Liver Injury From Chinese Herbal Products: What the Reports Show

Urgent first

Yellow skin or eyes, dark urine, pale stools, severe tiredness, itching, or pain in the upper right abdomen after starting a herbal product are reasons to stop the product and see a doctor promptly. Collapse, confusion or vomiting blood needs emergency care (US: 911). For poisoning advice in the US, call Poison Help at 1-800-222-1222. Bring the product with you.

What "herb-induced liver injury" means

Herb-induced liver injury (HILI) is liver damage judged to be caused by a herbal product. The liver processes most of what we swallow, so it is often where problems show up. HILI is hard to study: herbal products are mixtures, people take several things at once, and cause is decided case by case. A review of HILI in mainland China notes that its epidemiology and risk factors are still unclear because of the complexity of herbs, and that China has the most extensive herb use and the most HILI cases worldwide. [1] This page reports patterns in published reports. It cannot give a rate for any one product.

What the reports show

A US registry. The Drug-Induced Liver Injury Network (DILIN) enrolled people with liver injury at eight US referral centers from 2004 to 2013, comparing injury from medications with injury from herbals and dietary supplements (HDS). The proportion of cases attributed to HDS increased significantly, and injury from non-bodybuilding HDS led more often to death or transplantation than injury from medications (13% vs 3%). [2] This registry covers all herbal and dietary supplements, not Chinese herbs alone, so it shows the seriousness of supplement-related injury rather than a rate for TCM.

A systematic review of case reports. A review of 53 detailed case reports from Europe, Asia and North America found most cases were women, and that recovery took on average 78 days (standard deviation 59). The authors noted Europe had more reports than Asia, possibly because of under-reporting in Asia. [3] Case reports are weak evidence: they show a link is possible, not how often it happens.

A herb that is repeatedly named. A review describes Reynoutria multiflora (Polygonum multiflorum, "He Shou Wu") as the most common herb that can cause HILI. [4] A mainland China review also describes risk factors in patients, in the herbs themselves, and in "unreasonable prescriptions". [1] Other herbs are reported; see Chinese Herbs With Known Safety Concerns.

Why it can be hard to spot

Symptoms may start weeks after beginning a product and can look like a virus. Because products are mixtures, doctors need the exact product, names of every ingredient and a list of everything else you take. Contamination and hidden drugs can also be the cause rather than the named herb; see Adulteration and Substitution.

If you already have liver disease or take liver-affecting medicine

The NHS says not to take herbal medicines if you have kidney or liver problems. [5] Talk with your doctor before any herbal product and see Liver Safety and Supplements and TCM for Kidney and Liver Conditions.

What to do

• Keep the container, label and receipt, and a list of all products taken.
• Stop the product and seek medical advice if you have signs of liver trouble; do not wait for it to pass.
• Tell your doctor about all herbal use. [6]
• Report the event; see Reporting a Problem With a Chinese Herbal Product.

Evidence label: evidence of harm for specific herbs in case reports and registries; insufficient evidence for the frequency in users.