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Black Cohosh, A Herbal Remedy, Induces Autoimmune Hepatitis: Presented at ACG

By Charlene Laino

BALTIMORE, MD -- October 23, 2003 -- Black cohosh, a herbal remedy used by some women to relieve symptoms of menopause, may cause serious liver problems, say physicians who have linked the alternative therapy to a case of autoimmune hepatitis.

"Physicians need to be aware of this herbal product, its uses and its dangers," said Stanley M. Cohen, MD, Assistant Professor of Medicine, University of Chicago, Illinois, United States. "If you have a female patient with an abnormal liver test or symptoms of liver disease, consider herbs -- specifically black cohosh -- as a cause.

Dr. Cohen presented the case report here on October 12^th at the 68^th Annual Scientific Meeting of the American College of Gastroenterology.

Dr. Cohen said that the use of black cohosh has increased since last year, when the Women's Health Initiative study demonstrated that use of oestrogen was associated with an increased risk of breast cancer and cardiovascular events.

"Since then, women have been looking for other products that can relieve menopausal symptoms," Dr. Cohen said, "and one of the most popular is black cohosh," known scientifically as Actaea racemosa.

According to Catherine Ulbricht, PharmD, RPh, founder and Editor of the Natural Standard Research Collaboration, which aggregates and synthesizes data on complementary therapies, several controlled trials and case series have reported black cohosh to improve menopausal symptoms.

"But although these initial studies are suggestive, they have been few in number and have universally suffered from methodological weaknesses," said Dr. Ulbricht, who is also Senior Attending Pharmacist, Massachusetts General Hospital, Boston, United States. "The mechanism of action of black cohosh remains unclear, and the effects on oestrogen receptors or hormonal levels (if any) have not been fully elucidated. Safety and efficacy data beyond six months are not available," she noted.

Dr. Cohen said his team came to the conclusion that the patient, a 57-year old woman, likely suffered from black cohosh-induced autoimmune hepatitis after ruling out more likely causes.

The woman, who came in complaining of increasing fatigue and lethargy over the past two weeks, suffered from diabetes mellitus and hypertension, Dr. Cohen said. For at least two years previously, she had been taking labetolol, fosinopril, verapamil, metformin, aspirin and insulin.

At the advice of her primary physician, this patient had recently stopped hormone replacement therapy. She started taking black cohosh 3 weeks prior to the onset of symptoms.

The patient said she did not drink, smoke or use intravenous drugs, and had no transfusions, tattoos or recent travel to areas where hepatitis is endemic.

Physical examination was unrevealing, Dr. Cohen said. Hepatitis A, B and C serologies and smooth-muscle antibodies were negative; however, the patient's alkaline phosphatase was mildly elevated, and antinuclear antibodies were positive at 1:640.

A liver biopsy revealed piecemeal necrosis and lobular infiltrates with extensive plasma cells and eosinophils, both features of autoimmune and drug-induced hepatitis, Dr. Cohen said.

The woman's symptoms completely resolved just 2 weeks after black cohosh was discontinued and a tapering course of prednisone was started, Dr. Cohen said. Liver function tests returned to normal about 9 weeks later.

While the team of physicians described this as the first case of autoimmune hepatitis likely induced by black cohosh, Dr. Cohen noted that a search of the literature revealed 5 other reports of associated hepatic toxicities -- 1 case of fulminant hepatic failure, 2 cases of hepatitis and 2 cases of mild elevation of liver enzymes.


[Study Title: A Case of Autoimmune Hepatitis Associated With the Use of Black Cohosh: Abstract 53]

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