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Two Patients with Acute Liver Injury Associated with Use of the Herbal Weight-Loss Supplement Hydroxycut
Stevens T, Qadri A, Zein NN.
Ann Intern Med. 2005 Mar 15;142(6):477-8.
TO THE EDITOR: Background: Many herbal supplements contain compounds that are potentially hepatotoxic. Newly formulated Hydroxycut (MuscleTech, Mississauga, Ontario, Canada) is a concoction of plant extracts designed to speed weight loss by increasing metabolism and curbing appetite.
Objective: To report 2 cases of severe hepatotoxicity associated with use of the weight-loss aid Hydroxycut.
Case Reports: Two men presented to our emergency department within a 2-month period and were admitted to the hospital. They were previously healthy and reported no recent foreign travel; sick contacts; or risk factors for viral, alcoholic, autoimmune, or hereditary liver disease. Except for Hydroxycut, they reported no recent use of herbal or prescription medications. Both underwent a similar serologic work-up, including viral studies (hepatitis A, B, and C viruses; Epstein–Barr virus; cytomegalovirus), antinuclear and anti– smooth-muscle antibody levels, acetaminophen level, and toxicology screening, which was unremarkable.
Patient 1, a 27-year-old man, presented with 8 days of fatigue and jaundice. He had been taking Hydroxycut for 5 weeks, 3 tablets 3 times per day. Laboratory analysis revealed a serum aspartate aminotransferase level of 1808 U/L (normal range, 5 to 50 U/L), a serum alanine aminotransferase level of 3131 U/L (normal range, 7 to 40 U/L), a bilirubin level of 133 micromol/L (7.8 mg/dL) (normal range, 0 to 26 micromol/L [0.0 to 1.5 mg/dL]), an alkaline phosphatase level of 171 U/L (normal, 40 to 150 U/L), an albumin level of 39 g/L (normal range, 35 to 50 g/L), a prothrombin time of 16 seconds (normal range, 9 to 13 seconds), and a platelet count of 208 X 109 cells/L (normal range, 150 to 400 X 109 cells/L). The aminotransferase levels peaked on hospital day 2 (aspartate aminotransferase level, 1969 U/L; serum alanine aminotransferase level, 3962 U/L). Four weeks later, results of the liver function tests had improved substantially (serum aspartate aminotransferase level, 114 U/L; serum alanine aminotransferase level, 304 U/L; bilirubin level, 22 micromol/L [1.3 mg/dL]).
Patient 2, a 30-year-old man, presented with 10 days of jaundice, fever, vomiting, and fatigue. For 5 days, between the 16th and 11th days before presentation, he had been taking 9 tablets of Hydroxycut per day. Except for jaundice and minimal abdominal tenderness, results of physical examination were normal. Laboratory analysis revealed a serum bilirubin level of 133 micromol/L (7.8 mg/dL), an alkaline phosphatase level of 530 U/L, an aspartate aminotransferase level of 59 U/L, a serum alanine aminotransferase level of 45 U/L, an albumin level of 28 g/L, a prothrombin time of 15 seconds, and a platelet count of 217 X 109 cells/L. An abdominal computed tomography scan and endoscopic retrograde cholangiogram were negative. On hospital day 4, liver biopsy revealed cholestasis and portal inflammation. The laboratory abnormalities improved, and the patient was discharged on hospital day 9. Two months later, results of liver tests were normal.
Discussion: To our knowledge, these are the first reported cases of hepatotoxicity associated with the use of Hydroxycut. Although the evidence reported here is not definitive, the lack of evidence for other causes and the temporal relationship of Hydroxycut ingestion to liver injury suggest a causative relationship. It is not clear which of the ingredients in Hydroxycut may have been responsible for hepatotoxicity.
A MEDLINE search did not reveal previous cases of hepatotoxicity resulting from Garcinia cambogia, Gymnema sylvestre, willow bark, glucomannan, green tea, or guarana extract. Patient 2 presented with a cholestatic liver injury pattern, and histologic examination confirmed portal inflammation and cholestasis.
Several herbs have been reported to produce cholestatic hepatitis including chaparral, kava, and Jin Bu Huan. Patient 1 presented with markedly elevated aminotransferase levels; although a biopsy was not obtained, hepatocyte necrosis was the likely pattern of injury. It is not unusual for a single herbal preparation to produce more than 1 type of clinicopathologic liver injury.
Conclusion: Evidence for the efficacy of Garcinia cambogia in promoting weight loss is not compelling. We therefore urge caution in the use of this supplement. Of broader concern are the widespread use of herbal preparations and lack of adequate monitoring of adverse outcomes.
Tyler Stevens, MD
Asif Qadri, MD
Nizar N. Zein, MD
Cleveland Clinic Foundation
Cleveland, OH 44118
Stevens T, Qadri A, Zein NN.
Ann Intern Med. 2005 Mar 15;142(6):477-8.
TO THE EDITOR: Background: Many herbal supplements contain compounds that are potentially hepatotoxic. Newly formulated Hydroxycut (MuscleTech, Mississauga, Ontario, Canada) is a concoction of plant extracts designed to speed weight loss by increasing metabolism and curbing appetite.
Objective: To report 2 cases of severe hepatotoxicity associated with use of the weight-loss aid Hydroxycut.
Case Reports: Two men presented to our emergency department within a 2-month period and were admitted to the hospital. They were previously healthy and reported no recent foreign travel; sick contacts; or risk factors for viral, alcoholic, autoimmune, or hereditary liver disease. Except for Hydroxycut, they reported no recent use of herbal or prescription medications. Both underwent a similar serologic work-up, including viral studies (hepatitis A, B, and C viruses; Epstein–Barr virus; cytomegalovirus), antinuclear and anti– smooth-muscle antibody levels, acetaminophen level, and toxicology screening, which was unremarkable.
Patient 1, a 27-year-old man, presented with 8 days of fatigue and jaundice. He had been taking Hydroxycut for 5 weeks, 3 tablets 3 times per day. Laboratory analysis revealed a serum aspartate aminotransferase level of 1808 U/L (normal range, 5 to 50 U/L), a serum alanine aminotransferase level of 3131 U/L (normal range, 7 to 40 U/L), a bilirubin level of 133 micromol/L (7.8 mg/dL) (normal range, 0 to 26 micromol/L [0.0 to 1.5 mg/dL]), an alkaline phosphatase level of 171 U/L (normal, 40 to 150 U/L), an albumin level of 39 g/L (normal range, 35 to 50 g/L), a prothrombin time of 16 seconds (normal range, 9 to 13 seconds), and a platelet count of 208 X 109 cells/L (normal range, 150 to 400 X 109 cells/L). The aminotransferase levels peaked on hospital day 2 (aspartate aminotransferase level, 1969 U/L; serum alanine aminotransferase level, 3962 U/L). Four weeks later, results of the liver function tests had improved substantially (serum aspartate aminotransferase level, 114 U/L; serum alanine aminotransferase level, 304 U/L; bilirubin level, 22 micromol/L [1.3 mg/dL]).
Patient 2, a 30-year-old man, presented with 10 days of jaundice, fever, vomiting, and fatigue. For 5 days, between the 16th and 11th days before presentation, he had been taking 9 tablets of Hydroxycut per day. Except for jaundice and minimal abdominal tenderness, results of physical examination were normal. Laboratory analysis revealed a serum bilirubin level of 133 micromol/L (7.8 mg/dL), an alkaline phosphatase level of 530 U/L, an aspartate aminotransferase level of 59 U/L, a serum alanine aminotransferase level of 45 U/L, an albumin level of 28 g/L, a prothrombin time of 15 seconds, and a platelet count of 217 X 109 cells/L. An abdominal computed tomography scan and endoscopic retrograde cholangiogram were negative. On hospital day 4, liver biopsy revealed cholestasis and portal inflammation. The laboratory abnormalities improved, and the patient was discharged on hospital day 9. Two months later, results of liver tests were normal.
Discussion: To our knowledge, these are the first reported cases of hepatotoxicity associated with the use of Hydroxycut. Although the evidence reported here is not definitive, the lack of evidence for other causes and the temporal relationship of Hydroxycut ingestion to liver injury suggest a causative relationship. It is not clear which of the ingredients in Hydroxycut may have been responsible for hepatotoxicity.
A MEDLINE search did not reveal previous cases of hepatotoxicity resulting from Garcinia cambogia, Gymnema sylvestre, willow bark, glucomannan, green tea, or guarana extract. Patient 2 presented with a cholestatic liver injury pattern, and histologic examination confirmed portal inflammation and cholestasis.
Several herbs have been reported to produce cholestatic hepatitis including chaparral, kava, and Jin Bu Huan. Patient 1 presented with markedly elevated aminotransferase levels; although a biopsy was not obtained, hepatocyte necrosis was the likely pattern of injury. It is not unusual for a single herbal preparation to produce more than 1 type of clinicopathologic liver injury.
Conclusion: Evidence for the efficacy of Garcinia cambogia in promoting weight loss is not compelling. We therefore urge caution in the use of this supplement. Of broader concern are the widespread use of herbal preparations and lack of adequate monitoring of adverse outcomes.
Tyler Stevens, MD
Asif Qadri, MD
Nizar N. Zein, MD
Cleveland Clinic Foundation
Cleveland, OH 44118
