Black cohosh hepatotoxicity

Mahady, G., T. Low Dog, D.N. Sarma, and G.I. Giancaspro. 2009. Suspected black cohosh hepatotoxicity—Causality assessment versus safety signal. Maturitas 64(2) 139-140. 

Teschke, R., R. Bahre, A. Genthner, et al. 2009. Suspected black cohosh hepatotoxicity—Challenges and pitfalls of causality assessment. Maturitas 63(4) 302-314. 

Teschke R, Bahre R, Fuchs J, Wolff A. Black cohosh hepatotoxicity quantitative causality evaluation in nine suspected cases. Menopause 2009 16(5) 956-65. 

Suspected black cohosh hepatotoxicity— challenges and pitfalls of causality assessment. Maturitas 2009 63(4) 302-14. 

Black cohosh has been one of the most studied herbal remedies for vasomotor symptoms, and it has not demonstrated a substantial benefit over placebo. The mechanism of action, safety profile, drug-drug interactions, and adverse effects of black cohosh remain unknown. In non-placebo-controlled trials conducted for 6 months or less, black cohosh demonstrated a small reduction in vasomotor symptoms. It has not been shown to be effective for vasomotor symptoms in women with breast cancer.33 There have been case reports of hepatotoxicity with the use of black cohosh.36 Caution should be exercised when considering the use of this product, especially in patients with liver dysfunction. 

Black cohosh Menopausal symptoms Hepatotoxicity Avoid1... 

Cases of hepatotoxicity have occurred these cases are rare given the widespread use of black cohosh. 

Herbal medicines are becoming more and more popular, and indeed some herbal products may be considered to benefit people with liver disease, e.g. Silybum marianum (milk thistle), Picrorhiza kurroa, Phyllanthus, etc. Herbal hepatotoxicity is increasingly being recognised, for example, with kava kava, black cohosh, and many traditional Chinese remedies. The range of liver injury includes minor transaminase elevations, acute and chronic hepatitis, steatosis, cholestasis, zonal or diffuse hepatic necrosis, veno-occlusive disease and acute liver failure. In addition to the potential for hepatotoxicity, herb-drug interactions may affect the safety and efficacy of concurrent medical therapy [15]. 

Broad attention has been paid to case reports of hepatotoxic-ity in persons taking black cohosh. An assessment by the European Medicines Agency (EMEA) of 7 published and 42 unpublished cases of hepatotoxicity reported in persons taking black cohosh products concluded, "Overall, all discussed cases of literature and pharmacovigilance reports are poorly documented" but nevertheless found three "possible" and two "probable" cases (EMEA 2006). Based on... 

A review of 69 published and unpublished case reports of black cohosh-associated hepatotoxicity indicated that there was an excluded, unlikely, unrelated, or unassess-able causality for black cohosh in 68 of 69 cases and "little, if any, supportive evidence for a significant hepatotoxic risk of black cohosh" (Teschke et al. 2009). Although one animal study on black cohosh rhizome has identified a biologically plausible mechanism of hepatotoxicity at high dose levels (Liide et al. 2007), no changes in liver enzyme levels have been observed in several human studies (Bai et al. 2007 Nasr and Nafeh 2009 Osmers et al. 2005 van Breemen et al. 2009). Healthcare practitioners and consumers should be aware of the possible association between products containing black cohosh and hepatotoxicity. 

Mahady, G.B., T. Low Dog, M.L. Barrett, et al. 2008. United States Pharmacopeia review of the black cohosh case reports of hepatotoxicity. Menopause 15(4) 628. 

Teschke, R., and A. Schwarzenboeck. 2009. Suspected hepatotoxicity by Cimicifugae racemosae rhizoma (black cohosh, root) Critical analysis and structured causality assessment. Phytomedicine 16(l) 72-84. 

The hepatotoxic effects of black cohosh have been analysed by the Dietary Supplement Information Expert Committee of the US Pharmacopeia s Council of Experts. Reports were obtained from diverse sources, including the European Medicines Agency [28 ]. There were 30 reports, all of which were considered to be possibly associated with the plant, using Naranjo s algorithm. The Expert Committee proposed that black cohosh products should be labeled with a cautionary statement. This is a change from a previous in 2002, which required no such statement. Meanwhile, other national regulatory authorities have issued similar warnings [29 , 30 , 31 , 32 ]. 

In contrast, in a prospective study of 87 postmenopausal women who took a dry extract of black cohosh 40 mg/day for 12 months total hepatic blood fiow, assessed by color Doppler ultrasound, was unaffected as were prothrombin time and concentration, serum albumin and bilirubin concentrations, and gamma-glutamyltransferase, alkaline phosphatase, and aminotransferase activities [33 ]. However, these results do not rule out an incidence of hepatotoxicity of up to 3.4%. 

Black cohosh Cimifuga racemosa), a member of the buttercup family, is a perennial plant that is native to North America. It is traditionally used for the treatment of rheumatism, rheumatoid arthritis, intercostal myalgia, sciatica, whooping cough, chorea, tinnitus, dysmenorrhoea and uterine colic. Several cases of hepatotoxicity requiring liver transplantation were associated with the use of black cohosh [27, 28, 29, 30 ]. 

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