Primary Care Corner with Geoffrey Modest MD: Herbal/dietary supplements and liver injury

By: Dr. Geoffrey Modest

There was a rather disturbing article in the journal Hepatology showing increasing hepatoxicity from herbals and dietary supplements (HDS) (see DOI: 10.1002/hep.27317). The report is from the Drug-Induced Livery Injury Network (DILIN, supported by National Institute of Diabetes and Digestive and Kidney Diseases), reporting on the findings in 8 US referral centers (including centers in California, Connecticut, Indiana, Michigan, Minnesota, North Carolina, Pennsylvania, taxes), assessing consecutive patients from 2004-2013 with hepatoxocity from either medications or HDS, a total of 839 patients. attribution of cause of hepatotoxicity was from expert opinion, including biochemical evidence of hepatic injury with assessment for viral or autoimmune hepatitis, checking serum ceruloplasmin, iron studies, and a-1 antitrypsin, and reviewing biopsy if available.


–130 patients (15.5%) with liver injury from HDS, 709 from medications

–The incidence of HDS hepatotoxicity increased from 7% to 20% over the 10-year observation period

–Of the HDS cases, 45 were from bodybuilding HDS and 85 from non-bodybuilding

–Bodybuilding HDS cases were exclusively in men (median age 31) and were milder: prolonged jaundice (median 91 days), but no fatalities or liver transplants.

–Non-bodybuilding HDS cases mostly in middle-aged women (median age 47, 65% women), and more frequently led to death or liver transplantation as compared to medication-induced hepatotoxicity (13% vs 3%)

So, this seems to be a very real problem, even though this is not a rigorous population-based study. more than 1/2 the US population consumes HDS. Although overall the consumption is highest in non-Hispanic white women >40yo and with higher levels of education, my experience is that use of these supplements is very common in our multicultural poor inner-city community. I see a lot of young men taking testosterone and other body-building HDS, and many people who buy TV-advertised (and quite expensive) supplements (ie, I don’t think this is only a white middle-class issue).  There are even data that taking multivitamins are not helpful in general population. The Physicians Health Study II of 14,641 men >50yo and followed 11.2 years found no benefit of multivitamins on major cardiovascular events or total mortality, even if they had baseline history of coronary artery disease (see JAMA. 2012;308(17):1751-1760) and another study of 1700 people, 82% men, taking multivitamins after an MI and followed 55 months similarly found no benefit (see Ann Intern Med. 2013;159:797-804)  all of this confirms the oft-repeated concept (by me, at least) that we should be eating well and exercising, not looking to micro- or macro-nutrient additions to improve health (ie, there is no easy fix….).

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