More reports of potential hepatotoxicity of Herbalife products: Reply
Authors: Daniel Shouval, Eran Elinav
Journal: Journal of Hepatology (2008)

The Letter to the Editor by Manso and colleagues from Spain [[1]Manso G, López-Rivas L, Duque JM, Salgueiro E. Spanish reports of hepatotoxicity associated with herbalife® products. J Hepatol, in press.Google Scholar] reiterates the deep concern recently raised [2Elinav E. Pinsker G. Safadi R. Pappo O. Bromberg M. Anis E. et al.Association between consumption of Herbalife® nutritional supplements and acute hepatotoxicity.J Hepatol. 2007; 47: 514-520Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar, 3Schoepfer A.M. Engel A. Fattinger K. Marbet U.A. Criblez D. Reichen J. et al.Herbal does not mean innocuous: ten cases of severe hepatotoxicity associated with dietary supplements from Herbalife® products.J Hepatol. 2007; 47: 521-526Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar, 4Stickel F. Slimming at all costs: Herbalife®-induced liver injury.J Hepatol. 2007; 47: 444-446Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar] regarding the potential hepatotoxicity of one or more Herbalife™ products. This report adds 4 more patients to the already described 22 patients from two countries, who developed a variable degree of liver injury in association with the intake of Herbalife™ products. Two of the Spanish patients developed quite severe hepatitis with jaundice and 3/4 recovered after stopping intake of the products. Although the information provided is not complete, causality may be established in at least two cases as probable and in the remaining two cases as possible, based on the same criteria as reported in Ref. [2Elinav E. Pinsker G. Safadi R. Pappo O. Bromberg M. Anis E. et al.Association between consumption of Herbalife® nutritional supplements and acute hepatotoxicity.J Hepatol. 2007; 47: 514-520Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar, 3Schoepfer A.M. Engel A. Fattinger K. Marbet U.A. Criblez D. Reichen J. et al.Herbal does not mean innocuous: ten cases of severe hepatotoxicity associated with dietary supplements from Herbalife® products.J Hepatol. 2007; 47: 521-526Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar, 4Stickel F. Slimming at all costs: Herbalife®-induced liver injury.J Hepatol. 2007; 47: 444-446Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar].The development of hepatitis in two sisters, one of whom has or progressed to chronic hepatitis, is an important observation which may shed further light on the potential mechanism of hepatotoxicity in these sisters. Although it cannot be established for certain if autoimmunity or a pharmaco-genetic preponderance is the driving force behind these events, the reactive hepatitis in the two sisters suggests a common mechanism. Dr. Manso et al. raise the possibility that green tea or aloe vera ingredients, previously reported to induce hepatotoxicity may also be the cause in the Spanish group of patients. However, these ingredients were not taken uniformly by all the reported patients from Israel and Switzerland, and therefore a detailed list of all the ingredients including the chemical composition is required as stated in the two original reports. In Spain as well as in Israel and Switzerland, it was not possible to establish the true incidence of hepatotoxicity among Herbalife™ users since the number of consumers and their demographic characteristics are only partially known. A rough calculation suggested an incidence of 25–30 cases per 100,000 Herbalife™ products among Israeli consumers. We agree with the colleagues from Spain that the true incidence may be higher since liver injury may remain occult and asymptomatic as is well known by practising hepatologists. Thus, it is important to draw the attention of the Journals readers to reports of similar cases.