Efficacy of intravenous glycyrrhizin in the early stage of acute onset autoimmune hepatitis

Analysis of autoimmune hepatitis with acute presentation in the early stage of illness

BACKGROUND AND AIM

There is no gold standard for making the diagnosis of autoimmune hepatitis (AIH), and the diagnosis of acute onset AIH (A-AIH) is most challenging. A-AIH sometimes develops into acute liver failure with poor prognosis if the diagnosis is delayed. Therefore, it is most important for the better prognosis to diagnose non-severe A-AIH early and treat appropriately. However, features in the early stage of A-AIH are unclear. We examined initial characteristics of non-severe A-AIH in detail and tried to find novel clinical features for the early diagnosis.

METHODS

Clinical, biochemical, immunological, radiological, and histological features of 71 patients (54 women, mean age 57.9 ± 14.3 years) with non-severe A-AIH admitted to community hospitals between 2001 and 2022 were analyzed retrospectively.

RESULT

Forty-six had no symptom on onset and liver injuries were discovered by regular medical checkups. The mean duration from onset to consultation was 25.0 ± 29.3 days. Liver histology showed acute hepatitis in 59% and chronic hepatitis in 41%. Patients with symptoms revealed more male sex (P = 0.039), higher alanine aminotransferase (P < 0.001), higher total bilirubin (P < 0.001), and higher rate of histological acute hepatitis (P = 0.0013) than those without symptoms significantly. Male sex, presence of symptoms on onset, occurrence of jaundice in the course, and histological acute hepatitis were correlated.

CONCLUSIONS

Sixty-five percent of non-severe A-AIH patients were asymptomatic on onset, suggesting that A-AIH would develop insidiously and present a longer clinical course than that reported. Male patients more often revealed true acute hepatitis clinically, biochemically, and histologically than female ones.

A Reappraisal of the Antiviral Properties of and Immune Regulation through Dietary Phytochemicals

In the present era of the COVID-19 pandemic, viral infections remain a major cause of morbidity and mortality worldwide. In this day and age, viral infections are rampant and spreading rapidly. Among the most aggressive viral infections are ebola, AIDS (acquired immunodeficiency syndrome), influenza, and SARS (severe acute respiratory syndrome). Even though there are few treatment options for viral diseases, most of the antiviral therapies are ineffective owing to frequent mutations, the development of more aggressive strains, drug resistance, and possible side effects. Traditionally, herbal remedies have been used by healers, including for dietary and medicinal purposes. Many clinical and scientific studies have demonstrated the therapeutic potential of plant-derived natural compounds. Because of unsafe practices like blood transfusions and organ transplants from infected patients, medical supply contamination. Our antiviral therapies cannot achieve sterile immunity, and we have yet to find a cure for these pernicious infections. Herbs have been shown to improve therapeutic efficacy against a wide variety of viral diseases because of their high concentration of immunomodulatory phytochemicals (both immunoinhibitory and anti-inflammatory). Combined with biotechnology, this folk medicine system can lead to the development of novel antiviral drugs and therapies. In this Review, we will summarize some selected bioactive compounds with probable mechanisms of their antiviral actions, focusing on the immunological axis of these compounds.

Glycyrrhizin Enhances the Proliferation of Diabetic Bone Marrow-derived Mesenchymal Stem Cells: A Potential Therapeutic Agent in Endodontic Surgery

AIM

This study aimed to evaluate the effects of glycyrrhizin, as a potential therapeutic agent in endodontic surgery, on the proliferation and viability of diabetic human bone marrow-derived mesenchymal stem cells (hBM-MSCs).

MATERIALS AND METHODS

Diabetic human bone marrow-derived mesenchymal stem cells (hBM-MSCs) were isolated and characterized by flow cytometry. The cells were treated with different concentrations of Glycyrrhizin (Gly) (12.5, 25, 50, and 100 µg/mL) and 0.1% dimethyl sulfoxide (DMSO) as the control group. MTT assay was performed to evaluate the cell proliferation and viability after 24, 48, and 72 hours of the cell treatment with Gly. The optical density (OD) was measured at 570 nm. Each assay was repeated three times. The corrected OD and cell viability were determined. ANOVA followed by the Bonferroni post hoc test evaluated the statistical significance at p < 0.05.

RESULTS

Flow cytometric analysis of the isolated cells showed positive expression of mesenchymal markers (CD105 and CD90) and negative expression of hematopoietic markers (CD34 and CD14). After 24 and 48 hours of cell treatment, Gly in 100 µg/mL concentration significantly decreased the diabetic hBM-MSC proliferation as compared with the control (p < 0.05). Gly in 12.5-50 µg/mL concentrations significantly increased the cell proliferation after 72 hours of treatment as compared with the control (p < 0.05). The diabetic hBM-MSC proliferation and viability at 12.5-50 µg/mL concentrations were significantly greater than that at 100 µg/mL concentration (p < 0.05).

CONCLUSION

Under the present study conditions, Gly (in 12.5-50 µg/mL concentrations) did not show cytotoxicity to diabetic hBM-MSCs and enhanced their proliferation. Gly may represent a potential therapeutic agent in endodontic surgery in diabetic patients.

CLINICAL SIGNIFICANCE

Preclinical assessment of Gly effects on diabetic hBM-MSCs is important for determining its effective concentration range, anticipating its therapeutic potential, and designing future in vivo studies.

LC-MS/MS standardization and validation of glycyrrhizin from the roots of Taverniera cuneifolia: A potential alternative source of Glycyrrhiza glabra

Glycyrrhizin is a triterpene glycoside derived from Glycyrrhiza glabra and related species which is a renowned phytochemical used to cure a variety of ailments such as inflammation, sore throat, hepatitis etc. It is in huge demand owing to its various valuable properties. With the ever-increasing demand of glycyrrhizin, the search for alternative sources for glycyrrhizin is on rise. One such species with a scientific basis and good concentration of glycyrrhizin is Taverniera cuneifolia. A thin-layer chromatography (TLC) method was established to determine the presence of glycyrrhizin in T. cuneifolia. Further, standardisation and validation, a High performance liquid chromatography (model NEXERA-X2) with LCMS system (Model LCMS-8040) from Shimadzu were used. The analysis was performed by using shim-pack XR-ODS, C18 (75 mm × 3.0 mm) 2.2 μm. In this analysis, the mobile phase used was a combination of acetonitrile and a 20 mM ammonium acetate buffer that was subjected to gradient time programming and monitored by Multiple Reaction Monitoring (MRM) in positive ion mode. The method was validated for linearity, accuracy, precision, recovery, detection, and quantitation limit. The technique was confirmed to be linear within the concentration range of 5 ng/mL to 500 ng/mL with R² > 0.991. The LOD and the LOQ were 2 ng/mL and 5 ng/mL respectively. The suggested approach satisfied the acceptance criteria for linearity, accuracy, precision, specificity, robustness, LOD, LOQ, and system adaptability.

Can Antiviral Activity of Licorice Help Fight COVID-19 Infection?

The phytotherapeutic properties of Glycyrrhiza glabra (licorice) extract are mainly attributed to glycyrrhizin (GR) and glycyrrhetinic acid (GA). Among their possible pharmacological actions, the ability to act against viruses belonging to different families, including SARS coronavirus, is particularly important. With the COVID-19 emergency and the urgent need for compounds to counteract the pandemic, the antiviral properties of GR and GA, as pure substances or as components of licorice extract, attracted attention in the last year and supported the launch of two clinical trials. In silico docking studies reported that GR and GA may directly interact with the key players in viral internalization and replication such as angiotensin-converting enzyme 2 (ACE2), spike protein, the host transmembrane serine protease 2, and 3-chymotrypsin-like cysteine protease. In vitro data indicated that GR can interfere with virus entry by directly interacting with ACE2 and spike, with a nonspecific effect on cell and viral membranes. Additional anti-inflammatory and antioxidant effects of GR cannot be excluded. These multiple activities of GR and licorice extract are critically re-assessed in this review, and their possible role against the spread of the SARS-CoV-2 and the features of COVID-19 disease is discussed.

Advances in Pharmacological Activities and Mechanisms of Glycyrrhizic Acid

Licorice (Glycyrrhiza glabra L.) is widely regarded as an important medicinal plant and has been used for centuries in traditional medicine because of its therapeutic properties. Studies have shown that metabolites isolated from licorice have many pharmacological activities, such as antiinflammatory, anti-viral, participation in immune regulation, anti-tumor and other activities. This article gives an overview of the pharmacological activities and mechanisms of licorice metabolites and the adverse reactions that need attention. This review helps to further investigate the possibility of licorice as a potential drug for various diseases. It is hoped that this review can provide a relevant theoretical basis for relevant scholars' research and their own learning.

An "essential herbal medicine"-licorice: A review of phytochemicals and its effects in combination preparations

ETHNOPHARMACOLOGICAL RELEVANCE

Licorice (Gancao in Chinese, GC), the dried root and rhizome of Glycyrrhiza uralensis Fisch., Glycyrrhiza inflata Bat. or Glycyrrhiza glabra L., is an "essential herbal medicine" in traditional Chinese medicine (TCM). There is a classic traditional Chinese medicine theory says that "nine out of ten formulas contain licorice" and licorice is considered as one of the most important herbal medicine which can reduce toxicity and increase efficacy of certain herbal medicine while it is combined application. In addition, it is a "medicine food homology" herbal medicine and also be widely used as a health food product and natural sweetener. However, no systematic literature review has been compiled to reveal its superiority. Herein, the aim of this work is to develop an overview of the state on phytochemicals, as well as effects of licorice in combination preparations, which can provide better understand the superiority of licorice and the special position in the application of TCM. Besides, ethnobotany, ethnopharmacological uses, quality control and toxicology of licorice have also been researched, which would provide reference for future clinical and basic research needs.

MATERIALS AND METHODS

The information about licorice was collected from various sources including classic books about Chinese herbal medicine, and scientific databases including scientific journals, books, and pharmacopoeia. A total of 124 bibliographies, which are published from 1976 to 2019, have been searched and researched.

RESULTS

In this study, the interaction of chemical compounds between licorice and toxic herbal medicine, pharmacological effect of licorice, and the effect of licorice on pharmacokinetics of toxic compounds are considered as the main mechanisms underlying the effects of licorice in combination preparations. Besides, ethnobotany, ethnopharmacological uses and chemical constituents have been summarized.

CONCLUSION

This work comprehensively reviews the state on ethnobotany, ethnopharmacological uses, phytochemicals, combined applications, quality control and toxicology of licorice. It will provide systematic insights into this ancient drug for further development and clinical use.

Potential Neuroprotective Effect of the HMGB1 Inhibitor Glycyrrhizin in Neurological Disorders

Glycyrrhizin (glycyrrhizic acid), a bioactive triterpenoid saponin constituent of Glycyrrhiza glabra, is a traditional medicine possessing a plethora of pharmacological anti-inflammatory, antioxidant, antimicrobial, and antiaging properties. It is a known pharmacological inhibitor of high mobility group box 1 (HMGB1), a ubiquitous protein with proinflammatory cytokine-like activity. HMGB1 has been implicated in an array of inflammatory diseases when released extracellularly, mainly by activating intracellular signaling upon binding to the receptor for advanced glycation end products (RAGE) and toll-like receptor 4 (TLR4). HMGB1 neutralization strategies have demonstrated disease-modifying outcomes in several preclinical models of neurological disorders. Herein, we reveal the potential neuroprotective effects of glycyrrhizin against several neurological disorders. Emerging findings demonstrate the therapeutic potential of glycyrrhizin against several HMGB1-mediated pathological conditions including traumatic brain injury, neuroinflammation and associated conditions, epileptic seizures, Alzheimer's disease, Parkinson's disease, and multiple sclerosis. Glycyrrhizin's effects in neurological disorders are mainly attributed to the attenuation of neuronal damage by inhibiting HMGB1 expression and translocation as well as by downregulating the expression of inflammatory cytokines. A large number of preclinical findings supports the notion that glycyrrhizin might be a promising therapeutic alternative to overcome the shortcomings of the mainstream therapeutic strategies against neurological disorders, mainly by halting disease progression. However, future research is warranted for a deeper exploration of the precise underlying molecular mechanism as well as for clinical translation.

Diammonium Glycyrrhizinate Mitigates Liver Injury Via Inhibiting Proliferation Of NKT Cells And Promoting Proliferation Of Tregs

Purpose

Diammonium glycyrrhizinate (DG) is a replacement for glycyrrhizic acid, which is used as a hepatic protector in clinical practice for most liver diseases. The potential role of immune response during autoimmune hepatitis—induced by concanavalin A (Con A)—remains to be elucidated.

Methods

C57BL/6J mice were treated with two different doses of DG (75 and 200 mg/kg) 2 hrs before administering Con A. The mice were sacrificed after administering Con A for 0, 6, and 24 hrs. Liver damage grade and serum alanine aminotransferase (ALT), aspartate aminotransferase (AST) and total bilirubin levels were evaluated. The expression level of cleaved-caspase 3 in liver was detected by Western blotting. Inflammatory cytokines such as tumor necrosis factor α (TNF-α), interleukin-6 (IL-6), and interferon γ (IFN-γ) in liver were detected by RT-PCR. Thymus, peripheral blood, spleen, and liver tissues were collected to analyze the percentages of NKT cells, subsets of CD4⁺CD25⁻CD69⁺ and CD8⁺CD69⁺ T cells, and subsets of regulatory T cells (Tregs).

Results

Our results revealed that DG pre-treatment significantly decreased the serum ALT and AST levels and improved the histological damage in Con A-induced autoimmune liver injury. Pre-treatment with DG down-regulated the inflammatory cytokines upon challenge with Con A. The DG pre-treatment inhibited the apoptosis of T lymphocytes in the thymus. Further, it effectively suppressed the proliferation of CD4⁺CD25⁻CD69⁺ and CD8⁺CD69⁺ subsets in the peripheral blood and spleen. In addition, the DG pretreatment significantly downregulated the frequency of NKT cells, while upregulating the frequency of Tregs in the liver.

Conclusion

We believe that the potential protective effect of DG against Con A-induced hepatitis may be partially attributed to its inhibitory activities on inflammatory cytokines in the livers, lymphocyte apoptosis in the thymus, NKT cells proliferation, and activation of CD8⁺T cells; further, there may also be a possibility of DC promoting Tregs proliferation.

Atorvastatin calcium inclusion complexation with polysaccharide arabinogalactan and saponin disodium glycyrrhizate for increasing of solubility and bioavailability

The aim of the present investigation was to enhance the solubility and dissolution of atorvastatin calcium (ATV), a poorly water-soluble drug with larch polysaccharide arabinogalactan (AG) and disodium glycyrrhizate (Na₂GA) as carriers of drug delivery systems for improving its bioavailability. The interactions of ATV with AG or Na₂GA were investigated by DSC, XRD, SEM, and NMR techniques. The molecular weights of supramolecular systems-inclusion complexes and micelles-which are the hosts for ATV molecules were measured. On the other hand, the rapid storage assay (+ 40 °C for 3 months) showed that the chemical stability of ATV/AG and ATV/Na₂GA complexes had been enhanced compared with pure ATV. In vitro drug release showed a significant increase in ATV's dissolution rate after formation of a complex with Na₂GA or AG. Pharmacokinetic tests in vivo on laboratory animals showed a significant increase in ATV's bioavailability after its introduction as a complex with Na₂GA or AG. Moreover, ATV/AG and ATV/Na₂GA complexes showed a more prominent decrease of total cholesterol (TC) level compared to net ATV. Therefore, the novel mechanochemically synthesized complexes of ATV with AG or Na₂GA as drug delivery systems might be potential and promising candidates for hypercholesterolemia treatment and deserved further researches.

Phytocompounds modulating Aquaporins: Clinical benefits are anticipated

A series of plant-derived bioactive compounds belonging to the class of polyphenols, terpenes and capsaicinoids, interact with important pathophysiological pathways at a molecular, cellular and systemic level. Mechanisms of action include altering cell growth and differentiation, apoptosis, autophagy, inflammation, redox balance and metabolic and energy homeostasis. These effects might also involve the expression and function of Aquaporins (AQPs), a family of membrane channel proteins, involved in several body functions. The ultimate translational beneficial effect of such phytocompounds on AQPs in health and disease is a matter of intensive research. Results might provide novel therapeutic approaches to a number of human diseases. Here, we give an updated overview of this fast growing and promising field, discussing a number of phytocompounds and their action on AQPs and related potential clinical achievements.

Liquorice (Glycyrrhiza glabra): A phytochemical and pharmacological review

In the last years, consumers are paying much more attention to natural medicines and principles, mainly due to the general sense that natural compounds are safe. On the other hand, there is a growing demand by industry for plants used in traditional medicine that could be incorporated in foods, nutraceuticals, cosmetics, or even pharmaceuticals. Glycyrrhiza glabra Linn. belongs to the Fabaceae family and has been recognized since ancient times for its ethnopharmacological values. This plant contains different phytocompounds, such as glycyrrhizin, 18β‐glycyrrhetinic acid, glabrin A and B, and isoflavones, that have demonstrated various pharmacological activities. Pharmacological experiments have demonstrated that different extracts and pure compounds from this species exhibit a broad range of biological properties, including antibacterial, anti‐inflammatory, antiviral, antioxidant, and antidiabetic activities. A few toxicological studies have reported some concerns. This review addresses all those issues and focuses on the pharmacological activities reported for G. glabra. Therefore, an updated, critical, and extensive overview on the current knowledge of G. glabra composition and biological activities is provided here in order to explore its therapeutic potential and future challenges to be utilized for the formulation of new products that will contribute to human well‐being.

Early Combination Therapy with Corticosteroid and Nucleoside Analogue Induces Rapid Resolution of Inflammation in Acute Liver Failure due to Transient Hepatitis B Virus Infection

Objective Patients with acute hepatitis B sometimes develop acute liver failure (ALF), which has a poor prognosis. The efficacy of nucleoside analogue (NA) monotherapy for ALF due to transient hepatitis B virus infection (HBV-ALF) remains controversial. Further investigations are necessary in nations with a shortage of donor livers for liver transplantation. In the present study, we aimed to clarify the efficacy of combination therapy with corticosteroid (CS) and NA in the treatment HBV-ALF. Patients We examined the clinical and biochemical features of 19 patients with HBV-ALF who were treated in the early stage of the disease between 2000 and 2015. Results Fourteen patients received CS and NA (CS + NA group) and 5 received NA monotherapy (NA group). Eleven patients (58%) survived and 8 (42%) died. The survival rates in the CS + NA and NA groups were 64% and 40%, respectively (p=0.60). The mean alanine aminotransferase (ALT) levels declined significantly at week 2 in both groups. The mean PT activities improved significantly at weeks 1 and 2 in the CS + NA group (p<0.05) but not in the NA group. None of the surviving patients developed persistent infection. Conclusion Combination therapy with CS and NA induces the rapid resolution of inflammation leading to a rapid recovery of the liver function. When it is administered at a sufficiently early stage, it would have a survival benefit and prevent persistent infection in HBV-ALF.

Glycyrrhizin ameliorates atopic dermatitis-like symptoms through inhibition of HMGB1

Atopic dermatitis (AD) is a chronic relapsing inflammatory skin disease prevalent worldwide. This study investigated the effects of glycyrrhizin, an extract of licorice root, on the well-established model of 2,4-dinitrochlorobenzene-induced AD-like symptoms in mice. The severity of dermatitis, histopathological changes, serum IgE levels, changes in expression of high-mobility group box 1 (HMGB1), the receptor for advanced glycation end products (RAGE), nuclear factor (NF)-κB and inflammatory cytokines were evaluated. Treatment with glycyrrhizin inhibited the HMGB1 signaling cascade and ameliorated the symptoms of AD. Furthermore, in an in vitro study, the expression of RAGE was detected in a mouse mast cell line, P815 cells, and rmHMGB1 was found to be a potent inducer of mast cell activation by increasing Ca²⁺ influx, upregulating the CD117 and activating NF-κB signaling; these effects were also inhibited by glycyrrhizin. These findings implicate HMGB1 in the pathogenesis of AD and suggest that GL could be an effective therapeutic approach for cutaneous inflammation.

Aquaporins as Targets of Dietary Bioactive Phytocompounds

Plant-derived bioactive compounds have protective role for plants but may also modulate several physiological processes of plant consumers. In the last years, a wide spectrum of phytochemicals have been found to be beneficial to health interacting with molecular signaling pathways underlying critical functions such as cell growth and differentiation, apoptosis, autophagy, inflammation, redox balance, cell volume regulation, metabolic homeostasis, and energy balance. Hence, a large number of biologically active phytocompounds of foods have been isolated, characterized, and eventually modified representing a natural source of novel molecules to prevent, delay or cure several human diseases. Aquaporins (AQPs), a family of membrane channel proteins involved in many body functions, are emerging among the targets of bioactive phytochemicals in imparting their beneficial actions. Here, we provide a comprehensive review of this fast growing topic focusing especially on what it is known on the modulatory effects played by several edible plant and herbal compounds on AQPs, both in health and disease. Phytochemical modulation of AQP expression may provide new medical treatment options to improve the prognosis of several diseases.

Autoimmune Hepatitis in the Asia-Pacific Area

Autoimmune hepatitis has been considered as a relatively rare immunological liver disease, especially in the Asia-Pacific area. Although the diagnosis criteria and immunosuppressive treatment regimens have been established, there are still some challenges. According to the different presentations, the personalized management of patients who suffer from this disease, including those with chronic or acute severe onset, the autoantibody-negative phenotype and cirrhosis are necessarily descriptive. Each subgroup of patients should receive an individualized therapy. Here, we review the recent studies of autoimmune hepatitis, mainly focusing on the epidemiology and genetics, personalized diagnostics, individualized treatment strategies, special subgroups and outcomes. Most of the research in the literature is based on Japanese and Chinese populations.

The Vasodilatory Effects of Anti-Inflammatory Herb Medications: A Comparison Study of Four Botanical Extracts

Inflammation plays a pivotal role in the development and progression of cardiovascular diseases, in which, the endothelium dysfunction has been a key element. The current study was designed to explore the vasodilatory effect of anti-inflammatory herbs which have been traditionally used in different clinical applications. The total saponins from Actinidia arguta radix (SAA), total flavonoids from Glycyrrhizae radix et rhizoma (FGR), total coumarins from Peucedani radix (CPR), and total flavonoids from Spatholobi caulis (FSC) were extracted. The isometric measurement of vasoactivity was used to observe the effects of herbal elements on the isolated aortic rings with or without endothelium. To understand endothelium-independent vasodilation, the effects of herb elements on agonists-induced vasocontractility and on the contraction of endothelium-free aortic rings exposed to a Ca²⁺-free medium were examined. Furthermore, the role of nitric oxide signaling in endothelium-dependent vasodilation was also evaluated. In summary, FGR and FSC exhibit potent anti-inflammatory effects compared to CPR and SAA. FGR exerts the strongest vasodilatory effect, while CPR shows the least. The relaxation induced by SAA and FSC required intact endothelia. The mechanism of this vasodilation might involve eNOS. CPR-mediated vasorelaxation appears to involve interference with intracellular calcium homeostasis, blocking Ca²⁺ influx or releasing intracellular Ca²⁺.

Autoimmune hepatitis: Standard treatment and systematic review of alternative treatments

Autoimmune hepatitis is a rare chronic inflammatory liver disease, affecting all ages, characterised by elevated transaminase and immunoglobulin G levels, positive autoantibodies, interface hepatitis at liver histology and good response to immunosuppressive treatment. If untreated, it has a poor prognosis. The aim of this review is to summarize the evidence for standard treatment and to provide a systematic review on alternative treatments for adults and children. Standard treatment is based on steroids and azathioprine, and leads to disease remission in 80%-90% of patients. Alternative first line treatment has been attempted with budesonide or cyclosporine, but their superiority compared to standard treatment remains to be demonstrated. Second-line treatments are needed for patients not responding or intolerant to standard treatment. No randomized controlled trials have been performed for second-line options. Mycophenolate mofetil is the most widely used second-line drug, and has good efficacy particularly for patients intolerant to azathioprine, but has the major disadvantage of being teratogenic. Only few and heterogeneous data on cyclosporine, tacrolimus, everolimus and sirolimus are available. More recently, experience with the anti-tumour necrosis factor-alpha infliximab and the anti-CD20 rituximab has been published, with ambivalent results; these agents may have severe side-effects and their use should be restricted to specialized centres. Clinical trials with new therapeutic options are ongoing.

A Randomized Controlled Trial of Glycyrrhizin Plus Tenofovir vs. Tenofovir in Chronic Hepatitis B with Severe Acute Exacerbation

Objectives:

Severe acute exacerbation (SAE) of chronic hepatitis B (CHB) may progress to liver failure with high potential mortality despite the prompt treatment with nucleos(t)ide analogs. This study aimed to evaluate the efficacy and safety of glycyrrhizin in the treatment of CHB with SAE.

Methods:

Sixty patients with SAE of CHB were randomly treated with tenofovir plus intravenous glycyrrhizin (group A, n=30) or with tenofovir alone (group B, n=30). Primary end points were the improvement of serum levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) and model for end-stage liver disease (MELD) score. Secondary end point was overall mortality or receipt of liver transplantation by week 24.

Results:

Patients in group A had significant reductions of serum AST and ALT levels from baseline at days 3, 5, 8, and 15 than those in group B (all P<0.05). The MELD score significantly decreased since week 1 in the group A patients, whereas there were no changes relative to baseline in group B patients at weeks 1 and 2. By week 24, one (3.3%) of group A patients and four (13.3%) of group B patients died (n=3) or received liver transplantation (n=1) (P=0.177). Multivariate analysis identified baseline MELD score (P=0.021) as an independent factor for mortality or receipt of liver transplantation. There were no differences in the rates of grade 3 hypertension, hypokalemia and ascites between two groups.

Conclusions:

Early introduction of glycyrrhizin can be safe and helpful for patients with SAE of CHB.

Infectious complications, steroid use and timing for emergency liver transplantation in acute liver failure: analysis in a Japanese center

BACKGROUND

Corticosteroid (CS) has been introduced in most acute liver failure (ALF) patients for the purpose of suppressing pro-inflammatory cytokines in Japan where a shortage of donor livers exists, whereas CS use is evaluated to be no benefit in Western countries. In the present study, we aimed to clarify the association between infectious complications and CS use in ALF, and determine when to evaluate treatment response and consider the timing for switching to liver transplantation (LT).

METHODS

Corticosteroid was administered to patients in the early stage prospectively. Clinical and biochemical features of 110 adult patients were analyzed.

RESULTS

Corticosteroids were administered to 78 (71%) patients. The duration between start of CS and onset of infection was 17 ± 10 days. Multivariate analysis revealed that infection was associated with age >50 years (P = 0.034) and T-BIL >15 mg/dl (P < 0.001), and not with CS use (P = 0.10). Accumulative incidence of infection was not different between patients with and without CS (P = 0.18).

CONCLUSIONS

Corticosteroid use did not significantly increase the incidence of infection. Two weeks after introduction of CS is a critical point for evaluating treatment response, avoiding infectious complications and switching to LT.

Analysis of infectious complications and timing for emergency liver transplantation in autoimmune acute liver failure

BACKGROUND

Autoimmune hepatitis (AIH) is one of major etiologies of acute liver failure (ALF), and the survival rate without liver transplantation (LT) of patients with fulminant AIH is especially poor worldwide. We investigated the clinicopathological features of infectious complications in autoimmune ALF retrospectively and tried to determine when to continue corticosteroid (CS) treatment or abandon it for LT.

METHODS

Twenty patients with autoimmune ALF, comprising five severe hepatitis, 13 fulminant hepatitis and two late onset hepatic failure, were analyzed.

RESULTS

Corticosteroids were administered to 19 patients. Seventeen infectious complications were observed in 12 patients. The median (range) duration between the introduction of CS and onset of infection was 15 (10–41) days. There were no significant differences in clinicobiochemical features between patients with and without infection. Of 20 patients, eight (40%) recovered without LT, four (20%) received LT and eight (40%) died without LT. Dead or transplanted patients had more advanced liver failure on admission than recovered ones (P < 0.01).

CONCLUSIONS

Two-week after the introduction of CS is a critical point for avoiding infectious complications. Therefore, we should have evaluated efficacy of CS and performed LT by then at the latest in case of failure to improve.

Glycyrrhiza glabra

Liquorice foliage

Hepatoprotective properties of extensively studied medicinal plant active constituents: possible common mechanisms

CONTEXT

We focused on certain plant active constituents considered to be the most promising/studied for liver disease and that were critically investigated from the basic science point of view and, to some extent, the clinical one. Due to insufficient pharmacological data, most of the herbal formulations containing these molecules cannot be recommended for the treatment of liver disease.

OBJECTIVE

To present the most promising compounds tested experimentally and/or clinically and describe in brief popular models in experimental testing of potential hepatoprotective compounds.

METHODS

A literature search using Web of Science (WOS), PubMed, and Google search was performed.

RESULTS

Focusing on a few herbal hepatoprotective active constituents is useful to health professionals working in the field of therapeutics to develop evidence-based hepatoprotective agents by conducting research on pure chemical structures or on molecular modifications using computational chemistry. This review demonstrates that multi-pathways in the liver pathobiology can be interrupted at one or more levels by natural hepatoprotective studied, such as interference with the oxidative stress at multiple levels to reduce reactive oxygen/nitrogen species, resulting in ameliorating hepatotoxicity.

CONCLUSION

Hepatoprotective constituents of herbal medications are poorly absorbed after oral administration; methods that can improve their bioavailability are being developed. It is recommended that controlled prospective double-blind multicenter studies on isolated active plant constituents, or on related newly designed molecules after structural modifications, should be performed. This effort will lead to expanding the existing, limited drugs for the vast majority of liver diseases.

Virological efficacy of combination therapy with corticosteroid and nucleoside analogue for severe acute exacerbation of chronic hepatitis B

The short-term prognosis of patients with severe acute exacerbation of chronic hepatitis B (CHB) leading to acute liver failure is extremely poor. We have reported the efficacy of corticosteroid in combination with nucleoside analogue in the early stages, but virological efficacy has not been documented. Our aim was to elucidate the virological efficacy of this approach. Thirteen patients defined as severe acute exacerbation of CHB by our uniform criteria were prospectively examined for virological responses to treatment. Nucleoside analogue and sufficient dose of corticosteroids were introduced as soon as possible after the diagnosis of severe disease. Of the 13 patients, 7 (54%) survived, 5 (38%) died and 1 (8%) received liver transplantation. The decline of HBV DNA was significant between the first 2 weeks (P = 0.02) and 4 weeks (P < 0.01). Mean reduction in HBV DNA during the first 2 weeks was 1.7 ± 0.9 log copies per mL in overall patients, 2.1 ± 0.8 in survived patients and 1.2 ± 0.9 in dead/transplanted patients. The decline of HBV DNA was significant between the first 2 weeks (P = 0.03) and 4 weeks (P = 0.02) in survived patients, but not in dead/transplanted patients. Our study shows that corticosteroid treatment in combination with nucleotide analogue has sufficient virological effect against severe acute exacerbation of CHB, and a rapid decline of HBV DNA is conspicuous in survived patients.

Simultaneous Determination of Nine Active Compounds of the Traditional Chinese Medicinal Prescription Shaoyao-Gancao-Tang and Analysis of the Relationship between Therapeutical Effect and Compatibility of Medicines

A simple and sensitive HPLC-DAD detection method was established for the simultaneous determination of nine compounds including oxypaeoniflorin, albiflorin, paeoniflorin, benzoylpaeoniflorin, glycyrrhizic acid, liquiritin, isoliquiritin, liquiritigenin, and isoliquiritigenin in the Traditional Chinese Medicinal Prescription Shaoyao-Gancao-Tang (SGT) and we analyze the relationship between therapeutical effect and compatibility of medicines by using an Agilent extend-C18 column at a flow rate of 1 mL/min. The column temperature was maintained at 30°C and the detection wavelength was set at 230 nm for oxypaeoniflorin, albiflorin, paeoniflorin, benzoylpaeoniflorin, and glycyrrhizic acid; 276 nm for liquiritin and liquiritigenin; 360 nm for isoliquiritin and isoliquiritigenin. The total contents of the nine compounds in SGT varied from 4.65 to 20.06 mg/mL. The results of this study showed that the content of chemical compounds of Traditional Chinese Medicinal Prescription is mainly influenced by the dosage and compatibility of medicines and the therapeutical effect of Traditional Chinese Medicinal prescription is mainly influenced by the dosage and compatibility of medicines. The method could be suitable for quality control of SGT with bioactive multicompounds.

Glycyrrhizic acid in the treatment of liver diseases: literature review

Glycyrrhizic acid (GA) is a triterpene glycoside found in the roots of licorice plants (Glycyrrhiza glabra). GA is the most important active ingredient in the licorice root, and possesses a wide range of pharmacological and biological activities. GA coupled with glycyrrhetinic acid and 18-beta-glycyrrhetic acid was developed in China or Japan as an anti-inflammatory, antiviral, and antiallergic drug for liver disease. This review summarizes the current biological activities of GA and its medical applications in liver diseases. The pharmacological actions of GA include inhibition of hepatic apoptosis and necrosis; anti-inflammatory and immune regulatory actions; antiviral effects; and antitumor effects. This paper will be a useful reference for physicians and biologists researching GA and will open the door to novel agents in drug discovery and development from Chinese herbs. With additional research, GA may be more widely used in the treatment of liver diseases or other conditions.

Efficacy of α-glycyrrhizic acid in management of early autoimmune hepatitis

AIM: To investigate the efficacy of α-glycyrrhizic acid (α-GL) in the management of early autoimmune hepatitis (AIH).

METHODS: Seventy-six patients with AIH treated at our hospital between February 2009 and October 2012 were enrolled into the study. The patients were divided randomly into two groups: a treatment group and a control group, with 38 patients in each group. Patients in the treatment group received magnesium isoglycyrrhizinate injection for 3 wk and diammonium glycyrrhizinate enteric-coated capsules for 1 year. Patients in the control group received compound glycyrrhizin injection for 3 wk and compound glycyrrhizin tablets for 1 year.

RESULTS: The liver function of patients in both groups improved significantly after treatment (ALT: 31.00 U/L ± 4.27 U/L vs 76.42 U/L ± 9.34 U/L, AST: 29.26 U/L ± 3.57 U/L vs 73.21 U/L ± 10.69 U/L, GLOB: 32.27 ± 4.84 g/L vs 36.10 g/L ± 3.83 g/L; ALT: 49.26 U/L ± 6.05 U/L vs 77.79 U/L ± 6.45 U/L, AST: 42.05 U/L ± 5.87 U/L vs 74.53 U/L ± 5.91 U/L, GLOB: 35.56 g/L ± 1.05 g/L vs 36.71 g/L ± 2.29 g/L; all P < 0.05), and the improvement was more significant in the treatment group than in the control group (all P < 0.05). The levels of IgG and gamma globulin declined significantly after treatment in both groups (IgG: 13.47 g/L ± 0.57 g/L vs 16.87 g/L ± 1.29 g/L, gamma globulin: 13.45 g/L ± 1.67 g/L vs 17.07 g/L ± 3.29 g/L; IgG: 15.39 g/L ± 1.28 g/L vs 17.14 g/L ± 1.36 g/L, gamma globulin: 15.07 g/L ± 2.08 g/L vs 17.47 g/L ± 2.29 g/L; all P < 0.05), and the decline was more significant in the treatment group (all P < 0.05). The C3 level increased significantly after treatment in both groups (1.048 g/L ± 0.103 g/L vs 0.597 g/L ± 0.074 g/L; 0.840 g/L ± 0.121 g/L vs 0.611 g/L ± 0.053 g/L; both P < 0.05), and the increase was more significant in the treatment group (P < 0.05). The effective rate was significantly higher in the treatment group than in the control group (86.8% vs 73.7%, P < 0.05).

CONCLUSION: α-GL has a more significant effect than β-GL in controlling inflammatory activity in early AIH.

Rikkunshito ameliorates bleomycin-induced acute lung injury in a ghrelin-independent manner

Acute lung injury (ALI) is a critical syndrome consisting of acute respiratory failure associated with extensive pulmonary infiltrates. The pathological characterization of ALI includes injuries of alveolar epithelial cells (AECs), alveolar neutrophilic infiltration, and increases in proinflammatory cytokines, which cause destruction of the alveolar capillary barrier and subsequent devastating lung fibrosis. Rikkunshito (RKT), a traditional Japanese herbal medicine, is widely used for the treatment of patients with gastrointestinal symptoms and is known to stimulate ghrelin secretion. The therapeutic effects of RKT on organ inflammation and fibrosis remain unknown. We investigated the pharmacological potential of RKT in the treatment of ALI by using a bleomycin-induced ALI model in mice. RKT or distilled water (DW) was given to mice daily starting 12 h after bleomycin administration. The RKT-treated mice showed a definitively higher survival rate than the DW-treated mice after injury. They also had smaller reductions in body weight and food intake. The amelioration of neutrophil alveolar infiltration, pulmonary vascular permeability, induction of proinflammatory cytokines, activation of the NF-κB pathway, apoptosis of AECs, and subsequent lung fibrosis were notable in the RKT-treated mice. RKT administration increased the plasma ghrelin levels in wild-type mice, and it also mitigated the ALI response in both ghrelin-deficient mice and growth hormone secretagogue receptor-deficient mice after lung injury. Our results indicate that RKT administration exerts protective effects against ALI by protecting the AECs and regulating lung inflammation independently of the ghrelin system, and they highlight RKT as a promising therapeutic agent for the management of this intractable disease.

A case of primary biliary cirrhosis and autoimmune hepatitis overlap showing acute presentation and transient seropositivity for immunoglobulin G and anti-nuclear antibody

Autoimmune hepatitis (AIH) is generally regarded as a clinically and histologically "chronic" hepatitis. It often shows acute presentation like acute hepatitis without typical clinicopathological features of AIH, especially in a case of overlap with primary biliary cirrhosis (PBC). A 52-year-old man showed mild liver dysfunction for the first time at an annual medical check. Two months later, he showed jaundice, and laboratory tests revealed elevation of liver enzymes, hyperbilirubinemia and prolonged prothrombin time activity like acute liver failure. Anti-mitochondrial antibody was positive and other viral and autoimmune markers were negative. His liver function tests improved upon treatment with ursodeoxycholic acid and maximum intravenous glycyrrhizin (IVGL), but liver dysfunction was again exacerbated after the gradual reduction of IVGL. He showed transient elevation of immunoglobulin G (IgG) and anti-nuclear antibody (ANA) at only one point, and liver histology was compatible with PBC and AIH overlap syndrome. Corticosteroid was administered and his liver function tests returned to normal. It is important for the diagnosis of acute onset AIH to monitor IgG level and ANA titer, especially in patients without IgG and ANA elevations at first appearance.

Therapeutic strategies in inflammasome mediated diseases of the liver

Tissue stress and cell death result in inflammation even in the absence of pathogens. Such sterile inflammation is dependent on a cytosolic complex of proteins inside immune cells termed the inflammasome. This complex converts two groups of extracellular signals into an inflammatory response via activation of caspase-1 and secretion of IL-1β and IL-18. Group 1 signals are typically TOLL like receptor agonists and result in transcriptional upregulation of inflammasome components and pro-cytokines. Group 2 signals are diverse, ranging from uric acid to ATP, and lead to assembly and activation of the inflammasome complex. Inflammasome components are required for a wide range of acute and chronic pathologies, including experimental alcoholic and non-alcoholic steatohepatitis, and drug-induced liver injury. Collectively, group 1 and 2 signals, inflammasome components, and cytokine receptors provide a rich source of therapeutic targets. Many of the advances in the field have come from standard reductionist experiments. Progress in the understanding of complex human systems will, however, be dependent on novel strategies such as systems analysis, which analyze large data sets to provide new insights.