http://www.medscape.com/viewarticle/463059
Black Cohosh Linked to Autoimmune Hepatitis
Charlene Laino
Oct. 16, 2003 (Baltimore) — Physicians reported this week the first case of autoimmune hepatitis likely induced by the use of black cohosh, an herbal remedy gaining popularity as an alternative to hormone replacement therapy (HRT) in the post-Women's Health Initiative era.
"Physicians need to be aware of this herbal product, its uses and its dangers," said Stanley M. Cohen, MD, assistant professor of medicine at the University of Chicago in Illinois. "If you have a female patient with an abnormal liver test or symptoms of liver disease, consider herbs, specifically black cohosh, as a cause."
He spoke with Medscape during a poster session here at the 68th annual scientific meeting of the American College of Gastroenterology.
The case report is an important reminder that physicians should always ask their patients about the use of herbal remedies, said Eamonn Quigley, MD, from the Department of Medicine at Cork University Hospital in Ireland.
"For the most part, they won't tell you unless you ask," he said. "Many physicians have made the assumption that herbal remedies are innocuous, but we now know they are not."
Dr. Quigley noted that several studies have shown high use of herbal products among patients with liver disease.
The use of black cohosh has increased since last year, when the Women's Health Initiative study demonstrated that use of HRT 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," also known 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, including hot flashes, mood disturbances, diaphoresis, palpitations, and vaginal dryness, for up to six months.
"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 a senior attending pharmacist at Massachusetts General Hospital in Boston.
"The mechanism of action of black cohosh remains unclear, and the effects on estrogen receptors or hormonal levels, if any, have not been fully elucidated. Safety and efficacy data beyond six months are not available," she added.
Dr. Cohen and colleagues came to the conclusion that their patient, a 57-year old woman, likely suffered from black cohosh–induced autoimmune hepatitis after exhaustive examination.
The woman, who presented with history of increasing fatigue and lethargy for two weeks, was receiving treatment for diabetes mellitus and hypertension, he said. For at least two years, she had been taking labetolol, fosinopril, verapamil, metformin, aspirin, and insulin.
At the advice of her primary physician, she had recently stopped HRT. She had started taking black cohosh three weeks prior to the onset of symptoms.
The patient said she did not drink, smoke, or use intravenous drugs, and had had no transfusions, tattoos, or recent travel to areas in which hepatitis is endemic.
Physical examination was unrevealing, Dr. Cohen said. Hepatitis A, B, and C serologies and smooth muscle antibodies were negative, but 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.
Black cohosh was discontinued, and the woman's symptoms resolved completely after two weeks. A tapering course of prednisone was started, Dr. Cohen said, and liver function tests were back to normal about nine weeks later.
Although this is the first reported case of autoimmune hepatitis likely induced by black cohosh, Dr. Cohen noted that a search of the literature revealed five other reports of associated hepatic toxicities — one case of fulminant hepatic failure, two cases of hepatitis, and two cases of mild elevation of liver enzymes.
"Patients on black cohosh should be monitored for evidence of hepatic dysfunction," Dr. Cohen said. "If physicians look for this, we'll be seeing more cases."
ACG 68th Annual Scientific Meeting: Abstract 53. Presented Oct. 12, 2003.
Black Cohosh Linked to Autoimmune Hepatitis 
