a cautionary note
Symptomatic liver injury (hepatotoxicity) associated with administration of complementary and alternative products (Ayurveda-AP-Mag Capsules) in a beta-interferon treated multiple sclerosis patient (2011)
https://onlinelibrary.wiley.com/doi/abs ... 11.03373.x
Sir,
We report a case of hepatotoxicity (elevated biochemical liver enzymes) suspected to be associated with supplementation of Ayurveda-AP Mag (Ayush Herbs, Redmond, WA, USA) (containing
Azadirachta indica and
Momoridica charantia), in a patient with relapsing–remitting multiple sclerosis (RRMS) who was also treated with beta-interferon.
...
She had started her first disease-modifying therapy, beta-interferon-1a (Avonex 30 mcg/wk intra-muscular; Biogen Idec, Cambridge, MA, USA) 6 years previously and had tolerated drug well.
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After consulting with a 'naturopathic doctor' for her MS, she started taking a mixture of complementary and alternative medicines (CAMs), including: Human Micro Flora (HMF) Powder, Ayurveda-AP Mag Capsules (Ayush Herbs), Ayurveda-Ashwagandha Capsules (Ayush Herbs), AyurvedaLivit 2 Tablets (Ayush Herbs), Thorne research-L-Glutamine Dietary Supplement Capsules (Thorne Research, Sandpoint, ID, USA) and Thorne Research MediClear-Multi VitaminMineral Supplement (Thorne Research).
Prior to taking these CAMs, her biochemical liver test results were unremarkable (within normal range). ...
One month after initiation of the multiple CAMs products, she presented with symptoms of pruritus, fatigue, feelings of malaise, and gastrointestinal symptoms.
Her liver panel was:
...
ALT = 886 (N < 50 U/l; 18 times the upper normal limit);
AST = 406 (N < 35 U/l; 11 times the upper normal limit).
She was advised to discontinue both beta-interferon and the CAMs. Her liver panel was repeated 4 days later; results were similar, and ALT had risen a little further
to 19 times the upper normal limit. Three weeks later, her liver laboratory values were repeated; all had returned to below the upper normal limit.
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Each CAM product was examined for its potential to cause hepatotoxicity. Two ingredients in the Ayurveda-AP-Mag capsules were associated with liver injury:
Azadirachta indica and
Momoridica charantia. The former has been used in pesticides and was associated with hepatotoxic effects in animals and humans (including jaundice) [1,2]. Administration of
Momoridica charantia has been associated with elevated biochemical liver test results (GGT and AP) in animal studies [3,4].
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Based on the limited published literature, the most likely causative agent(s) appear to be
Momoridica charantia and
Azadirachta indica [1–4], although few studies in humans could be found. Given the potential seriousness of the adverse event, the patient was advised not to re-challenge.
Our patient was also exposed to beta-interferon, which has an established association with liver injury [5]. However, as she had tolerated beta-interferon well for the previous 6 years, this appeared unlikely as the direct causative agent. We cannot rule out that a beta-interferon-CAM interaction precipitated the adverse event. Viral serology for hepatitis A, B, and C were negative, as were autoimmune and the other metabolic markers tested; these, coupled with the presenting clinical features, excluded an autoimmune-related hepatic event.
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Naturopathic doctors (NDs) in British Columbia have their own regulating body and licensing exams. We were unable to verify whether this patient consulted a registered practitioner.
