Essence), and Shen (Spirit), as well as Organ Systems. Organ Systems are domains within the body that govern particular body tissues, emotional states, and activities.

Chinese traditional medicine theory postulates that the key to health lies in the internal ability of the body to remain strong. In this theory, people are born with a certain amount of Original Qi, which is easily depleted as energy is used by the body and not replaced. It is not easy to increase the Original Qi, and a person must work hard during life just to retain it. Chinese exercise programs-along with proper eating and sleeping habits-are highly recommended for maintaining Original Qi. According to Chinese medical philosophy, a person who consistently lacks sleep, lacks proper nutrition, abuses drugs or alcohol, or has excessive or unsafe sex, becomes deficient in Qi and other substances. When weakened, the person is more susceptible to infection by harmful external pathogens.

THERAPEUTIC MODALITIES USED IN CHINESE TRADITIONAL MEDICINE

The various therapeutic modalities of Chinese traditional medicine include dietary therapy, massage therapy, heat therapies, exercise, medi- tation, acupuncture, and herbal medicine. Heat therapies include the use of moxibustion, which is the burning of the common herb mugwort (artemesia vulgaris) over certain areas of the body to stimulate or warm these areas. Exercise therapy ranges from martial arts to more subtle forms of movement such as T’ai Chi and Qi Gong. Acupuncture, perhaps the best-known form of Chinese traditional medicine in the United States, is the art of inserting fine, sterile, metal filiform needles into certain points of the body to control the flow of energy in the meridians. Acupuncture, which also includes electrostimulation and hand stimula- tion, is most appreciated for its ability to relieve pain, although it is also able to help the body change its energy patterns to heal itself of organic syndromes and symptoms. In these treatments, Chinese traditional med- icine does not often distinguish energetic effects from physiologic effects. Herbal medicine and dietary therapies involve ingestion of substances or foods that may help with digestion and other organic functions.

Different Modalities, Different Aims

These various modalities of Chinese traditional medicine have dif- ferent aims. Some focus on balancing the body’s energy, whereas others focus on building the physical body and adding substances to balance and to change the body materially. Acupuncture is associated with balancing the body’s energy levels, whereas herbal substances are more like drugs or food in that they have specific organic effects. For example,

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within the Enhance herbal preparation* (used widely in both HIV and HCV), herbs are used to Tonify the Spleen Qi, and Build Xue. When there is Qi Tonification, the body is affected energetically by a rise in the amount of energy available for certain functions. Qi Tonic herbs often have the specific effects of increasing digestion and food absorption, thereby increasing the quality of the blood. In addition, breathing exer- cises are known to strengthen Qi (Qi is equivalent to the word for air in Chinese). With correct breathing, more oxygen becomes available to enter the bloodstream.

CHINESE TRADITIONAL MEDICINE AND HEPATITIS C VIRUS

In Western medicine, extremely harmful pathogens include severe bacterial or viral infections, such as HIV or HCV, but these terms are inappropriate in Chinese traditional medicine. Instead, Chinese medicine "recognizes the existence of Pestilences-called Zi qi or yi qi. These are diseases that are not caused by the climatic factors of Heat, Cold, Wind, Dampness, or Summer Heat dryness, but by external infectious agents . . . that are severely toxic because they strike directly at the interior of the body."3 In HCV, the particular pestilence is identified as toxic heat, which is considered by Chinese traditional medicine to be both an epidemic factor-something that is seen in a number of patients-and its own individual, treatable syndrome. For example different viral mani- festations such as in HIV and HCV may be called toxic heat. These viral entities are not identical invasions of toxic heat, however; they are each characterized by a different set of syndromes within which toxic heat is a part.

Chinese Traditional Medicine Diagnoses for Hepatitis C Virus

According Chinese traditional medicine, patients have experienced the various syndromes found in HCV for more than 2000 years. Chinese traditional medicine treatments for these syndromes that have been used over the past millennia are considered to be generally safe and effective for all patients. In both ancient China and in the modern world of new viral diseases such as HCV and HIV, Chinese traditional medicine also recognizes that people have individual constitutions and patterns of disease that exist in conjunction with age-old syndromes. Therefore, Chinese traditional medicine asserts that the best form of treatment is to modify, alter, or give adjuncts to the base therapies.

Chinese medical theory states that hepatitis is not a singular disease

*This herbal formula is designed by the author for clinical purposes and is formulated, produced, and distributed by Health Concerns, Oakland, California.

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but combinations of stages and syndromes. The diagnosis and staging of HCV is accomplished by using tongue diagnosis, pulse diagnosis, and questioning to determine if the patient’s initial Western diagnosis is consistent with Chinese medicine theory.

The Organ Systems primarily disturbed in hepatitis are the Liver Organ Systems and Spleen/Stomach Organ Systems. These disturbed Organ System patterns affect a person’s digestion and energy. According to Chinese traditional medicine, acute viral hepatitis is generally associ- ated with excess Damp Heat or Damp Cold conditions. Although in a few cases, a person infected with HCV may have or notice acute symp- toms, such symptoms are rare. The stages in Chinese medicine at which a patient is diagnosed with HCV are usually the chronic stages of Qi Stagnation and Qi and Yin Deficiency. Advanced chronic disease in- cludes a development of the patterns of Xue Stagnation and Xue Defi- ciency. All HCV is associated with the li qi (Pestilence/Epidemic Factor), Toxic Heat.

The Chinese traditional medicine syndromes in greater detail: for Toxic Heat include the symptoms of itching, sensations of heat, agitation, red spots and red body of the tongue, and a rapid pulse.

In addition, as displayed in the box, 10 traditional Chinese medical patterns are specifically associated with acute and chronic viral hepatitis.

Excess Syndromes generally associated with acute hepatitis and increased liver enzymes.

These (and additional syndromes that develop as liver disease progresses) may persist in chronic hepatitis.

Bright yellow faceleyes Fever Costal pain Jaundice Nausea Pulse: wiry Tongue: red with yellow greasy fur

2. Spleen Damp-Heat Bright yellow face Abdominal pain Nausea Jaundice Fever Decreased appetite Pulse: slippery Tongue: Red with yellow greasy fur

3. Spleen Damp-Cold Sallow yellow face Abdominal pain Nausea

1. Liver/Gallbladder Damp-Heat

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Feels cold, often has fever Decreased appetite Pulse: slippery Tongue: pale with greasy white fur

Excess Syndrome generally associated with chronic hepatitis 4. Qi Stagnation

Fatigue Costal pain Fullness in abdomen Nausea Flatulence/bloating Often increased liver enzymes Swollen liver and spleen Pulse: wiry Tongue: purplish or normal with thin white coat

Deficiency syndromes generally associated with chronic hepatitis 5. Spleen Qi Deficiency

Fatigue Abdominal tenderness Nausedqueasiness Lack of appetite Muscle weakness Loose stools Pulse: deficient Tongue: Pale swollen with toothmarks

6. Liver Yin Deficiency Dryness of eyes, nails, throat, and mouth Fatigue Blurry vision Dizziness Muscle spasms

Numb limbs Quick temper Pulse: thin, deficient, wiry, rapid Tongue: reddish sides and pale or reddish color of whole tongue

Fatigue Bleeding (such as purpura) Leg edema Ascites Pulse: deficient Tongue: pale, swollen

8. Yin Deficiency (General) Fatigue Reddish cheeks Nightsweats Afternoon fevers or hot flashes Restlessness Waking during night

I Reddish cheeks and eyes

7. Qi Deficiency (General)

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Pulse: thin, deficient, and rapid Tongue: reddish tip and pale or reddish color of whole tongue

Deficiency Syndrome often associated with cirrhosis 9. Xue (Blood) Deficiency

Pale and lusterless face General dryness Enzymes often normalize Shrunken liver Pulse: deficient and thready/hollow if loss of blood Tongue: pale

Excess Syndrome often associated with liver cancer (in addition to Defi- ciency Syndromes) 10. Xue (Blood) Stagnation

Sharp stabbing costal pain Abdomen hurts with movement Pulse: choppy or wiry (with pain) Tongue: purple or purple sides

CHINESE MEDICINE TREATMENTS FOR LIVER DISEASE AND HEPATITIS C VIRUS

Acupuncture

Chinese traditional medicine uses acupuncture extensively in the treatment of liver disease, including chronic viral hepatitis. The primary goal of acupuncture treatment is to readjust the body’s Qi6 to allow the body to heal itself. Therefore, acupuncture treatment can be used to treat specific symptoms and to treat a general Epidemic Pattern. After a Chinese traditional medicine diagnosis is given for a client with HCV, an acupuncture treatment plan is developed considering the epidemic nature of the disease, the individual presenting complaints, and any underlying constitutional Chinese traditional medicine patterns of ill- ness. On a symptomatic level, acupuncture treatment for HCV addresses the digestive functions, appetite, energy level, stress/anxiety/depression, pain associated with organic illness, and other complications. Acupunc- ture has also been used extensively at Quan Yin Healing Arts Center and other practices to lower elevated transaminase levels as part of a chronic hepatitis protocol using special points.

Moxi bustion

An important part of Chinese traditional medicine treatment in liver disease is the use of moxibustion. Moxibustion is the burning of common herb mugwort (called moxa in Chinese) over certain points or areas.

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Moxa is rolled into a cigarlike stick or used loose over protected skin to create warmth and tonification. When burned over certain points, moxa has been shown in Chinese studies to increase digestive function and increase white blood count and platelets; moxa may also have an effect on the transformation of T cells. It is often used for pain syndromes and areas that seem or feel cold on the body. Moxibustion is often prescribed for home use.

Qi Gong

Qi Gong meditation and exercise is a common practice in China and is growing in popularity in the United States among people who have HCV, HIV, and other life-threatening illnesses such as cancer. Many studies from China, Japan, Germany, and the United States show the positive effect of Qi Gong meditation on immune function. Quan Yin Healing Arts Center and many other locations around the United States offer medical Qi Gong classes specifically for people infected with HIV and HCV.

Dietary Therapy

A healthy diet is considered a key part of maintaining Original Qi and harmony in the body. Most Chinese traditional medicine prac- titioners recommend that people with digestive disorders-including dis- ease of the liver-eat a cooked warm diet and make recommendations based on the specific Organ Pattern diagnosis. For example, for patients with chronic diarrhea, the suggestion is to eat white rice (not brown rice) daily, especially in the form of an easy-to-make rice porridge called congee or j 0 0 k . ~

Chinese Herbal Medicine for Hepatitis C Virus

Chinese traditional medicine treatment for HCV infection depends on the stage of the disease and the syndromes involved. Using herbal medications in conjunction with rest and certain dietary recommenda- tions may treat acute hepatitis symptoms fairly rapidly. Chronic HCV is more difficult to treat. Research and experience from China and at Chinese medicine clinics in the United States suggests that a minimum of a 1-year course of Chinese traditional medicine therapy is needed to alter the progression of HCV. In the clinics at the Quan Yin Healing Arts Center and Chicken Soup Chinese Medicine, Chinese traditional medicine therapy for chronic HCV usually includes specific combina- tions of herbal preparations, which often are designed specifically for the disturbed Organ System patterns. For example, the combination of Enhance and Clear Heat (Health Concerns, Oakland, California) herbal formulas, tested in an herbal study at San Francisco General Hospital,

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were developed for treatment of HrV and other chronic viral disease. Newly designed Chinese herbal formulas such as Hepatoplex One and Hepatoplex Two (Health Concerns, Oakland, California) are currently being used in hepatitis C treatment.

Although herbs are generally used in balanced formulas in Chinese traditional herbal medicine, two herbs stand out in the treatment of liver disease and chronic hepatitis.

Licorice/Glycyrrhizin

Glycyrrhizin extract has many antiviral uses. Research has demon- strated that glycyrrhizin is effective against the hepatitis B virus.15 In Japan, clinical trials of glycyrrhizin in treating chronic active hepatitis have been so successful that glycyrrhizin is now a standard medical treatment there.", 17, 18, 22 According to the Pharmacology of Chinese Herbs, glycyrrhizin has also been found to be effective in the treatment of interferon-resistant chronic hepatitis C and gastric ulcers and to reduce capillary permeability, a problem in advanced stages of hepatitis.1°

Licorice can cause adverse reactions in about 20% of those who take it, XXII and the extract, glycyrrhizin, can be toxic.

Silybum marianum (Milk Thistle)

Silybum marianum is a Western herb recently adopted into the Chi- nese pharmacopoeia. According to Interactions, milk thistle is considered hepatoprotective, antihepatotoxic, hepatorestorative, antioxidant, hypo- cholesterolemic, and anticarcinogenic against epithelial malignancies." It is normally taken in a standardized extract of 70% to 80% silymarin, up to 900 mg/day. Minimal toxicity has been shown; sometimes mild diar- rhea occurs because of a laxative effect. The hepatoprotective activity of milk thistle was originally discovered through its protective effect against Arnanita pkalloides (deathcap mushroom) toxin poisoning. Most studies have focused on the isolated flavonolignan complex silymarin. Silymarin acts to stabilize hepatocyte membranes and block receptor binding of various toxins and drugs. In vivo and in vitro studies show that silymarin has free-radical scavenging activity and enhances superox- ide dismutase action in erythrocytes and lymphocytes. Silymarin also protects against glutathione depletion and increases protein synthesis by hepatocytes when there is damage to parenchymatous tissue. Animal studies suggest that silymarin is as effective as colchicine in reversing hepatic fibrosis caused by carbon tetrachloride (CCL)-induced damage. The anti-inflammatory effects of silymarin are also based on multiple activities, including mast cell stabilization, inhibition of neutrophil mi- gration, Kuppfer 's cell inhibition, and inhibition of leukotriene and prostaglandin formation.ll

According to Interactions, "Numerous clinical trials have demon- strated the effectiveness of Silybum for treatment of chronic alcoholic liver disease, cirrhosis, fatty liver disease and viral hepatitis according to metabolic markers (transaminase level reduction) as well as histologi-

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cal and clinical criteria. A recent study on advanced cirrhosis has found no effects on mortality in serious liver disease suggesting that Milk Thistle cannot reverse the progress or inevitable outcome of advanced cirrhosis.””

Herbs and Liver Toxicity

Chinese Pre-prepared Herbal Preparations

Herbal patent medicines, tonics, elixirs, and prepackaged solutions are particularly risky for anyone, whether they have liver disease or not. In the United States the Food and Drug Administration does not offi- cially regulate herbal medicines. Although many positive changes have recently been made in labeling regulations, and many herbal companies are beginning to abide by more stringent Good Manufacturing Practices (GMP) standards, ingredient labels are still far too often incomplete or mistranslated. This caveat especially applies to herbal pills which are often counterfeited as coming from reputable factories in China. These counterfeit formulas may not include all the ingredients stated on the package or may be more dangerous in that some herbs included may not be listed, may be incorrectly identified by the counterfeiters and added to the formulas, or may include unregulated pharmaceuticals. Herbalists and herb companies are becoming more self-regulating, and these companies and herbalists should be sought out when making decisions regarding herbs. Another problem arises when herbs that are dangerous or inappropriate in combination with other herbs are mistakenly used in the concoctions. Toxic herbs may be substituted for beneficial ones. Also, herbal ingredients that are generally harmless can cause liver damage in a very small group of allergic or intolerant individuals. Patients should avoid all self-prescribed premixed prepara- tions.

The practitioner should rely on and refer patients to the best-trained, most experienced, and recommended herbalist available to prescribe herbal therapies and monitor patients’ reactions. The National Commis- sion for the Certification of Acupuncture and Oriental Medicine (NCCAOM) can provide referrals to herbalists who are nationally certi- fied in Chinese herbology. In some states, testing in Chinese herbal medicine is included in the requirements for acupuncture licensure. Physicians and patients may contact the appropriate state regulatory agency (such as the state Acupuncture Board or Medical Board) for information on licensure information and referrals. Many states have professional organizations of Chinese medicine practitioners that can also make proper referrals.

Patients need to be particularly careful when combining herbs with interferon. Patients should discuss the potential reactions and interac- tions with both the Western and Chinese medicine practitioners before taking any medication or herbal remedy. Although universally liver- toxic substances are identifiable in the laboratory, liver hypersensitivity

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problems are not predictable. One person may experience no negative side effect from a medicinal substance, whereas another may have organ failure. Although hypersensitivity cannot be predicted in all cases, some indicators may offer clues as to which patients are vulnerable. Bsk factors include

Multiple allergies and previous adverse reactions to drugs or

A history of chronic skin rashes Liver disease Although herbs that benefit the liver are not harmful, it is recommended that patients with another, unrelated medical condition in addition to liver disease that is going to be treated with herbs, exercise extreme caution and monitor all possible adverse reactions carefully.) Any herb should be discontinued if a patient experiences a skin rash, substantial nausea, bloating, fatigue, or aching in the area of the liver, yellowing of the skin, or pale feces.

Sho-sai-koto. This Japanese herbal medicine preparation is known in Chinese herbal medicine as Xiao Chai Hu Tang and is used to improve hepatic dysfunction in chronic hepatitis. There are many reports of efficacy for chronic liver disease, and the preparation may be used successfully when there is a proper diagnosis and proper herbal follow- up. It is possible that the preparation seems to trigger interstitial pneu- monia in people with chronic HCV, particularly when used in combina- tion with interferon treatment. The herb Bupleurum (Chai Hu) may be the culprit and therefore should be used judiciously by trained herbalists in people with HCV.'*, l6

Jin Bu Huan. This formula for insomnia and pain caused some liver problems, but the exact trigger was never identified.

Ho Shou Wu. The medication, derived from Polygonurn rnultiflorurn, can trigger liver inflammation, skin rashes, and anaphylactic shock, probably because the herb contains anthraquinone compounds which are known liver toxins.

Aristolochia. This herb is used to treat fluid retention and rheumatic symptoms. It was banned in England after it was confused with an herb from the clematis plant that has the same name in Chinese as aristo- lochia: Mu Tong. The Mu Tong used was, in fact, the toxic species aristolochia rather than the other, harmless herb. Aristolochia was part of a formula implicated in 70 cases of kidney failure in Belgium in 1993.

herbs.

Common Toxic Ingredients Found in Preprepared Asian Patent Medicines

The Oriental Herbal Association has that reported the following contaminated preprepared pill and patent formulas contain heavy met- als, poisons, and other potentially liver-toxic substances:

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An Gong Niu Huang Wan-contains arsenic and mercury Bi Tong Pian-contains chlorpheniramine, an antihistamine Bi Yan Pian (Chung Lian Brand)-contains acetaminophen Dendrobum Moniliforme Farfunoeiminkam Wan-contains chlorpheniramine, an antihista-

Gan Mao Ling (Yang Chen)-contains chlorpheniramine, caffeine,

High strength Ym Chiao-contains chlorpheniramine, acetaminophen,

Huang Lien Shang Ching Pian-contains pulegone Ma Hsing Zhe Ke Pian-contains ephedrine, which can cause heart

Marguerite Acne Pills-contains sophoridane, an unknown medica-

Night Sight pills-contains mercury Niu Huang Chiang Ya Wan-contains mercury or lead in formula-

tions from various companies Pe Min Kan Wan (Chu Kiang, Yah Jiang)-contains acetaminophen,

chlorpheniramine, and phenylpropanolamine hydrochloride (in- creases blood pressure)

mine

acetaminophen

pulegone can trigger seizures, cerebral edema, and liver failure)

irregularities and convulsion

tion

Da Huo Luo Wan-contains mercury Shen Ling Bai Zhu Pian-contains isobomeol, a synthetic isomer of

borneol, a camphor-related compound Ta Huo Lo Tan-contains mercury and lead Tsai Tsao Wan-contains mercury Yin Chiao Chieh Tu Pian (Yang Cheng)-contains pulegone Zhi Sou Ding Chuan Wan-contains ephedrine and pseudoephedrine

(stimulants that can raise blood pressure and cause seizures) Zhong Gan Ling-contains aminopyrine and dipyrone that can lead

to fatal bone marrow toxicity and to agranulocytosis, an acute blood disease.

These premade formulations from certain companies outside the United States are contaminated with toxins; however, when trained herbalists compound them properly, they are safe. Also, the formulas used by companies adhering to GMP within or outside the United States are not contaminated. For example, Shen Ling Bai Zhu Pian from Tainjin Pharmaceutical Manufactory is listed because it contains isobomeol, an artifical isomer of borneol, a camphor-related compound. Shen Ling Bai Zhu San, however, is perfectly safe when made correctly in individual batches by a skilled herbalist.

Common Toxic Ingredients Found in Asian Patent Medicine

be on guard for these harmful ingredients: The Oriental Herbal Association warns that the practitioner should

Aconite, or aconitum-causes paralysis and death if not highly proc- essed before use

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Acorus-causes convulsions and death Borax-triggers severe kidney damage Borneol-triggers internal bleeding and death Cinnabar or calomel-a mercury compound Litharge and minium-contain lead oxide Myiabris-can trigger convulsions, vomiting, and death Orpiment or realgar-contains arsenic Scorpion or buthus-causes paralysis of the heart and death Strychnos nux vomica or semen strychni-strychnine-containing seeds

Toad secretion or bufonis-can paralyze heart muscle and lungs cause respiratory failure and death

Toxic Individual Herbs

According to Dr. David Diehl, herbal medicine is generally safe-safer than western pharmaceuticals. There are certain plants that are highly toxic; the most common examples are those that contain pyrolizidine alkaloids.” (David Diehl, MD, personal communication, 1998.) Those that contain alkaloids or are documented to have triggered toxic reactions include the following:

Amanita mushroom Chaparral (creosote bush, greasewood) Comfrey-taken internally Crotalaria (Ye Bai He) Eupatorium Germander-This toxic herb is often substituted for skullcap (scute)

and it is not toxic in well-formulated herbal remedies. The user should always insist that any ingredient identified as skullcap be the genuine article and not germander.

Groundsel (Senecio longilobus) Heliotropium Jin Bu Huan (Lycopodiurn serraturn) Mentha pulegium Mistletoe Pennyroyal (squawmint) oil or Hedeorna pulegoides Sassafras Senicio species Senna Sophora

Special Cases of Herbal Side Effects

Licorice/Glycyrrhizin

A mainstay of Chinese formulas, licorice is used in very small quantities to balance herbal action and often appears on the ingredient list as glycyrrhizin (licorice root). Licorice produces well-documented

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side effects such as hyperaldosteronism (an increase in levels of the adrenal hormone aldosteron, triggering imbalance of electrolytes) when taken in doses of more than 50-g/day or for 6 weeks or longer. No side effects have been seen when smaller doses were taken for more than 30 days or when higher doses were taken for a very short period of time.

According to the Pharmacology of Chinese Herbs,lo regular daily intake of 100 mg of glycyrrhizin or 50 g of licorice root may trigger disturbances in the body’s electrolyte balance, cause high blood pressure, reduce thyroid function, and produce other serious side effects. (Other research- ers caution against taking 50 g/day for 6 weeks or more.) They also caution that ”elderly persons who are susceptible to the effects of licorice may show rapid deterioration of renal (kidney) function.” Patients should not take glycyrrhizin if they have hypertension, fluid retention problems or disorders, or kidney disease, or during pregnancy. Some hazardous tonics include

Skullcap

Also called scutelleria, this herb is used in many formulas to good effect, but the toxic substance germander often is substituted for skullcap in formulas without being properly identified. As a result, skullcap looks like the offending substance. Several instances of skullcap toxicity are mentioned in the literature, but those mentions may in fact refer to unidentified substitutions of germander. Further research is needed to clarify this uncertainty (David Diehl, MD, personal communication, 1998). No formulation listing skullcap should be taken unless it can be ascertained that it, not germander, is in fact being used.

Dr. DieW. has found one mention of toxicity in the literature for the following herbs:

Calliepsis laureola, Atractylis Gunnifera, margosa oil, and valerian

Further research is needed.

(Valerian ojicinalis)

ANOTHER COMPLEMENTARY THERAPY NUTRITIONAL SUPPLEMENTS

For people diagnosed with liver disease, including HCV, using nutritional supplements is often a tricky business: Malnourishment is a problem when the liver can no longer metabolize nutrients properly, so supplementation might seem appropriate. On the other hand, the liver does not need to be burdened with another pill to process. Overtaxing the liver can do damage.

Determining what is safe and appropriate depends entirely on the health of the liver and the patient’s overall well-being. Therefore, the patient must consult with a well-informed physician, practitioner, or nutritionist before taking any supplement.

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Following are some common supplements and the recommended dosages for people who have not yet developed cirrhosis or other serious complications.

Lactobacillus Acidophilus

This organism, found in natural yogurt, is used to promote benefi- cial bacterial growth in the digestive tract and to suppress yeast (candidi- asis). The recommended dose is one fourth to one half teaspoon three times/day between meals. The best sources are powdered, refrigerated Lactobacillus acidophilus.

Multivitamin, Multimineral Supplement

According to the US Department of Agriculture, two thirds of Americans fail to get the Recommended Daily Allowance (RDA) of at least one vital nutrient, and those RDAs are fairly low. Most supplements supply doses far in excess of RDAs, and ongoing research indicates there are benefits from higher doses of many vitamins.

B Complex Vitamins

Sometimes B complex vitamins make people with hepatitis nause- ated, so a powered capsule form should be used if possible. The minerals in any multivitamin, multimineral supplement should include zinc, cal- cium, chromium, selenium, and copper. Patients should be careful not to take high doses of trace minerals without supervision of a trained practitioner or nutritionist. Niacin in high doses or in a long-acting form can cause a chemical hepatitis. Also, magnesium has a tendency cause diarrhea in persons with weak digestion and loose stools.

Low-dose Carotenoids

High doses of vitamin A can be liver toxic. Instead, people with liver disease should take beta-carotene or, preferably, mixed carotenoids, the nontoxic building block of vitamin A. The recommended dose is 5000 to 10,000 units/day.

Fat-soluble Vitamins

A patient with high bilirubin levels should be checked by the physician for blood levels of fat-soluble vitamins A, D, and K. If the

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levels are seriously low, high-dose supplements can be prescribed and the results carefully monitored.

Vitamin C

According to Chinese traditional medicine, vitamin C cools Toxic Heat, but a patient with diarrhea or loose stools (a common syndrome associated with HCV, as discussed previously) should not take vitamin C as a supplement. Vitamin C seems to work as an immune enhancer and an antioxidant that fights the ravages of free radicals that have been linked with heart disease and cancer. High doses of vitamin C may cause kidney stones in those who have a predisposition to the disorder. Vitamin C can erode tooth enamel, so it is important to rinse the mouth with clear water after taking powdered vitamin C. The recommended dosage is 60 mg/day.

Vitamin E

A patient who doesn’t digest oils well can take vitamin E in the dry form. The recommended dosage is 400 to 1200 IU/day.

Essential Fatty Acid

One tablespoon a day of flaxseed oil, raw sesame oil, or evening primrose oil is often used to decrease symptoms of fibromyalgia.

Testosterone Deficiency

Testosterone deficiency can arise in men with chronic liver disease, especially if they have cirrhosis. If the testosterone level is determined to be deficient, oral or transdermal injections can be administered to improve bone integrity and sexual function.

Low-dose Estrogen

Low-dose estrogen supplementation is a Western medical option suggested for postmenopausal women. Dr. Robert Gish considers that oral or transdermal estrogens are safe and do not cause a significant risk of liver injury unless the patient has unusual liver tumors such as adenomasZ3

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Iron

Because iron supplements can be liver toxic, they are not recom- mended unless prescribed to counter a diagnosed iron deficiency. Iron deficiency is common in people with liver disease because of the internal bleeding that can occur. If blood tests reveal iron deficiency, a prac- titioner may want to prescribe iron supplements.

Zinc

Zinc supplements enhance wound healing, may boost the immune system, and are used to lower blood ammonia levels in people with cirrhosis and encephalopathy.

USE OF EASTERN AND WESTERN THERAPIES TOGETHER

If the person with liver disease including HCV and the patient’s Eastern and Western practitioners decide to use a combination of Eastern and Western therapies, it is wise to discuss the specific treatment ap- proaches with both the Eastern and Western practitioners. Some Chinese herbal therapies, Western herbal therapies, or nutritional supplements may be inappropriate in severe liver disease or in conjunction with interferon therapy.

Chinese traditional medicine and other CAM therapies, however, may be very useful and are often highly effective in the management of side effects of drug therapies. In some cases, these therapies may be used as an alternative to Western pharmaceutical treatments. Clinical trials are absolutely necessary to measure efficacy for many of these treatments and to study safety issues.

ACKNOWLEDGMENT

The author thanks David Diehl, MD, FACP, associate clinical professor of medicine at The University of California at Los Angeles/School of Medicine, for his help in the section discussing herbs and liver toxicity.

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