The toxicity of Callilepis laureola, a South African traditional herbal medicine

Cytotoxic activity of several ent-kaurane derivatives of atractyligenin. Synthesis of unreported diterpenic skeleton by chemical rearrangement

Atractyloside, carboxyatractyloside, their aglycon atractyligenin, and several synthetic derivatives were tested and found to be active against a panel of human tumor cell lines. Atractyligenin was subjected to oxidation, bromination, and elimination reactions, obtaining several compounds. A singular skeleton was synthesized by chemical rearrangement starting from 3β-bromo-2,15-diketoatractyligenin methyl ester. The synthesized compounds resulted active against all cell lines tested. In particular, 15-ketoatractyligenin methyl ester and 3β-bromo-2,15-diketoatractyligenin methyl ester resulted the most active with IC50 values of 0.427 and 0.723 μM against A375 melanoma cell line. Excellent results were also obtained against the colon cancer cell line CaCo2, with slightly lower antiproliferative activity. An interesting extension of the study should be to analyze the atractyligenin derivatives also as target for human melanoma and human colon cancer cells.

The Detection of Toxic Compounds in Extracts of Callilepis laureola (Oxeye Daisy) and Senecio latifolius (Ragwort) by Ultra-Performance Liquid Chromatography-Mass Spectrometry (UPLC-MS/MS)

Methods used for the detection of toxic components of Callilepis laureola and Senecio latifolius have ranged from the use of thin-layer chromatography, spectrophotometry, and immunoassay to gas chromatography with mass spectrometry. However, each of these techniques has a number of drawbacks. In this chapter, we will describe a solid-phase extraction technique, which allows for the detection and quantitation of the toxins atractyloside and retrorsine in each plant extract using ultra-performance liquid chromatography-mass spectrometry (UPLC-MS/MS). This methodology offers high specificity and sensitivity and the ability to identify a broad range of analytes.

The screening of drug-induced nephrotoxicity using gold nanocluster-based ratiometric fluorescent probes

Herbal medicines are potential candidates for the treatment of various diseases, but their medication safety remains poorly regulated. Current screening methods for the herbal medicine-induced nephrotoxic effects include histological and serological assessments, which often fail to reflect the kidney dysfunction instantly. Here we report a ratiometric fluorescence approach for the rapid and facile screening of drug-induced acute kidney injury using chromophore-modified gold nanoclusters. These gold nanoclusters are highly sensitive to reactive oxygen species (ROS), with a detection limit of 14 nM for ˙OH. After passing through the glomerular filtration barrier, the gold nanocluster-based probes can quantify the fluctuation of the ROS level in the kidneys and evaluate the risk of drug-induced nephrotoxicity. We further employed nephrotoxic triptolide as the model drug and the screening of drug-induced early renal injury was demonstrated using the nanoprobes, which is unattainable by conventional diagnostic approaches. Our fluorescent probes also allow the identification of other nephrotoxic components from herbal medicine such as aristolochine, providing a high-throughput strategy for the screening of herbal supplement-induced nephrotoxicity.

Assessment of acute and sub-chronic neurotoxicity of Morus alba L. fruits in rodents

Background

Morus alba L. fruits are consumed since long for their nutritional and medicinal values. Although there were studies on the neuroprotective activity of the fruit extract, safety profile of the fruit extract is not yet explored as per the recommended standard guidelines over the central nervous system (CNS). The present work was aimed to assess the neurotoxicity profile of chemically characterized extract of M. alba L. fruits (MA) using validated OECD guidelines, i.e., 425 and 424 in rodents.

Results

Neurobehavioural parameters were examined for motor, sensory and behavioural responses using actophotometer, hot plate and light and dark box test, respectively as per OECD 424. Interestingly, no sign of mortality and/or adversity on mice treated per-orally with MA (2000 mg/kg) was observed during the limit test as per OECD 425. Further, rats treated with MA (1000, 300 and 100 mg/kg, p.o.) for 28 days, showed insignificant (p < 0.05) changes in body weight, food consumption, neurobehavioural responses, organ weights and biochemical, haematological and histopathological features when compared with vehicle-treated animals.

Conclusion

The outcome of findings suggests that MA is safe in acute oral as well as sub-chronic (28 days) administration in mice and rats respectively. MA (1000 mg/kg) did not pose any toxic sign and symptoms on neurobehavioural responses in rats even after 28 days repeated treatment in compliance with OECD 424.

LC-MS Analysis, 15-Lipoxygenase Inhibition, Cytotoxicity, and Genotoxicity of Dissotis multiflora (Sm) Triana (Melastomataceae) and Paullinia pinnata Linn (Sapindaceae)

This study aims to evaluate the anti-inflammatory, cytotoxicity, and genotoxicity activities of Dissotis multiflora (Sm) Triana and Paullinia pinnata Linn used traditionally in Cameroon to treat infectious diseases. Phytochemical screening was carried out using the LC-MS procedure. The ferrous oxidation-xylenol orange (FOX) assay was used to determine the 15-lipoxygenase (15-LOX) inhibitory activity of the plant samples. The tetrazolium-based colorimetric (MTT) assay was performed using Vero cells. The Ames test was carried out using Salmonella typhimurium TA98 and TA100 tester strains. LC-MS chromatogram of D. multiflora led to the identification of four known compounds, namely, 5-(3,5-dinitrophenyl)-2H-tetrazol (2), 2,2'-{[2-(6-amino-9H-purine-9-yl)ethyl]imino}diethanol (14), 1,2,5-oxadiazolo [3,4-b]pyrazine, 5,6-di (3,5-dimethyl-1-piperidyl) (19), and nimbolinin D (20) while four compounds were also identified in P. pinnata known as 2-hydroxycarbamoyl-4-methyl-pentanoic acid (2), pheophorbide A (16), 1-[4-({2-[(1-methyl-1H-indol-5-yl)amino]-4-pyrimidinyl}oxy)-1-naphthyl]-3-[1-(4 methylphenyl)-3-(2-methyl-2-propanyl)-1H-pyrazol-5-yl]urea (17), and nimbolinin D (18). D. multiflora and P. pinnata inhibited 15-LOX activity in concentration-dependent manner. The LC₅₀ (concentration that kills 50% of cells) values of the extracts ranged from 0.13 ± 00 to 1 ± 00 mg/mL for P. pinnata and D. multiflora, respectively. P. pinnata was cytotoxic at concentrations tested while D. multiflora was not. The selectivity index (SI) values ranged from 0.16 to 10.30 on Vero cell lines. No genotoxic effect was observed against both strains tested. These extracts are sources of compounds which can be used to control infectious diseases and associated inflammation. However, caution should be taken while using P. pinnata for medicinal purposes.

Acute toxic kidney injury

Substances toxic to the kidney are legion in the modern world. The sheer number and variety, their mutual interactions and, metabolism within the body are a challenge to research. Moreover, the kidney is especially prone to injury owing to its physiology. Acute kidney injury (AKI) induced by poisonous or primarily nephrotoxic substances, may be community acquired with ingestion or inhalation or nosocomial. Many nephrotoxic plants, animal poisons, medications, chemicals and illicit drugs can induce AKI by varying pathophysiological pathways. Moreover, the epidemiology of toxic AKI varies depending on country, regions within countries, socioeconomic status and health care facilities. In this review, we have selected nephrotoxic insults due to medication, plants, animal including snake venom toxicity, environmental, (agri)chemicals and also illicit drugs. We conclude with a section on diagnosis, clinical presentation and management of poisoning accompanied by various organ dysfunction and AKI.

Use of traditional and alternative healers by psychiatric patients: A descriptive study in urban South Africa

This study investigates the pattern of use of traditional and alternative healers among psychiatric patients in Nelson Mandela Metropole. An interview schedule was applied to 254 subjects at six sites, enquiring about consultations with traditional and alternative healers in the past year. Multivariate analysis was performed to determine predictors of consultation. Overall, 78 (31%) of respondents had consulted a healer in the past year. The ethnic distribution was: 156 (61%) Black, 53 (21%) Coloured (Mixed Race), 42 (17%) White and three (1%) Indian. The male to female ratio was 119 (46.85%):135 (53.14%). The healers gave no advice about psychiatric medication to 48 (61.5%) of consulters, 23 (29.5%) were told to continue their medication, four (5.1%) told to stop, and one (1.3%) told to stop and restart later. In multivariate models, predictors of consultation were being Black and of lower education. Although 45 (58%) of the consulters indicated that medical treatment was more helpful than the healer's, 45 (58%) intended to consult again. Overall, 22% of consulters reported abuse by the healer.

African Herbal Remedies with Antioxidant Activity: A Potential Resource Base for Wound Treatment

The use of traditional herbal remedies as alternative medicine plays an important role in Africa since it forms part of primary health care for treatment of various medical conditions, including wounds. Although physiological levels of free radicals are essential to the healing process, they are known to partly contribute to wound chronicity when in excess. Consequently, antioxidant therapy has been shown to facilitate healing of such wounds. Also, a growing body of evidence suggests that, at least, part of the therapeutic value of herbals may be explained by their antioxidant activity. This paper reviews African herbal remedies with antioxidant activity with the aim of indicating potential resources for wound treatment. Firstly, herbals with identified antioxidant compounds and, secondly, herbals with proven antioxidant activity, but where the compound(s) responsible for the activity has not yet been identified, are listed. In the latter case it has been attempted to ascribe the activity to a compound known to be present in the plant family and/or species, where related activity has previously been documented for another genus of the species. Also, the tests employed to assess antioxidant activity and the potential caveats thereof during assessment are briefly commented on.

Integrating traditional medical knowledge into mainstream healthcare in Limpopo Province

In most African states, the majority of the population depend on indigenous healing knowledge for their healthcare. This knowledge is in danger of being obliterated due to a number of factors such as it being not documented, low life expectancy where people die before transferring it to the next generation and the governments failing to incorporate it into the mainstream health system that is often overloaded. This qualitative study adopted a hermeneutic phenomenology to investigate the development of a framework to integrate knowledge of traditional healing into the mainstream healthcare system in the Limpopo province. Data were collected through interviews with traditional healers chosen through snowball sampling technique augmented by observations and analysis of legislation, notes, records and other forms of documents held by healers. Data were analysed and interpreted thematically according to the objectives of the study. The study established that indigenous medical knowledge is marginalised, and healers are not getting support from the government despite the important role they play in the national health systems. Traditional healing is not properly regulated creating a loophole for anyone to practise as a healer. A framework that points the link factors that attempt to create an understanding of how knowledge of traditional healing can be managed and integrated into the mainstream healing is proposed. It is concluded that failure to recognise traditional healing and integrate it in the mainstream health system will continue to hamstring the health system with resources in South Africa.

Direct Intrahepatic Portocaval Shunt for Sinusoidal Obstruction Syndrome Associated with Hepatotoxicity of Pyrrolizidine Alkaloids

We retrospectively identified 89 consecutive patients from January 2004 to January 2012 to investigate efficacy of direct intrahepatic portocaval shunt (DIPS) combined with inferior vena cava (IVC) stenting for sinusoidal obstruction syndrome (SOS) associated with hepatotoxicity of pyrrolizidine alkaloids. Indications for treatment were variceal hemorrhage and/or refractory ascites. Patients were treated with DIPS plus IVC stenting (group A, n=68) or DIPS alone (group B, n=21). A technical success rate of 100% was obtained in all 89 patients, and there were no early procedure-related adverse events or 30-day mortality. Mean portosystemic gradient decreased in both groups. Changes in aspartate and alanine aminotransferases and total bilirubin did not differ between the groups. Ascites disappeared in group A but was not obvious in group B until IVC stenting. During follow-up, recurrent bleeding and ascites and incidence of hepatic encephalopathy did not differ between the groups. The 1-, 3-, and 5-year survival rate was 98, 89.59, and 80%, respectively. Satisfactory clinical results were obtained for combined DIPS and IVC stenting for SOS associated with pyrrolizidine-alkaloid-related decompensated cirrhosis.

The mutagenic and antimutagenic activity of Sutherlandia frutescens extracts and marker compounds

BACKGROUND

Sutherlandia frutescens (L.) R. Br is endemic to Southern Africa where it has been traditionally used for cancer and diabetes. In recent times it has been marketed for its reputed (but not proven) anticancer, antidiabetic and anti-HIV properties. Little is known about the mutagenic and antimutagenic potential of extracts and common marker compounds of Sutherlandia frutescens. Therefore this study aimed to investigate the putative efficacy and possible long-term adverse effects of using this herb.

METHODS

Ethylacetate (EA) and 50% Methanol (MeOH) extracts were screened for mutagenic and antimutagenic activity using the Ames assay utilising TA97a, TA98, TA100 and TA102 in the presence and absence of metabolic activation. Four compounds, L-arginine, L-canavanine, GABA and D-pinitol known to occur in sutherlandia were also included. The total polyphenolic content of the both extracts was determined using the Folin-Ciocalteau method and FRAP and ABTS were used to determine the anti-oxidant potential of the extracts.

RESULTS

The extracts and the standards did not show any cytotoxicity except in TA97a. The EA extract exhibited antimutagenicity against all the bacterial strains at all concentrations tested. The MeOH extract showed both pro-mutagenic and antimutagenic activities with 2-acetamidofluorene and aflatoxin B1 in the presence of metabolic activation of TA98 and TA100, respectively. All compounds, except L-canavanine exhibited antimutagenic activity against all strains. L-canavanine, on the other hand showed co-mutagenicity with 9-aminoacridine on TA97a, at all test concentrations. The extracts and pure compounds exhibited their antimutagenic activity in a dose response manner. L-arginine and GABA showed an some antimutagenic response. EA extract had three times the total phenolic content (12.56 μg GE / mg) observed in the MeOH extract. There was correlation between total phenolic content, antioxidant potential and antimutagenicity.

CONCLUSION

Both extracts exhibited a protective effect, with the EA extract exhibiting greater potency. L-canavanine acted as a co-mutagen in a dose response manner without metabolic activation. It is suggested that the EA extract be priotized for future development work as it showed a better risk profile and activity.

Herbal Hepatotoxicity: Clinical Characteristics and Listing Compilation

Herb induced liver injury (HILI) and drug induced liver injury (DILI) share the common characteristic of chemical compounds as their causative agents, which were either produced by the plant or synthetic processes. Both, natural and synthetic chemicals are foreign products to the body and need metabolic degradation to be eliminated. During this process, hepatotoxic metabolites may be generated causing liver injury in susceptible patients. There is uncertainty, whether risk factors such as high lipophilicity or high daily and cumulative doses play a pathogenetic role for HILI, as these are under discussion for DILI. It is also often unclear, whether a HILI case has an idiosyncratic or an intrinsic background. Treatment with herbs of Western medicine or traditional Chinese medicine (TCM) rarely causes elevated liver tests (LT). However, HILI can develop to acute liver failure requiring liver transplantation in single cases. HILI is a diagnosis of exclusion, because clinical features of HILI are not specific as they are also found in many other liver diseases unrelated to herbal use. In strikingly increased liver tests signifying severe liver injury, herbal use has to be stopped. To establish HILI as the cause of liver damage, RUCAM (Roussel Uclaf Causality Assessment Method) is a useful tool. Diagnostic problems may emerge when alternative causes were not carefully excluded and the correct therapy is withheld. Future strategies should focus on RUCAM based causality assessment in suspected HILI cases and more regulatory efforts to provide all herbal medicines and herbal dietary supplements used as medicine with strict regulatory surveillance, considering them as herbal drugs and ascertaining an appropriate risk benefit balance.

Scientific and Regulatory Perspectives in Herbal and Dietary Supplement Associated Hepatotoxicity in the United States

In the United States (US), the risk of hepatotoxicity linked to the widespread use of certain herbal products has gained increased attention among regulatory scientists. Based on current US law, all dietary supplements sold domestically, including botanical supplements, are regulated by the Food and Drug Administration (FDA) as a special category of foods. Under this designation, regulatory scientists do not routinely evaluate the efficacy of these products prior to their marketing, despite the content variability and phytochemical complexity that often characterizes them. Nonetheless, there has been notable progress in the development of advanced scientific methods to qualitatively and quantitatively measure ingredients and screen for contaminants and adulterants in botanical products when hepatotoxicity is recognized.

Herbal hepatotoxicity in traditional and modern medicine: actual key issues and new encouraging steps

Plants are natural producers of chemical substances, providing potential treatment of human ailments since ancient times. Some herbal chemicals in medicinal plants of traditional and modern medicine carry the risk of herb induced liver injury (HILI) with a severe or potentially lethal clinical course, and the requirement of a liver transplant. Discontinuation of herbal use is mandatory in time when HILI is first suspected as diagnosis. Although, herbal hepatotoxicity is of utmost clinical and regulatory importance, lack of a stringent causality assessment remains a major issue for patients with suspected HILI, while this problem is best overcome by the use of the hepatotoxicity specific CIOMS (Council for International Organizations of Medical Sciences) scale and the evaluation of unintentional reexposure test results. Sixty five different commonly used herbs, herbal drugs, and herbal supplements and 111 different herbs or herbal mixtures of the traditional Chinese medicine (TCM) are reported causative for liver disease, with levels of causality proof that appear rarely conclusive. Encouraging steps in the field of herbal hepatotoxicity focus on introducing analytical methods that identify cases of intrinsic hepatotoxicity caused by pyrrolizidine alkaloids, and on omics technologies, including genomics, proteomics, metabolomics, and assessing circulating micro-RNA in the serum of some patients with intrinsic hepatotoxicity. It remains to be established whether these new technologies can identify idiosyncratic HILI cases. To enhance its globalization, herbal medicine should universally be marketed as herbal drugs under strict regulatory surveillance in analogy to regulatory approved chemical drugs, proving a positive risk/benefit profile by enforcing evidence based clinical trials and excellent herbal drug quality.

Adverse drug reactions in some African herbal medicine: literature review and stakeholders' interview

BACKGROUND

In view of the large consumption of herbal medicine in Africa countries, it is likely that many adverse drugs reactions go unrecorded with either patients failing to present to health services, or no pharmacovigilance analysis being made, or the analysis not being reported centrally. This problem is of interest especially for those who are working in the general area of adverse drug reactions or stakeholders in the domain of herbal medicine for considering safety issues.

METHODS

We are particularly interested in the way that the use of very well-known and highly valued plants is linked to the observation of adverse drug reactions in African countries. We investigated, through a literature review and using the Internet (with a semantic search strategy), some well-known or popular medicinal plants used in African herbal medicine (AHM). Other information on the properties related to use, and characteristics of medicinal plants was complemented by some interviews with stakeholders.

RESULTS

Although substantial progress has been made in elucidating the mechanisms of action of many drugs, the pharmacological actions of many medicinal plants are generally not well understood. The results of a literature review suggest that the reported adverse drug reactions of herbal remedies are often due to a lack of understanding of their preparation and appropriate use. The results of stakeholders' interviews suggest that there is a growing need to provide patients with correct information about the herbal medicines they consume.

CONCLUSION

An important aspect of herbal medicine is the correct, timely, and integrated communication of emerging data on risk as an essential part of pharmacovigilance, which could actually improve the health and safety of patients. This calls for improved collaboration between traditional practitioners and modern healthcare professionals, researchers, and drug regulatory authorities. In addition, there is a need for an adverse drug reaction reporting system to facilitate the collection, monitoring, and evaluation of adverse drug events.

Plants traditionally used individually and in combination to treat sexually transmitted infections in northern Maputaland, South Africa: antimicrobial activity and cytotoxicity

ETHNOPHARMACOLOGICAL RELEVANCE

Although medicinal plants are used extensively to treat sexually transmitted infections (STIs) in rural northern Maputaland, KwaZulu-Natal, the efficacy and safety of these plants have not previously been evaluated.

AIM OF STUDY

A study was designed to investigate the in vitro antimicrobial activity and cytotoxicity profiles of a selection (individual plants and selected combinations) of traditionally used plants in this study area.

MATERIALS AND METHODS

Aqueous and organic (dichloromethane: methanol, 1:1) extracts were prepared. Antimicrobial activity was assessed using the minimum inhibitory concentration (MIC) assay against the STI associated pathogens; Candida albicans ATCC 10231, Ureaplasma urealyticum clinical strain, Oligella ureolytica ATCC 43534, Trichomonas vaginalis clinical strain, Gardnerella vaginalis ATCC 14018 and Neisseria gonorrhoeae ATCC 19424. For the combination study, interactions were assessed using the fractional inhibitory concentration (ΣFIC). The plant species were assessed for safety using the 3-[4,5-dimethyl-2-thiazol-yl]-2,5-diphenyl-2H-tetrazolium bromide (MTT) cellular viability assay on the human embryonic kidney epithelial (Graham, HEK-293) cell line.

RESULTS

For the antimicrobial studies, U. urealyticum was the most sensitive of the six test organisms, with the aqueous extract of Ranunculus multifidus (0.02mg/ml) and the organic extract of Peltophorum africanum (0.04mg/ml) being the most antimicrobially active plant species studied. Sclerocarya birrea was found to have the broadest spectrum of activity (mean MIC of 0.89mg/ml). The only plant species to exhibit some degree of cytotoxicity against the kidney epithelial cell line was Kigelia africana (100µg/ml), with 22% and 16% cell death for the aqueous and organic extracts, respectively. Of the 13 combinations studied, several synergistic combinations were evident, the most prominent being the combination of Albizia adianthifolia and Trichilia dregeana (aqueous extract) with an ΣFIC value of 0.15 against O. ureolytica. Synergistic interactions were observed regardless of the ratio of the aqueous mixtures of the two plants. Syzygium cordatum and S. birrea (aqueous extract) was also a combination of interest, demonstrating synergistic (ΣFIC=0.42) interactions against O. ureolytica. This combination, however, also displayed some cytotoxicity towards the human epithelial cell line.

CONCLUSION

This study demonstrated that anecdotal evidence of plant use does not always correlate with in vitro activity. Furthermore, the toxicological profiling is of utmost importance as if not combined in its correct ratio can lead to potential adverse effects.

Toxicology of some important medicinal plants in southern Africa

Africa is home to two major floral kingdoms: the Paleotropical kingdom of central Africa and the Capensis kingdom of the Western Cape province of South Africa, the latter of which consists of approximately 10,000 species, representing about 20% of Africa's floral 'gold mine', better known as the Cape herbal medicine. Needless to say, such rich flora comes with numerous plants with a potential to cause poisoning to humans. This review document reports important toxic medicinal plants and their toxic ingredients for plant species resident in the southern African region. These include important medicinal uses and pharmacological properties ranging from antimicrobial, antiviral, anticancer, anti-inflammatory as well as those that are used as aphrodisiacs and for maternal health care.

Evaluation of the Bronchorelaxant, Genotoxic, and Antigenotoxic Effects of Cassia alata L

Aqueous-ethanolic extract of Cassia alata (AECal) and its derived fractions obtained through liquid-liquid fractionation were evaluated for their bronchorelaxant, genotoxic, and antigenotoxic effects. Contractile activity of rats' tracheas in the presence of tested materials, as well as its modifications with different inhibitors and blockers, was isometrically recorded. The antigenotoxic potential of AECal was evaluated on cyclophosphamide- (CP-) induced genotoxicity in the rat. Animals were pretreated with the extract, then liver comet assay was performed. AECal and its chloroformic fractions (CF-AECal) relaxed the contraction induced by Ach, but both were significantly less potent in inhibiting contraction induced by KCl (30 mM; 80 mM). Propranolol, indomethacin, L-NAME, methylene blue, and glibenclamide did not modify the relaxant effect of CF-AECal. TEA altered the response of trachea to CF-AECal. CF-AECal caused a rightward shift without affecting the E max in cumulative concentration-response curves of Ach only at low concentrations. In animals pretreated with the extract, the percentage of CP-induced DNA damage decreased. Our results suggest that (1) muscarinic receptors contribute at least in part to the relaxant effects of CF-AECal; (2) CF-AECal interferes with membrane polarization; and (3) AECal is not genotoxic in vivo and contains chemopreventive phytoconstituents offering protection against CP-induced genotoxicity.

Review article: herbal and dietary supplement hepatotoxicity

BACKGROUND

Herbal and dietary supplements are commonly used throughout the World. There is a tendency for underreporting their ingestion by patients and the magnitude of their use is underrecognised by Physicians. Herbal hepatotoxicity is not uncommonly encountered, but the precise incidence and manifestations have not been well characterised.

AIMS

To review the epidemiology, presentation and diagnosis of herbal hepatotoxicity. This review will mainly discuss single ingredients and complex mixtures of herbs marketed under a single label.

METHODS

A Medline search was undertaken to identify relevant literature using search terms including 'herbal', 'herbs', 'dietary supplement', 'liver injury', 'hepatitis' and 'hepatotoxicity'. Furthermore, we scanned the reference lists of the primary and review articles to identify publications not retrieved by electronic searches.

RESULTS

The incidence rates of herbal hepatotoxicity are largely unknown. The clinical presentation and severity can be highly variable, ranging from mild hepatitis to acute hepatic failure requiring transplantation. Scoring systems for the causality assessment of drug-induced liver injury may be helpful, but have not been validated for herbal hepatotoxicity. Hepatotoxicity features of commonly used herbal products, such as Ayurvedic and Chinese herbs, black cohosh, chaparral, germander, greater celandine, green tea, Herbalife, Hydroxycut, kava, pennyroyal, pyrrolizidine alkaloids, skullcap, and usnic acid, have been individually reviewed. Furthermore, clinically significant herb-drug interactions are also discussed.

CONCLUSIONS

A number of herbal medicinal products are associated with a spectrum of hepatotoxicity events. Advances in the understanding of the pathogenesis and the risks involved are needed to improve herbal medicine safety.

Herbal hepatotoxicity: a tabular compilation of reported cases

BACKGROUND

Herbal hepatotoxicity is a field that has rapidly grown over the last few years along with increased use of herbal products worldwide.

AIMS

To summarize the various facets of this disease, we undertook a literature search for herbs, herbal drugs and herbal supplements with reported cases of herbal hepatotoxicity.

METHODS

A selective literature search was performed to identify published case reports, spontaneous case reports, case series and review articles regarding herbal hepatotoxicity.

RESULTS

A total of 185 publications were identified and the results compiled. They show 60 different herbs, herbal drugs and herbal supplements with reported potential hepatotoxicity, additional information including synonyms of individual herbs, botanical names and cross references are provided. If known, details are presented for specific ingredients and chemicals in herbal products, and for references with authors that can be matched to each herbal product and to its effect on the liver. Based on stringent causality assessment methods and/or positive re-exposure tests, causality was highly probable or probable for Ayurvedic herbs, Chaparral, Chinese herbal mixture, Germander, Greater Celandine, green tea, few Herbalife products, Jin Bu Huan, Kava, Ma Huang, Mistletoe, Senna, Syo Saiko To and Venencapsan(®). In many other publications, however, causality was not properly evaluated by a liver-specific and for hepatotoxicity-validated causality assessment method such as the scale of CIOMS (Council for International Organizations of Medical Sciences).

CONCLUSIONS

This compilation presents details of herbal hepatotoxicity, assisting thereby clinical assessment of involved physicians in the future.

Structural characterization and antimicrobial evaluation of atractyloside, atractyligenin, and 15-didehydroatractyligenin methyl ester

We report the first complete structure elucidation of the ent-kaurane diterpenoid glycoside atractyloside (1) by means of NMR and X-ray diffractometry techniques. Extensive one- and two-dimensional NMR experiments were employed to assign the proton and carbon signals of 1, and crystallography experiments established the configurations of all stereogenic centers. Furthermore, we present a novel semisynthetic route for the preparation of the highly cytotoxic aglycone derivative of 1, 15-didehydroatractyligenin methyl ester (3). All compounds were tested for their antibiotic activity against Enterococcus faecalis, Escherichia coli, and several strains of Staphylococcus aureus, including fluoroquinolone-resistant (SA1199B) and two epidemic MRSA (EMRSA-15 and -16) strains. Compound 3 exhibited moderate activity against all of the Staph. aureus strains with an MIC value of 128 mg/L.

Nephrotoxicity of alternative medicine practice

The use of alternative medicine is highly prevalent around the world; in many areas, this is so because of lack of access to, or trust in, Western medicine, and also because they are considered "natural" and therefore safe. The kidney is an organ vulnerable to toxic insults by virtue of its anatomy and function. Reports of nephrotoxicity associated with alternative medicine use encompass all forms of renal dysfunction, ranging from electrolyte abnormalities and proteinuria to acute and CKD, renal failure, and death. In countries where intensive care and dialysis support are not available, mortality is high. Mechanisms of alternative medicine-associated kidney injury include direct nephrotoxicity, which may be augmented by underlying predisposing conditions such as dehydration; contamination, or adulteration of remedies; inappropriate use or preparation of a remedy; or interactions with other medications. The use of alternative medicines is underreported to clinicians. Because many patients strongly believe in the powers of alternative medicines, it is important that alternative medicines not be demonized as a whole, but that their use and consequences be closely observed and reported to build a more comprehensive understanding of their impact in our clinical practice and to foster research on the potential harm or, in some cases, possible benefits.

Pharmacological, genotoxic and phytochemical properties of selected South African medicinal plants used in treating stomach-related ailments

ETHNOPHARMACOLOGICAL RELEVANCE

The evaluated medicinal plants are used in South African traditional medicine in treating stomach-related ailments.

AIMS OF THE STUDY

The study aimed at evaluating the pharmacological, genotoxic and phytochemical properties of the seven selected medicinal plants used for treating stomach-related ailments.

MATERIALS AND METHODS

Ethyl acetate (EtOAc), ethanol (EtOH) 70% and water extracts of the selected plant parts were evaluated for their antimicrobial and anthelmintic activities using microdilution assays. Gram-positive bacteria (Enterococcus faecalis and Staphylococcus aureus), Gram-negative bacterium (Escherichia coli) and Candida albicans were used for antimicrobial assays. Caenorhabditis elegans was used for the anthelmintic assay. Plant extracts were also assayed for their cyclooxygenase-inhibitory activity against cyclooxygenase-1 and -2 enzymes. The Ames test was used to evaluate the genotoxicity of the plant extracts. A spectrophotometric method was used to determine the total phenolics, gallotannins, flavonoids and saponins.

RESULTS

Twelve extracts exhibited minimum inhibitory concentration (MIC) <1 mg/mL against the bacterial test strains, and five extracts exhibited MIC <1 mg/mL against Candida albicans. The EtOAc extract of Tetradenia riparia had the best minimum lethal concentration (MLC) value (0.004 mg/mL) against Caenorhabditis elegans. All the EtOAc extracts exhibited percentage inhibition in the range of 50.7-94.7% against COX-1 and -2 enzymes at 250 μg/mL. All the plant extracts were non-mutagenic towards Salmonella typhimurium tester strains TA98, TA100 and TA1537 without metabolic activation. Phytochemical analysis revealed relatively high amounts of total phenolics, gallotannins and flavonoids in the evaluated plant extracts.

CONCLUSIONS

The general pharmacological activities exhibited by some of the plant extracts in this study support the traditional uses of the selected plants in treating stomach-related ailments. The Ames test showed that all the plant extracts were non-mutagenic but cytotoxicity tests are needed to ascertain the safety for long-term consumption.

Recommendations for the development of regulatory guidelines for registration of traditional medicines in South Africa

The regulation and registration of traditional medicines (TM) continues to present challenges to many countries regardless of the fact that an increased number of the population utilises TM for their health care needs. There have been improvements in the legal and policy framework of South Africa based on the WHO guidelines. However, there are currently no guidelines or framework for the registration of TM in South Africa. This article reviews literature and existing guidelines of specific countries and regions and makes recommendations for South African guidelines.

Acute toxicity and hepatotoxicokinetic studies of Tamarindus indica extract

Tamarindus indica is widely used as a food and beverage and in traditional medicine. The apparent lack of dose standardization in herbal medicine necessitates the evaluation of the lethality T. indica on Artemia salina nauplii and chicken embryos via in vitro and in vivo techniques. Furthermore, hepatotoxicokinetics of the crude extract and fractions on Wister rats was also assessed. At concentrations of 200, 20 and 2 µg/mL, crude extract and fractions showed brine shrimp death percentages ranging from 86.70% to 3.30% and the sub-fractions showed death percentage ranges of 46.70% to 3.30%. Calculated LD₅₀ values ranged from 832 µg/mL to 5,019 µg/mL. Dosing Wister rats with 25% and 50% concentration of LD₅₀ determined for crude extract and fractions on chicken embryos showed an elevation in the ALT and AST levels in the serum. Brine shrimps and chicken embryos showed a positive correlation, with R² values of 0.541 and 0.588 (P ≤ 0.05) for fractions and subfractions, respectively, as media for the lethality assay. Dose standardization in folk herbal medicine is imperative as T. indica used as food and medicine has been shown to be toxic at high doses. Brine shrimp and chicken embryos may be comparably used as medium for toxicity assay.

Isoniazid-associated hepatitis and antiretroviral drugs during tuberculosis prophylaxis in hiv-infected adults in Botswana

RATIONALE

Little is known about the incidence of isoniazid-associated hepatitis in HIV-infected Africans who receive both isoniazid preventive therapy (IPT) and antiretroviral therapy (ART).

OBJECTIVES

To assess the rate of and risk factors for isoniazid (INH)-associated hepatitis in persons living with HIV (PLWH) during IPT.

METHODS

PLWH recruited for a clinical trial received 6 months of open-label, daily, self-administered INH at public health clinics. At screening PLWH were excluded if they had any cough, weight loss, night sweats, or other illness. Alcohol abuse was defined as meeting any CAGE criterion. INH-associated hepatitis (INH-hepatitis) was defined as having either alanine or aspartate aminotransferase greater than 5.0 times the upper limit of normal regardless of symptoms when INH was not excluded as the cause.

MEASUREMENTS AND MAIN RESULTS

Of 1,995 PLWH enrolled between 2004 and 2006, 1,762 adhered to at least 4 months of IPT and were analyzed. Nineteen (1.1%) developed hepatitis probably or possibly associated with INH including one death at month 6; 14 of 19 (74%) occurred in months 1-3. Antiretroviral therapy (ART) was received by 480 participants but was not statistically associated with INH-hepatitis (relative risk [RR], 1.56; 95% confidence intervals [CI], 0.62-3.9); those receiving nevirapine had a higher rate (2.0%) than those receiving efavirenz (0.9%; P = 0.34). Although alcohol use did not reach significance (RR, 1.42; 95% CI, 0.57-3.51), meeting at least one CAGE criterion approached statistical significance (RR, 2.37; 95% CI, 0.96-5.84). Neither age greater than 35 years nor the presence of hepatitis B virus core antibody was associated with INH-hepatitis.

CONCLUSIONS

The observed rates of INH-hepatitis were similar to published data. Six months of IPT, which is recommended by the World Health Organization, was relatively safe in this, the largest cohort of African PLWH. Clinical trial registered with www.clinicaltrials.gov (NCT 00164281).

Toxicity studies on dermal application of plant extract of Dodonaea viscosa used in Ethiopian traditional medicine

Despite advances in the understanding of the medicinal properties of many herbs, the consumer today is confronted with the lack of or misinformation concerning the safety of these herbs that rivals the heyday of the patent medicine era. In the present study, Dodonaea viscosa (Sapindaceae), a medicinal plant commonly used for skin diseases in Ethiopia was subjected to a systematic dermatotoxicity study. To this effect, the dermatotoxicity of an 80% methanol extract of the leaf was investigated in animals following standard procedures for irritation, sensitization, acute toxicity and repeated toxicity tests. The skin irritation test in rabbits showed the extract to be a slight or negligibly slight irritant, with a primary irritation index of 0.45. A sensitization test in mice by the mouse ear swelling test method revealed the extract to be a non-sensitizer in the dose range 12-30 mg/mL. The percent responder was zero. The acute and repeated dermal toxicity tests on rats did not show any overt sign of toxicity. The findings of this study collectively indicate that dermal application of D. viscosa is not associated with any toxicologically relevant effects and the data could provide satisfactory preclinical evidence of safety to launch a clinical trial on a standardized formulation of the plant extracts.

[Study of four cases of poisoning by Atractylis gummifera L. in Morocco]

Atractylis gummifera L., a poisonous thistle responsible for frequent and sometimes mortal poisonings is known in Mediterranean region and in occident as this plant is used in alternative medicine. The clinical and biological data of four cases of poisoning in Morocco by Atractylis gummifera L. reported and discussed in this study will have to help to review this poisoning in order to inform better and to take care of the poisoned persons. Also this study may contribute to prevent the use of this plant in traditional medicine.

Herbal hepatotoxicity

There is appropriate concern about the potential risk for hepatotoxicity from herbal products because they are unregulated and therefore not standardized with regard to their contents. This is particularly the case for the crude herbals that are commonly formulated as a mixture, so that their ingredients may be ambiguous and even contain harmful contaminants. Presented here is an overview of the more commonly recognized herbal products that have been reported to be associated with liver injury. Although many of them are clearly implicated, there are some, particularly those identified solely through an occasional case report, for which the relationship is uncertain.

Evaluation of the mutagenic and antimutagenic effects of South African plants

Dichloromethane and 90% methanol extracts of 42 South African plants were screened for mutagenicity and antimutagenicity using the Salmonella/microsome mutagenicity assay (Ames) against Salmonella typhimurium TA98 and TA100 bacterial strains in the presence and absence of metabolic activator S9. The methanol extracts from whole plants of Helichrysum simillimum, Helichrysum herbaceum and Helichrysum rugulosum indicated mutagenicity. These are the first reported tests on the mutagenicity of Helichrysum species. Six species indicated antimutagenic properties, all in the presence of S9: methanol leaf extract of Bauhinia galpinii, and dichloromethane leaf extracts of Bauhinia galpinii, Clerodendrum myricoides, Datura stramonium, Buddleja saligna, Millettia sutherlandii and Sutherlandia frutescens.

Hepatotoxicity associated with herbal products

A significant number of herbal products have been associated with hepatotoxicity. Attribution of liver injury to a specific herbal pro-duct may be difficult. There are few clinical or laboratory manifestations that specifically suggest that liver injury is the result of aspecific herbal. Compounding this difficulty is that the patient may have liver disease from another cause, may be consuming other potentially hepatotoxic products, or may be using a contaminated herbal product. The most important clue often is the temporal relationship between initiation of the herbal product and the appearance of liver injury; of equal importance is the resolution of the injury following withdrawal of the herbal product.

Identification of atractyloside by LC-ESI-MS in alleged herbal poisonings

An LC-MS screening method was developed to detect the presence of atractyloside (ATR), the toxic principle of a commonly used medicinal plant in South Africa, Callilepis laureola, in biological matrices such as body fluids and human viscera.

Kidney injury from alternative medicines

In the developing world, up to 80% of the population uses traditional medicine for primary health care. In industrialized countries, adaptations of traditional medicine, termed "complementary" or "alternative" medicine (CAM), are used by a growing number of patients for preventive or palliative care. However, alternative medicine (AM) may be an important risk for the development of acute and chronic kidney injury because of several factors: nonconventional preparations rarely meet the required essential standards of consistency in composition and biological activity; many of these products contain undisclosed over-the-counter or prescription drugs or can be adulterated with hormones and glandular extracts; herbal preparations can be contaminated by pesticides and heavy metals; and because of errors in plant identification and confusing terminology, opportunities for mistakes and deliberate substitution can occur. Furthermore, there is a lack of reports of adverse events and drug interactions because of a lack of professional surveillance, and specific data on systemic and kidney toxicity are not easily available. Kidney injury/kidney syndromes caused by AM consist of acute tubular necrosis/toxicity (eg, Fanconi's syndrome), acute interstitial nephritis, papillary necrosis, hypertension, kidney stones, urinary retention, chronic tubulointerstitial nephritis with fibrosis, urinary tract carcinoma, and acute rejection of the kidney transplant. To improve the care for patients using AM, extension of physicians' knowledge about its possible hazards and toxicity is essential. This review deals with acute and chronic kidney toxicity caused by animal-, plant-, and mineral-based, nonconventional medicine and kidney failure caused by drug interactions with AM.

Assessing African medicinal plants for efficacy and safety: pharmacological screening and toxicology

This paper reviews progress in establishing the scientific rationale for and safety of traditional medicine use in Africa. Selected plants were screened for antibacterial, antifungal, anthelmintic, anti-amoebic, antischistosomal, antimalarial, anti-inflammatory and antioxidant activity, as well as psychotropic and neurotropic activity using appropriate in vitro tests. Isolation of active compounds, in almost all cases, provided scientific validation for the use of the plants in traditional medicine. Although plants used medicinally are widely assumed to be safe, many are potentially toxic. Where poisoning from traditional medicines has been reported, it is usually because the plants used have been misidentified in the form in which they are sold, or incorrectly prepared and administered by inadequately trained personnel. The issue of quality control may, in the interim, be addressed using chromatographic techniques.

The cytotoxic effects of a traditional Zulu remedy, impila (Callilepis laureola)

The traditional Zulu remedy impila (Callilepis laureola) can cause acute fatal hepatocellular necrosis, especially in children. We investigated the mechanism(s) of toxicity using HuH-7 hepatocytes. Impila tubers were extracted with boiling water and the aqueous extract was used at different concentrations to study the effects on the morphology of the cells. Flow cytometry and labelling with fluorescent antibodies to tubulin were also used. At high concentrations, necrosis occurred; however, at lower concentrations, the extracts gave rise to a variety of changes including hypercondensation of chromatin, multinucleate cells, nuclear fragmentation and apoptosis. In addition, we observed destruction of cytoplasmic tubulin. These findings give further insight into the mechanism of toxicity of herbal remedies containing atractyloside.

Mechanism of Impila (Callilepis laureola)-induced cytotoxicity in Hep G2 cells

OBJECTIVES

To determine the mechanism(s) of Impila (Callilepis laureola)-induced toxicity in human hepatoblastoma Hep G2 cells in vitro and the possible prevention of this toxicity by N-acetylcysteine (NAC).

DESIGN AND METHODS

Cells were treated with an aqueous extract of Impila (10 mg/mL) for up to 24 h. NAC (5 mM) was administered either concomitantly with Impila or one hour post Impila treatment. Cytotoxicity was quantitated spectrophotometrically by the metabolism of the tetrazolium dye MTT. Total glutathione (GSH) was measured using the Tietze assay.

RESULTS

Impila produced cytotoxicity and depleted GSH in a concentration- and time-dependent manner. A significant depletion in GSH was observed after 15 min (p < 0.0001 vs. control), whereas significant cytotoxicity was only observed after at least 3 h (p < 0.0001 vs. control). Both concomitant and posttreatment with NAC prevented Impila-induced GSH depletion and resulted in a significant decrease in Impila-induced cytotoxicity (p < 0.001 vs. NAC-untreated cells).

CONCLUSION

Our results suggest the mechanism of Impila-induced cytotoxicity in Hep G2 cells in vitro involves depletion of cellular GSH. Preventing GSH depletion by supplementing cells with NAC reduces cytotoxicity.