Reply to: “Herbal medicine hepatotoxicity revisited”
Authors: Dominique Larrey, Stéphanie Faure
Journal: Journal of Hepatology (2011)

Herbal medicine hepatotoxicity revisitedJournal of HepatologyVol. 56Issue 2PreviewIn the April 2011 issue of the Journal of Hepatology, an editorial discussed hepatotoxicity associated with the use of herbal preparations [1]. The focus of the article is primarily on the need to develop specific biomarkers for compounds or ingredients suspected to be associated with hepatotoxicity in order to establish clinical specificity when determining if a relationship exists between an adverse event and the consumption of these agents. We agree that identification methods are crucial to product safety and the industry continues to develop and validate identification methods for many commercialized ingredients. Full-Text PDF Open AccessHerbal medicine hepatotoxicity: A new step with development of specific biomarkersJournal of HepatologyVol. 54Issue 4PreviewHepatic impairment resulting from the use of conventional drugs is widely acknowledged, but there is less awareness of the potential hepatotoxicity of alternative medicines such as herbal preparations [1]. The increasing attraction for herbals medicines is partly explained by the return to natural products occurring along with the ecological movement in industrialized countries [1]. It is also related to the limited efficacy or the important side effects of treatments of various chronic diseases [1–5]. Full-Text PDF Open Access The author's letter states that the mention of some instances of herbal medicines is immaterial in the context of the article's discussion. We do not agree with this view for the following reasons. The interest in biomarkers is particularly important for complex herbal medicines and dietary supplements with reports of hepatotoxicity. Herbalife® is one, well illustrated example, which is supported by at least six peer-review publications [1Elinav E. Pinsker G. Safadi R. 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 (101) Google Scholar, 2Schoepfer A.M. Engel A. Fattinger K. et al.Herbal does not mean innocuous: 10 cases of severe hepatotoxicity associated with dietary supplements from Herbalife® products.J Hepatol. 2007; 47: 521-526Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar, 3Duque J.M. Ferreiro J. Salgueiro E. Manso G. Hepatotoxicity associated with the consumption of herbal slimming products.Med Clin (Barcelona). 2007; 128: 238-239Crossref PubMed Google Scholar, 4Chao S. Anders M. Turbay M. et al.Toxic hepatitis by consumption Herbalife products a case report.Acta Gastroenterol Latinoam. 2008; 38: 274-277PubMed Google Scholar, 5Stickel F. Droz S. Patsenker E. et al.Severe hepatotoxicity following ingestion of Herbalife nutritional supplements contaminated with Bacillus subtilis.J Hepatol. 2009; 50: 111-117Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 6Johannsson M. Ormarsdottir S. Olafsson S. Hepatotoxicity associated with the use of Herbalife.Laeknabladid. 2010; 96: 167-172PubMed Google Scholar] and a recent review gathering no less than 30 cases [[7]Stickel F. Kessebohm K. Weimann R. Seitz H.K. Review of liver injury associated with dietary supplements.Liver Int. 2011; 31: 595-605Crossref PubMed Scopus (91) Google Scholar]. The causality of several products sold under the brand name «Herbalife®» has been assessed by using internationally recognized criteria (WHO score, RUCAM) and has been analysed as certain (positive rechallenge) or probable in a large number of these cases [1Elinav E. Pinsker G. Safadi R. 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 (101) Google Scholar, 2Schoepfer A.M. Engel A. Fattinger K. et al.Herbal does not mean innocuous: 10 cases of severe hepatotoxicity associated with dietary supplements from Herbalife® products.J Hepatol. 2007; 47: 521-526Abstract Full Text Full Text PDF PubMed Scopus (146) Google Scholar, 3Duque J.M. Ferreiro J. Salgueiro E. Manso G. Hepatotoxicity associated with the consumption of herbal slimming products.Med Clin (Barcelona). 2007; 128: 238-239Crossref PubMed Google Scholar, 4Chao S. Anders M. Turbay M. et al.Toxic hepatitis by consumption Herbalife products a case report.Acta Gastroenterol Latinoam. 2008; 38: 274-277PubMed Google Scholar, 5Stickel F. Droz S. Patsenker E. et al.Severe hepatotoxicity following ingestion of Herbalife nutritional supplements contaminated with Bacillus subtilis.J Hepatol. 2009; 50: 111-117Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 6Johannsson M. Ormarsdottir S. Olafsson S. Hepatotoxicity associated with the use of Herbalife.Laeknabladid. 2010; 96: 167-172PubMed Google Scholar, 7Stickel F. Kessebohm K. Weimann R. Seitz H.K. Review of liver injury associated with dietary supplements.Liver Int. 2011; 31: 595-605Crossref PubMed Scopus (91) Google Scholar]. We appreciate that the manufacturer has made great efforts to cooperate with health agencies and to produce the safest possible product. The fact that the manufacturer did not identify toxic products does not exclude the role of a particular component or an unexpected contaminating product in the overall preparation, particularly when the composition is fairly complex. Furthermore, there are numerous examples of «classical» drugs associated with very well documented cases of liver idiosyncratic reactions in a small proportion of subjects, for which extensive toxicological studies did not disclose any specific risk [[8]Senior J.R. What is idiosyncratic hepatotoxicity? What is not?.Hepatology. 2008; 47: 1814-1815Crossref Scopus (33) Google Scholar]. So, an idiosyncratic reaction with one of the components of Herbalife® is a reasonable possibility. The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.