What exactly is hepatotoxicity, and why should I be worried?

The liver is a vital organ that is responsible for many body functions, including blood cell composition, breakdown of nutrients we eat, balancing cholesterols, and ridding our body of foreign chemicals, such as alcohol and drugs.
Hepatotoxicity is damage that occurs to the liver by chemical means. Medications that we use every day can ultimately be damaging our liver!
Unfortunately, hepatotoxicity from commonly known drugs is often a cause of liver injury. It is estimated as many as 1000 drugs can be blamed for some form of liver damage.
The liver’s role in detoxification makes it especially vulnerable to damaging substances. Liver cells, hepatocytes, can be injured by various pathways depending on the type of drug being metabolized. Reactive particles can destruct the cellular components of the hepatocytes, leading to cell death. Other metabolites alter liver enzymes responsible for drug metabolism leading to toxicity. Drug fragments can also bind to liver proteins initiating an autoimmune attack on the liver tissue.
Effects of hepatotoxicity can be seen throughout the body. General symptoms include: nausea, vomiting, upper right stomach pain, loss of appetite, brown urine, and yellowing of the skin and eyes (jaundice.) It is important to note these changes early and notify the health-care provider immediately if they are experienced. Early intervention is the safest way to limit damage to the liver!
Who is at risk for hepatotoxicity? EVERYONE! It may be a patient you are monitoring, a family member you are educating, or yourself. Concerns extend far beyond high dosages of prescription medications. Hepatotoxicity can result from combining multiple drugs, alcohol consumption with medications, genetic predispositions, age-related metabolism rates, and underlying diseases. Over-the-counter products, such as Tylenol, and herbal remedies, that are often considered “safe”, play a HUGE role in liver damage.
The key to lowering your risk is EDUCATION. Knowledge about hepatotoxicity is critical to keeping EVERYONE safe.

Kaplowitz, N. (2004). Drug-induced liver injury. Clinical Infectious Diseases: An Official Publication Of The Infectious Diseases Society Of America, 38 Suppl 2S44-8.

More information on hepatotoxicity, like specific symptoms to look out for can be found here: http://www.liverdisordersfocus.com/articles/liver-disorders/drug-induced-liver-damage.php

Wednesday, October 21, 2009

Herbal Supplements: Benefit or Risk?

The use of herbal products has become one of the biggest trends in recent years, as more “natural” drug therapy becomes popular. There are over 29,000 products available on the market. One reason for this is the rise in costs of perscription medication . The public believes that herbal supplements are harmless and reliable for treating or preventing many diseases. A major concern about herbal supplements is the risk of side effects. The FDA does not regulate their use, and the research on them is slim to none. The drugs are placed on the market on a trial and error basis, without any review of the benefits or risks. The producers of herbal supplements are not required to post warnings on labels; this has led to severe liver hepatotoxicity and damage to other organ systems.

Health professionals and the makers of herbal supplements are at odds on this subject. Because of the public view about herbal medication and the "all natural ingredients", use of these supplements has doubled over the last ten years. Between 20% to 30% of consumers have been admitted to a hepatic-clinic for liver injury. Ironically enough, herbal medications seem to be used most by people who have liver diseases.

The risk to the liver can be severe. Cases that  have been reported liver injury from mild, emergency transplant, and even death. This can be a surprising fact to most of the public, considering that the consensus of herbal supplements is harmless. In a public survey, 1 out of every 6 consumers report taking an herbal supplement in conjunction with their current prescriptions. This can be a dangerous combination!

There are thousands of stories about this herbal supplement side effects. The major concerns seem to be hepatotoxicity, especially associated with herbal products taken before surgery and use of these medications by the elderly. There are so many herbal products that it is almost impossible to list them along with potential side effects here; however, the number one injury most often cited is to the liver. Hepatotoxicity is at greater risk when acetaminophin and herabal supplements are taking together. Some of the most dangerous herbal drugs to the liver are; Black cohosh, Kava, Echinacea.

The lesson of the day: ask your healthcare provider before combining any drugs, perscriptioin or over-the-counter, with herbal medications. 

Are you at risk??

Barger, L. Herbs and Pain Relievers Don't Mix: The Dangers of Mixing Herbal Supplements and OTC Pain Relivers. Retrieved October 22, 2009. http.//herbalmedicine.suite101.com

Larson, A. Hepatotoxicity Due to Herbal Medications. Retrieved October 22, 2009. www.uptodate.com/patients


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Hepatotoxicity: Where We've Been, Where We Are, Where We're Going


Hepatotoxicity dates back to nearly 100 years. Just recently, they have discovered that some of the most common drugs can cause liver injury. These drugs are currently well known to the public and used by a majority of the population. The drugs in question are known as non-steroid anti-inflammatory drugs (NSAIDS), statins, anti-diabetics, and acetaminophen.

- Acetaminophen was known to cause liver damage in 1943, if not taken in therapeutic range. Even when taken appropriately, can cause hepatotoxicity if taken with other medications.
- The anti-diabetic drug, troglitazone, was the first drug to bring light to hepatotoxicity and the long-term causes it can have on the liver.


Hundreds of articles exist on the effects of drugs on the liver. The drug industry has been hit hard with removal of drugs from the market that cause liver damage. Liver hepatotoxicity is one of the most common reasons that drugs are withdrawn from the public's use. Even doses in the therapeutic range, have been known to cause toxicity of the liver. Although these drugs were known to work effectively, they were shown to cause severe liver damage, liver transplant, or death.

In 2006, the FDA added guidelines to follow if the immune system falls below a certain range. Liver enzymes should be tested in order to keep patients safe. This is currently the only way to diagnosis liver hepatoxicity, at least the most efficient way.

Recently, the public has become aware of acetaminophen related hepatotoxicity. One controversy on OTC drugs is the drug-drug interactions. The public is not as educated as they should be on the ease of overdosing on OTC drugs. As healthcare professionals, it should be an important goal to educate patients on liver safety.


Drug companies will have a never-ending battle with regulating the side effects of drugs. It could be considered a catch 22, drugs can dramatically improve ones life and at the same time be a silent killer. The FDA has taken steps to educate the public on these drugs, but the warnings do not seem to be eye catching enough.

Studies show that there is a possible genetic link to drug induced liver injury. Science Daily (2009) studies show that acetaminophen is toxic if taken in high doses, but a link exists showing that toxicity is more likely due to genetics. The study suggests that finding the genetic marker will help create safer drugs in the future. Studies also suggest that some patients become more susceptible due to their environmental factors.

Current preclinical and clinical liver safety testing does an excellent job in keeping the public safe from drugs capable of causing various forms of liver injury.

In any case, the FDA will constantly be on alert for drugs and their contraindications for hepatotoxicity. Healthcare professionals will need to be aware of the ever-changing revisions to drugs and safety changes.


Lucena, M., García-Cortés, M., Cueto, R., Lopez-Duran, J., & Andrade, R. (2008). Assessment of drug-induced liver injury in clinical practice. Fundamental & Clinical Pharmacology, 22(2), 141-158. http://search.ebscohost.com/

Watkins, P. (2005). Idiosyncratic liver injury: challenges and approaches. Toxicologic Pathology, 33(1), 1-5. http://search.ebscohost.com/

Fontana R, Watkins P, Bonkovsky H, et al. Drug-Induced Liver Injury Network (DILIN) prospective study: rationale, design and conduct. Drug Safety: An International Journal Of Medical Toxicology And Drug Experience [serial online]. 2009;32(1):55-68. Available from: MEDLINE

Ipswich, MA. Accessed October 16, 2009.Lee W, Senior J. Recognizing drug-induced liver injury: current problems, possible solutions. Toxicologic Pathology [serial online]. 2005;33(1):155-164. Available from: MEDLINE, Ipswich, MA. Accessed October 16, 2009.009.