Herbal medicine and liver toxicity

Recently, two major medical journals have published papers on herbal medicine products.

Recently, two major medical journals have published papers on herbal medicine products. The Annals of Internal Medicine published a statement from CONSORT (Consolidated Standards of Reporting Trials)[1] advocating for standardized reporting of clinical studies with Chinese herbal medicine, and an accompanying editorial[2] highlighting the need for conformity with acceptable scientific reporting practices. Coincidently, the CMAJ published an editorial[3] expressing concern about the suboptimal regulation of these products in Canada with an appeal for better government regulation, especially with regard to claims of efficacy and the current lack of need to provide scientific proof of these claims.

This summer, the Liver Transplant Program of Vancouver General Hospital (VGH) needed to urgently assess and transplant two patients transferred from community hospitals with acute fulminant liver failure. Both patients were previously healthy: one was middle-aged; the other was young. Both presented with coagulopathy, jaundice, hepatorenal syndrome, and hepatic encephalopathy of new onset. In both cases the cause of the acute liver failure was enigmatic prior to transfer to VGH, and the discovery of the significant use of herbal products was made by the liver transplant team’s allied health care professionals. Although one of the two patients was also on a prescription antidepressant, it was strongly felt that the herbal factors were the significant factors in the acute liver failure. The products used were traditional Chinese herbal medicine in one case and traditional Indian herbal products in the other. In both cases, the herbal products were combination products, obtained commercially.

These two tragedies could have been avoided, and it behooves physicians to be aware of what nonprescription products their patients are consuming and the associated risks. It is often assumed that these products are safe, even though the efficacy is questionable. Drug-induced liver injury from these products is not uncommon. In China, such injury from Chinese herbal medicine is estimated to be 25% of all reported cases (unpublished work from Dr Qi Xing-shun, General Hospital Shenyang Military District, 8 August 2017).

Given the safety implications, we also strongly feel that regulation of these products, on either the federal or provincial level, needs to be consistent with that applied to the pharmaceutical industry. Moreover, the public needs to be made aware of the potential dangers of these products.
—Eric M. Yoshida, MD, MHSc, FRCPC
—Trana Hussaini, PharmD
—Polly Cooper, MSW
—Vladmir Marquez-Azalagara, MD, FRCPC
—Siegfried R. Erb, MD, FRCPC
—Maja Segedi, MD, FRCSC
—Stephen W. Chung, MD, FRCSC
—Charles H. Scudamore, MD, FRCSC
Liver Transplant Program, Vancouver General Hospital 
—May Tee, MD
Surgery Residency Training Program, University of British Columbia


1.    Cheng CW, Wu TX, Shang HC, et al. CONSORT extension for Chinese herbal medicine formulas 2017: Recommendations, explanation, and elaboration. Ann Intern Med 2017;167:112-121.
2.    Linde K, Brinkhaus B. Randomized trials of Chinese herbal medicine: A new extension of CONSORT statement. Ann Intern Med 2017;167:133-134.
3.    Stanbrook M. Natural health products should be sold separately from drugs. CMAJ 2017;189:E848.

Eric M. Yoshida, OBC, MD, MHSc, FRCPC, Trana Hussaini, PharmD, Polly Cooper, MSW, Vladimir Marquez Azalgara, MD, MSc, FRCPC, Siegried R. Erb, MD, FRCPC, Maja Segedi, MD, MPH, FRCSC, Stephen Chung, MD, PhD, FRCSC, Charles H. Scudamore, MD, MSc, FRCSC, May Tee, MD. Herbal medicine and liver toxicity. BCMJ, Vol. 59, No. 7, September, 2017, Page(s) 348 - Letters.

Above is the information needed to cite this article in your paper or presentation. The International Committee of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.

About the ICMJE and citation styles

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