Fulminant hepatitis during self-medication with conjugated linoleic acid

The present report describes a 63-year-old female who presented with fulminant hepatic failure requiring liver transplantation caused by a weight loss dietary supplement containing conjugated linoleic acid (CLA). Thorough investigation, including liver biopsy, revealed no other cause of hepatotoxicity. In the last few years, a considerable number of reports have been published on toxic hepatitis, associated with non-conventional products, attributed with weight-reducing properties. We emphasize the importance of taking a cautious approach when consuming herbal supplements for the purpose of weight loss, as all that is "natural" may not always be healthy. Only one report of CLA-induced toxic hepatitis is related in the medical literature.     

Acute liver failure caused by 'fat burners' and dietary supplements: a case report and literature review

Globally, people are struggling with obesity. Many effective, nonconventional methods of weight reduction, such as herbal and natural dietary supplements, are increasingly being sought. Fat burners are believed to raise metabolism, burn more calories and hasten fat loss. Despite patient perceptions that herbal remedies are free of adverse effects, some supplements are associated with severe hepatotoxicity. The present report describes a young healthy woman who presented with fulminant hepatic failure requiring emergent liver transplantation caused by a dietary supplement and fat burner containing usnic acid, green tea and guggul tree extracts. Thorough investigation, including histopathological examination, revealed no other cause of hepatotoxicity. The present case adds to the increasing number of reports of hepatotoxicity associated with dietary supplements containing usnic acid, and highlights that herbal extracts from green tea or guggul tree may not be free of adverse effects. Until these products are more closely regulated and their advertising better scrutinized, physicians and patients should become more familiar with herbal products that are commonly used as weight loss supplements and recognize those that are potentially harmful.     

Liver Injury from Herbal,Dietary, and Weight Loss Supplements: a Review

Herbal and dietary supplement usage has increased steadily over the past several years in the United States. Among the non-bodybuilding herbal and dietary supplements, weight loss supplements were among the most common type of HDS implicated in liver injury. While drug induced liver injury is rare, its consequences are significant and on the rise. The purpose of this review is to highlight case reports of weight loss products such as Hydroxycut and OxyElite Pro as one form of HDS that have hepatotoxic potential and to characterize its clinical effects as well as pattern of liver injury. We also propose future strategies in the identification and study of potentially hepatotoxic compounds in an effort to outline a diagnostic approach for identifying any drug induced liver injury.     

Fulminant liver failure due to usnic acid for weight loss

The use of complementary and alternative medicine (CAM) in developed countries has increased significantly over the years. Among the most popular are the weight loss supplements or "fat burners." Liver failure due to these popular remedies has been widely recognized. Usnic acid has been an ingredient of dietary supplements that cause liver failure. Its hepatotoxicity has not been recognized because it is usually mixed with other ingredients that are presumably hepatotoxic. We describe a case of a 28-yr-old woman who presented with fulminant liver failure requiring orthotopic liver transplantation, after taking pure usnic acid for weight loss. This is the first report on fulminant liver failure associated with the ingestion of pure usnic acid. A discussion about hepatotoxicity of the different compounds of dietary supplements is presented. This is a reminder for the clinicians about the potential side effects of CAM.     

Dangerous dietary supplements: Garcinia cambogia-associated hepatic failure requiring transplantation

Commercial dietary supplements are marketed as a panacea for the morbidly obese seeking sustainable weight-loss. Unfortunately, many claims cited by supplements are unsupported and inadequately regulated. Most concerning, how ever, are the associated harmful side effects, often unrecognized by consumers. Garcinia cambogia extract and Garcinia cambogia containing products are some of the most popular dietary supplements currently marketed for weight loss. Here, we report the first known case of fulminant hepatic failure associated with this dietary supplement. One active ingredient in this supplement is hydroxycitric acid, an active ingredient also found in weight-loss supplements banned by the Food and Drug Administration in 2009 for hepatotoxicity. Heightened awareness of the dangers of dietary supplements such as Garcinia cambogia is imperative to prevent hepatoxicity and potential fulminant hepatic failure in additional patients.     

STEMI in a 24-Year-Old Man after Use of a Synephrine-Containing Dietary Supplement: A Case Report and Review of the Literature

Billions of dollars are spent annually in the United States in the largely unregulated market of dietary supplements. Many of these supplements are marketed as weight-loss and athletic-performance-enhancement products. The association of various ephedra-containing products with adverse cardiovascular events has led to a ban on the sale of these products by the U.S. Food and Drug Administration. The result has been the emergence of new formulations marketed for weight loss and athletic-performance enhancement that are “ephedra-free” but contain other sympathomimetic substances, the safety of which has not been established.We present the case of a previously healthy 24-year-old man who presented with an ST-segment-elevation myocardial infarction (STEMI) within hours of taking the ephedra-free product Nutrex Lipo-6x®. Emergent coronary angiography revealed the presence of extensive, diffuse thrombus in the left anterior descending coronary artery. The patient had no risk factors for coronary artery disease or myocardial infarction; this includes the absence of a hypercoagulable state and the absence of a history of illicit drug use. This case of STEMI—associated as it is with the use of a synephrine-containing product by a person without risk factors for coronary artery disease—is to our knowledge the 1st reported in the literature. We discuss the patient''s evaluation and clinical course, and we review the literature with respect to synephrine-containing dietary supplements. On the basis of synephrine''s chemical composition and mechanism of action, we propose a direct association between this patient''s use of Nutrex Lipo-6x^® and his STEMI.Key words: Citrus/adverse effects, coronary vasospasm/complications/etiology, dietary supplements/adverse effects/poisoning, myocardial infarction/chemically induced, plant preparations, synephrine, weight loss/drug effects, United States Food and Drug AdministrationEach year in the United States, over $20 billion is spent on dietary supplements, a significant proportion of which are marketed as weight-loss and athletic-performance-enhancement products. Severe neurologic and cardiovascular complications—including stroke, seizure, myocardial infarction, and sudden death^1,2—have been reported in association with ephedra and ephedrine-alkaloid-containing supplements. A major study has reported more than 16,000 adverse events associated with the use of ephedra-containing dietary supplements.³ As a result, the U.S. Food and Drug Administration (FDA) determined that ephedra and ephedrine-containing supplements are unsafe for unregulated use and prohibited their sale beginning in April 2004.⁴The result has been the emergence of new formulations marketed for weight loss and athletic-performance enhancement that are “ephedra-free” but contain other sympathomimetic substances, the safety of which has not been established. Many of these products contain synephrine, a sympathetic adrenergic agonist that is structurally related to ephedrine.Although an expanding body of literature reports adverse cardiovascular outcomes in association with the use of synephrine-containing products, the case reported here is, to our knowledge, the 1st in which a person with no history of identifiable cardiovascular risk factors experienced STEMI shortly after ingesting a synephrine-containing dietary supplement. We provide a review of the literature to date, discuss the pharmacologic actions of synephrine, and implicate synephrine as the possible causative agent, on the basis of its mechanism of action, for this case of ST-segment-elevation myocardial infarction (STEMI).     

Revisiting acute liver injury associated with herbalife products

In the November 27,2010 issue of the World Journal of Hepatology (WJH),three case reports were published which involved patients who had consumed various dietary supplements and conventional foods generally marketed as weight loss products.The reference to Herbalife products as contaminated and generally com-parable to all dietary supplements or weight loss prod-ucts is not scientifically supported.The authors provided an insufficient amount of information regarding patient histories,concomitant medications and other com-pounds,dechallenge results,and product specifications and usage.This information is necessary to fully assess the association of Herbalife products in the WJH case reports.Therefore,the article does not objectively sup-port a causal relationship between the reported cases of liver injury and Herbalife products or ingredients.     

Green tea extract:A potential cause of acute liver failure

The use of herbal products has increased significantly in recent years.Because these products are not subject to regulation by the Food and Drug Administration and are often used without supervision by a healthcare provider,the indication for and consumption of these supplements is quite variable.Moreover,their use is generally regarded as safe and natural by the lay-public.Unfortunately,there has been an increase in the number of reported adverse events occurring with the use of herbal products.We present a case of acute impending liver failure in an adolescent male using a weightloss product containing green tea extract.Our case adds to the growing concern surrounding the ingestion of green tea extract and serves to heighten healthcare provider awareness of a potential green tea extract hepatotoxicity.Despite the generally touted benefits of green tea as a whole,clinical concern regarding its use is emerging and has been linked to its concentration in multiple herbal supplements.Interestingly,the suspected harmful compounds are those previously proposed to be advantageous for weight-loss,cancer remedy,and anti-inflammatory purposes.Yet,we emphasize the need to be aware of not just green tea extract,but the importance of monitoring patient use of all dietary supplements and herbal products.     

How Physicians Should Evaluate Dietary Supplements

Dietary supplements occupy a unique niche within the realm of modern medicine. These products are often used by patients at their own discretion, in an unmonitored setting, and without the input of their physicians. Although laws pertaining to dietary supplement labeling prohibit specific claims for the treatment or prevention of disease, these products are widely used as “alternative” or “complementary” therapy. Dietary supplements are readily available, not classified as over-the-counter medications, and not regulated as such. Patients and providers alike often assume these products are at least safe and possibly effective. Historically, dietary supplement pharmacodynamic and pharmacokinetic data have been limited and of meager quality. Information on dietary supplements in nonmedical literature is typically unreliable, and even in the medical literature, numerous studies have used products that were not well characterized. Although greater attention has recently focused on dietary supplement quality and integrity, complex issues persist and must be addressed when evaluating literature and advising patients. We seek to clarify many of these issues and make practical suggestions for the clinician.     

Acute liver failure associated with Garcinia cambogia use

Millions of Americans regularly use herbal supplements, but many are unaware of the potential hidden dangers. Numerous supplements have been associated with hepatotoxicity and, indeed dietary/herbal supplements represent an increasingly common source of acute liver injury. We report a case of acute liver failure requiring liver transplantation associated with the use of Garcinia cambogia, a supplement widely promoted for weight loss. When patients present with acute hepatitis or liver failure from an unknown etiology, a careful history of supplement use should be performed.     

Acute liver injury induced by weight-loss herbal supplements

We report three cases of patients with acute liver injury induced by weight-loss herbal supplements. One patient took Hydroxycut while the other two took Herbalife supplements. Liver biopsies for all patients demonstrated findings consistent with drug-induced acute liver injury. To our knowledge, we are the first institute to report acute liver injury from both of these two types of weight-loss herbal supplements together as a case series. The series emphasizes the importance of taking a cautious approach when consuming herbal supplements for the purpose of weight loss.     

Americans' views on the use and regulation of dietary supplements

This article presents the views of Americans on what the government's future role should be in regulating or overseeing the growing sales of dietary supplements for health purposes. Based on results of multiple national opinion surveys, including the views of both users and nonusers of supplements, we found that a substantial percentage of Americans surveyed reported that they regularly take dietary supplements as a part of their routine health regimen. However, they reported that they do not discuss the use of dietary supplements with their physicians because they believe that the physicians know little or nothing about these products and may be biased against them. Many users felt so strongly about the potential health benefits of some of these products that they reported that they would continue to take them even if they were shown to be ineffective in scientifically conducted clinical studies. However, there also was broad public support for increased government regulation of these products. We found that a majority of Americans surveyed supported the following: to require that the Food and Drug Administration review the safety of new dietary supplements prior to their sale; to provide increased authority to remove from sale those products shown to be unsafe; and to increase government regulation to ensure that advertising claims about the health benefits of dietary supplements are true.     

Cardiovascular effects of ephedra alkaloids: a comprehensive review

The Ephedra alkaloids have received much press lately secondary to reported adverse events in those using whole extracts as "dietary supplements" for weight loss or athletic performance enhancement. These reports are troubling given the increasing use of these supplements by the general public. We reviewed the available literature as well as online material on these compounds, including information on their pharmacology, regulation, effects on weight loss and athletic performance, and adverse events. Extracts of Ephedra shrubs contain highly active alpha- and beta-adrenergic agonists that have profound effects on the heart and vasculature. Evidence for their effectiveness is limited. Adverse cardiovascular and cerebrovascular effects, including stroke, myocardial infarction, and sudden death, temporally related to their use are well described. The recent Food and Drug Administration ban on these compounds is not broad enough. Ephedra supplements contain a highly bioactive class of compounds that pose a significant risk to the public under the current regulatory framework. More stringent oversight by regulatory authorities is required to minimize the incidence of adverse events.     

Catechins in Dietary Supplements and Hepatotoxicity

Background

Many herbal dietary supplements (HDS) contain green tea extract (GTE) and its component catechins, although their presence may not always be indicated on the product label.

Purpose

Because GTE and catechins have been implicated in human hepatotoxicity in several case reports, our objective was to determine whether catechins were present in HDS that were implicated in hepatotoxicity, even if not identified among the labeled ingredients, and whether these compounds could be associated with liver injury.

Methods

We assayed 97 HDS implicated in human hepatotoxicity for catechins.

Results

We found that 29 of 73 HDS (39.7 %) that did not identify GTE or any of its component catechins on their label contained catechins. Among patients with confirmed hepatotoxicity, there was no statistically significant association between the presence of catechin or the dose consumed and liver injury causality score, severity, or pattern of liver injury. Catechin levels tended to be highest in products used for weight loss, although catechin concentrations were low in most products.

Conclusions

Many HDS commonly contain catechins that are implicated in hepatotoxicity, although their presence may not be indicated on the product label. Although our results did not establish an association between GTE or catechins with hepatotoxicity, they highlight some of the many complexities and uncertainties that surround the attribution of drug-induced liver injury (DILI) to HDS.     

Hepatotoxicity induced by herbs and medicines used to induce weight loss

In the last few years, a considerable number of reports have been published on hepatotoxicity associated with herbal products attributed with weight-reducing properties. Clinical expression of hepatotoxicity has ranged from symptoms of self-limiting hepatitis, indistinguishable from those caused by the hepatitis viruses, to forms of fulminant hepatitis causing death or requiring liver transplantation. These products, which are sold as dietary products or supplements, do not undergo the safety tests required of drugs before their release on to the market. To prevent the toxic effects of herbal products, the general public should be made aware of their harmful effects and since the benefits of these products have not been demonstrated avoid their use, while physicians should strongly discourage patients from taking these products. Authorization of the commercialization of all these natural products should be strictly regulated to minimize the harm they can cause.     

Perceptions of dietary supplements among older women with diabetes

PURPOSE: The purpose of this qualitative study was to explore the meaning of taking dietary supplements from the perspective of being an older woman with type 2 diabetes. METHODS: Nine women over the age of 65 with type 2 diabetes participated in a single, in-depth semistructured interview that focused on use of, views of, and methods of hearing about supplements. Interviews were audiotaped, transcribed verbatim, and analyzed using phenomenological methodology. RESULTS: Eight of the 9 participants used some form of dietary supplement daily. Respondents described methods of hearing about supplements ranging from their daughters to the media to "people talk." Individual supplements were used primarily to prevent or treat conditions related to aging, such as osteoporosis, arthritis, and vision loss. They were also taken to prevent or lessen conditions associated with diabetes, including heart disease. CONCLUSIONS: The older women with type 2 diabetes in this study used dietary supplements. However, taking supplements was not perceived as a means of controlling blood glucose and, as such, supplements were not taken as part of their diabetes treatment regimen.