By Malaysian Pharmaceutical Society
The liver functions to create and break down proteins, fats and carbohydrates in addition to detoxifying normal metabolic wastes (such as urea) and consumed chemicals and medication. It also produces bile, blood-clotting factors, immune agents to control infections and various forms of fats.
What causes your liver to fail?
While liver damage has many causes, the most common causes are
* Viral hepatitis
* Prolonged exposure to chemicals and substances harmful to liver tissue (this includes certain medication and excessive alcohol intake)
* Excessive weight
* Diseases of the gallbladder and bile ducts
There are also other less common causes of liver damage such as hemochromatosis (a hereditary iron metabolism disorder that leads to progressive accumulation of iron in the liver, pancreas and heart), autoimmune disorders and conditions caused by genetic factors (such as Wilson’s disease which can be detected during childhood).
What are the signs and types of liver damage?
Common signs of acute liver disease include jaundice (becoming yellow), dark-coloured urine, abnormal liver tests, fatigue, muscle weakness, abdominal pain, itching. Chronic liver disease occurs as the disease progresses and becomes potentially irreversible. In this process, your liver may start to form scar tissue (a process known as fibrosis). At this point the liver will become an unhealthy orange discolouration – also known as cirrhosis (derived from the Greek word kirrhos, meaning ‘orange coloured’)
As the scarred tissue replaces normal healthy liver cells, blood flow will be impaired leading to a condition called portal hypertension which may lead to gastrointestinal bleeding (a common complication). Other conditions associated with chronic liver disease include ascites (the accumulation of excess fluid in the abdomen), hepatic encephalopathy (a neuropsychiatric disorder caused by liver damage which is characterized by changes in patient’s personality, level of consciousness and motor function).
How can we take care of our liver?
Preventing Liver Damage
As the old adage goes, ‘prevention is better than cure’. Preventable factors that may damage the liver are infections, alcohol and drug abuse, certain health conditions and medications. Therefore, these are factors within control of otherwise healthy individuals to prevent liver disease or damage. At the moment there is no established treatment to reverse the damage in chronic liver disease. Hence, the most effective way to reduce the disease progression would be to remove or avoid the primary causes.
Preventing Viral Hepatitis
There are five types of Viral Hepatitis (from Hepatitis A all the way to Hepatitis E). The most contagious of the two is Hepatitis A and E. Both Hepatitis A and E are associated with poor sanitary conditions, contaminated food and water. To prevent from getting these two, travellers (in particular to countries with poor sanitary conditions) need to be cautious with uncooked food and drinking water. In addition, Hepatitis A vaccination is recommended for high risk individuals.
Meanwhile, Hepatitis B, C and D are the less contagious version of the disease which are spread predominantly via the parenteral routh (such as injection drug users) and sexual contact (except Hepatitis C, which is uncommon). Vaccinations against Hepatitis B is highly recommended. In addition, exposure to viral hepatitis can be minimised by not having unprotected sex, multiple sexual partners and not sharing personal items that my have traces of blood, such as piereced earrings and shaving razors. Also, expecting mothers are recommended to screen for viral hepatitis as transmission may also occur through childbirth
Alcoholic steatohepatitis or fatty liver disease develops in individuals who habitually consume alcohol. Steatohepatitis is the accumulation of fat droplets within the liver cells. When the liver metabolizes consumed alcohol, fatty acids are synthesized. Liver cells that are too engorged with the fatty acids will rupture- once the rupture is extensive the inflammation process will begin, leading to tissue fibrosis.
Liver conditions associated with excessive alcohol intake will generally improve with abstinence from alcohol. Limiting or complete abstinence from alcohol within its early stages (before significant liver damage) may reverse the injury process, which may otherwise progress to liver cirrhosis. At this stage the damage cannot be reversed.
Patients who have already developed alcoholic fatty liver disease should abstain from alcohol consumption. Alcohol rehabilitation services may be employed where necessary in favor of the patient’s well being. Supplemental health-foods and vitamins are also recommended.
Drug or Toxin-Induced Liver Disease
The liver has a role in the metabolism of foreign substances in the body. Most substances are deactivated and rendered into a form that can be easily excreted by the body. However, this can also put the liver at higher risk of damage from prolonged exposure to potentially harmful substances.
Common signs that may suggest possible liver injury caused by drug or medication include nausea, fatigue and jaundice. Skin rash may also raise suspicion for toxicity. If toxicity is suspected do seek professional advice immediately. The causative substance (may be drugs or herbs) would usually have been started 5 to 90 days before the onset of symptoms.
The use of alternative medicine should also be taken into account – over the years many have abandoned herbal remedies in view of adverse reactions, not to mention the possible interactions with concurrent medication. Recreational drugs should not be disregarded as well. Amphetamines have been known to cause liver damage, resulting in death in some cases. Many of these recreational drugs contain adulterants which contribute to the incidence of liver damage.
Patients with liver diseases may require dosage adjustments in certain medications. This is because the current disease state may have altered the functional capacity of the liver; usually resulting in reduced drug metabolism and impaired elimination of the drug by the liver. Changes in the drug therapeutic response will follow whereby drug efficacy is reduced or in some cases (where impaired elimination is present) increased drug toxicity. Where neither dosage nor frequency adjustments will not help, an alternative drug can be considered. Therefore it is very important that patients with liver diseases notify the healthcare provider about their current condition- this will greatly enhance the ability of the healthcare provider to optimize their drug
Generally, drug induced liver conditions is quite rare. However here is a short list of the most common drugs it is commonly associated with.
NSAIDs (low risk)
Paracetamol (low risk)
Herbal Remedies & Chinese Medicines:
Ackee, Bajiaolian, Camphor, Cycasin, Kava, Horse Chestnut Leaf,
Valerian, Comfrey, Pyrrolizidine alkaloids, Jin Bu Huan, Ma-huang, Sho-wu-pian
Importantly, no single formulation has been identified that will universally improve signs and symptoms of liver disease. Liver diseases are potentially fatal and individuals should be cautioned against self-treatment. Nevertheless, dietary supplements and healthier lifestyle options are appropriate strategies to adopt in the prevention of any disease. Optimisation of such measures will require an individualized approach. There is no better healthcare professional to approach than the pharmacist to make an informed decision.
ASK THE PHARMACIST
This week, we interviewed Mr. Gan Ber Zin, a senior pharmacist running a community pharmacy in Seremban. He has many years of experience as a hospital pharmacist including being the former Chief Pharmacist of Seremban Hospital. He is also the recipient of the WHO Fellowship & the Excellence Service Award . In this Q&A section, we would like him to offer his professional opinion on liver problems and supplements that can be overcomed based on his experiences.
Q: What are types of supplements available as liver tonic?
Mr. Gan: There are many types of supplements available for liver in the market today. Majority of the liver tonics that are available in retail are botanical or natural based products. In order to choose the right product, one needs to make sure that the product is specific for the liver, safe and consistent. To make sure that the product is consistent, especially for botanical products, it needs to be standardised. Choosing standardised extract botanical product is vital because it offers consistency, safety and efficacy, which most of us would agree at.
Today, there are some liver tonics in the market which are already supported with clinical trials. There are some very important milestones for liver tonics in the market especially in Malaysia. There is one particular local botanical product for liver tonic which is already available in the government hospitals, making it to be the first local botanical product in Malaysia to be used in the Government Hospitals, and also being one of the government’s initiative programme in the National Key Economic Area (NKEA) for further development in clinical claims. This unique herb is called Phyllanthus niruri and it is already available in retail pharmacies, clinics and hospitals. So choosing a particular liver tonic is very important choice for a patient.
Q. How soon can I see the effect and what type of effect should I expect?
Mr. Gan: Liver complications are asymptomatic. In this case, pain is not an indication for a problem. To monitor improvements and duration of treatment for liver tonics, I usually recommend the patient to do a simple Liver Function Test at the nearest diagnostic centre. It is all depending on the alleviation and level of the liver enzymes (ALT & AST).
For some cases, I see improvement in the skin health and also patient feels more energetic or less lethargic. Usually I always recommend prevention before it gets too late because liver is one of the most important organ we have.
Q. Drug induced liver toxicity, should I worry about it, and how can I prevent it?
Mr. Gan: Every person, whether patient or health care professional should be concerned about the possibilities of drug induced liver toxicity, especially when there are quite many products that can cause liver damage which are readily available over the shelves in outlets not under the supervision of trained professionals, eg sundry retail outlets, supermarkets, coffee shops, etc. More than 900 drugs have been implicated in causing liver injury and it is the most common reason for a drug to be withdrawn from the market. Certain medicinal agents, when taken in overdoses and sometimes even when introduced within therapeutic ranges, may injure the organ. Other chemical agents, such as those used in laboratories and industries, natural chemicals (e.g. microcystins) and herbal remedies can also induce hepatotoxicity. Chemicals that cause liver injury are called hepatotoxins.
Q. Fatty Liver, what is the best supplement, can it be healed?
Mr. Gan: Liver is injured by chemicals, drugs (treatment), hepatitis B and C viruses, alcohol, and even obesity through a process known as liver membrane oxidation (LMO) or lipid peroxidation. That is, the liver toxins mentioned above will induce oxidation in the membrane of the liver cells. As a result of this injury, liver enzymes (ALT and AST) which are present in the cells will leak out from the cells and enter the blood circulation. Hence, liver injury can be detected by measuring these liver enzymes in the blood. In order to treat this liver injury, the LMO must be stopped.
Drug-induced liver toxicity is growing in a very alarming rate. Most of us do not realise that many drugs that are available for treatment or over the counter are toxic for our liver. Many are not aware that even paracetemol at high dosage is toxic to the liver. Reports have already showed that paracetamol toxicity is the foremost cause of acute liver failure in the Western world, and accounts for most drug overdoses in the United States, the United Kingdom, Australia and New Zealand. We should be worried about our liver, especially if we are on long term drug therapy. We need to protect our liver. The liver is absolutely crucial to life. Because it is responsible for so many vital functions, when the liver is damaged, your health is at stake.
Fatty liver is commonly associated with alcohol or metabolic syndrome e.g.: diabetes, hypertension, obesity and dyslipidemia. It can also be due to any one of many other causes. In order to improve fatty liver condition, one needs to start off with a good nutritional and food intake regime. Fruits and vegetables play an integral part for a good nutritional regime because we need good amount of fibres, vitamins and phytonutrients which is vital to reduce the oxidative stress in our body. We also need to exercise regularly and choose the right liver tonic to protect the liver and also reduce the LMO.
I found out that Hepar-P acts very specifically at the site of injury and stop lipid peroxidation or the LMO, thereby repair the liver injury caused by these liver toxins. This is crucial because we need a liver tonic which is specific for the liver, just like putting out the fire at the core of the problem.
Q. Normally what kind of customer will look for liver tonic supplement? Why?
Mr. Gan: Customers who have existing elevated liver enzymes (due to hepatitis, drugs or alcohol) are the biggest group of customers that want to take a liver tonic. There are also customers who want to protect their liver either because they are aware of the potential liver damage by the medicines they are consuming. The alcohol consumers is another big group of customers who want a liver tonic.
Q. I drink socially (1-2 times a week) in moderate amounts. Should I worry about alcohol induced liver problems?
Mr. Gan: In my honest opinion, everyone should be worried about their liver. Drinkers especially women should take extra precaution about their liver health. Social drinkers too need to be worry; though the risk is lower to be alarmed on alcohol induced liver problems. So once if there is a risk, there must always be a possibility of having alcohol induced liver problems. You do not have to get drunk for the disease to develop. Alcohol induced liver problem usually leads to inflammation of the liver, which then leads to cirrhosis and other liver complications.
As the old adage goes, prevention is better than cure. My advice is that one needs to have a good balance diet, consume a good amount of antioxidant supplements, go for a regular liver function test, exercise and to take good liver tonic for a healthy liver and a healthy life.
Q. Is there any supplements that I can take when I consume alcohol to lower the risks?
Mr. Gan: Normally most customer will look into big brands, direct selling products and well advertised products. I believe many customers do not know how to choose a good liver tonic which is suitable for them, simply because they are not trained and not getting the right advice from people around them. However it is very unfortunate that the public’s choice of a liver tonic are mostly influenced by the companies that does the most advertisements in the media or by the direct selling members who are trained to make exaggerated claims of the products they are merchandising . Hence there is a big role for community pharmacist to advise and recommend the most effective liver tonic, that is, to recommend what is best and most suitable for their clients to solve their problem and worries. For me, choosing a good liver tonic is very important. Without any hesitation a good liver tonic must act specifically for the liver, safe and is effective and consistent in their end result. There are not many products which act on that pathway or mode of action. I believe recommending a good liver tonic for my customers is vital because it helps them to solve their condition and it also improves their quality of life which will lead to a satisfied and happy customer; and these is what I target to do as a community pharmacist .
As mentioned earlier I find that Hepar-P acts very specifically at the site of injury and stop lipid peroxidation or the LMO, thereby repair the liver injury caused by liver toxins (alcohol been one of them).
1. ^ a b Daly FF, Fountain JS, Murray L, Graudins A, Buckley NA (March 2008). “Guidelines for the management of paracetamol poisoning in Australia and New Zealand—explanation and elaboration. A consensus statement from clinical toxicologists consulting to the Australasian poisons information centres”. Med J Aust 188 (5): 296–301. PMID 18312195.
2. ^ Khashab M, Tector AJ, Kwo PY (March 2007). “Epidemiology of acute liver failure”. Curr Gastroenterol Rep 9 (1): 66–73. doi:10.1007/s11894-008-0023-x.PMID 17335680.
3. Hawkins LC, Edwards JN, Dargan PI (2007). “Impact of restricting paracetamol pack sizes on paracetamol poisoning in the United Kingdom: a review of the literature”. Drug Saf 30 (6): 465–79.doi:10.2165/00002018-200730060-00002.PMID 17536874.
4. ^ a b Larson AM, Polson J, Fontana RJ, et al. (December 2005). “Acetaminophen-induced acute liver failure: results of a United States multicenter, prospective study” (PDF). Hepatology 42 (6): 1364–72.