Herbal hepatotoxicity: Challenges and pitfalls of causality assessment methods

Table 1 Essential steps of herbal hepatotoxicity assessments

Quality specifications
Herbal product quality
Good agricultural practices
Good manufacturing practices
Definition of plant family, subfamily, species, subspecies, and variety
Definition of plant part
Definition of solvents and solubilizers
Lack of impurities, adulterants, and misidentifications
Minimum of batch and product variability
Lack of variety to variety variability
Clinical assessment quality
Brand name with details of ingredients, plant parts, batch number, and expiration date
Identification as herbal drug or herbal supplement
Herb as an ingredient of a polyherbal product or an undetermined herbal product
Manufacturer with address
Indication of herbal use with dates of symptoms leading to herbal treatment
Daily dose with details of the application form
Exact date of herb start and herb end
Accurate dates of emerging new symptoms after herb start in chronological order
Accurate date of initially increased liver values
Timeframes of challenge, latency period, and dechallenge
Verification or exclusion of a temporal association
Provided temporal association is verified, evaluation of a causal relationship
Gender, age, body weight, height, body mass index
Ethnicity, profession
Past medical history regarding general diseases and specifically liver diseases
ALT value initially including normal range
ALT values during dechallenge at least on days 8 and 30, as well as later on
ALT values during dechallenge to exclude a second peak
ALT normalization with exact date and actual value
ALP value initially including normal range
ALP values during dechallenge up to 180 d, as well as later on
ALP values during dechallenge to exclude a second peak
ALP normalization with exact date and actual value
AST value initially including normal range
Laboratory criteria for definition of hepatotoxicity and its pattern
Definition of risk factors such as age and alcohol
Alcohol and drug use
Statement regarding actual treatment including steroids or ursodesoxycholic acid
Assessment of preexisting and coexisting liver unrelated diseases
Assessment of preexisting and coexisting liver diseases
Consideration of the several hundreds of other possible liver diseases
Providing details to exclude alternative diagnoses
Assessment and exclusion of hepatitis A virus, hepatitis B virus, hepatitis C virus, hepatitis E virus, cytomegalovirus, Epstein-Barr virus, HSV, VZV
Liver and biliary tract imaging including color Doppler sonography of liver vessels
Specific evaluation of alcoholic, cardiac, autoimmune, and genetic liver diseases
Individual quantitative score of each alternative diagnosis
Comedicated synthetic drugs, herbal drugs, herbal and other dietary supplements
Definition of and search for accidental, unintended reexposure
Assessing of unintended reexposure
Search for evidence of prior known hepatotoxicity of the suspected herb
Assessing of known hepatotoxicity caused by the herb
Qualified data acquisition and documentation of complete data
Transparent presentation of all data
Causality assessment quality
Prospective assessment by the physician suspecting herb induced liver injury
Structured and quantitative method
Liver specific causality assessment method validated for hepatotoxicity
Use of the CIOMS scale
Gathering of all data required for the CIOMS scale item by item
Presentation of individual CIOMS items and of scores to regulatory agency
Gathering all clinical data and presentation to regulatory agency
Excluding all alternative causes and presentation to regulatory agency
Regulatory case assessment by skilled hepatologist with clinical experience
Regulatory assessment with assistance of external experts
Transparent presentation of regulatory verified causality assessment results

Required quality specifications of herbal products refer to herbs, herbal drugs, and herbal supplements including herbal mixtures. ALT: Alanine aminotransferase; ALP: Alkaline phosphatase; AST: Aspartate aminotransferase; CIOMS: Council for International Organizations of Medical Sciences; HSV: Herpes simplex virus; VZV: Varicella zoster virus.

Table 2 Check list for herb induced liver injury diagnosis

Items to be assessed	Information obtained
	Yes	No	Partial
Brand name with batch number and expiration date	□	□	□
Indication of herbal use	□	□	□
Dates of symptoms leading to herbal treatment	□	□	□
Daily dose	□	□	□
Application form of herbal product	□	□	□
Exact date of herb start	□	□	□
Exact date of herb end	□	□	□
Accurate dates of emerging new symptoms after herb start in chronological order	□	□	□
Accurate date of initially increased liver values	□	□	□
Time frame of challenge	□	□	□
Time frame of latency period	□	□	□
Time frame of dechallenge	□	□	□
Verification of temporal association	□	□	□
Exclusion of temporal association	□	□	□
Gender, age, body weight, height, BMI	□	□	□
Ethnicity, profession	□	□	□
Past medical history and actual assessment regarding preexisting general diseases	□	□	□
Past medical history and actual assessment regarding preexisting liver diseases	□	□	□
Risk factors such as age and alcohol	□	□	□
Quantification of alcohol and drug use	□	□	□
Comedicated synthetic drugs, herbal drugs, herbal and other dietary supplements with all details of product, daily dose, exact dates of start and end of use, indication	□	□	□
ALT value initially including exact date and normal range	□	□	□
ALT values during dechallenge at least on days 8 and 30, and later on, with exact dates	□	□	□
ALT values during dechallenge to exclude a second peak, with exact dates	□	□	□
ALT normalization with exact date and actual value	□	□	□
ALP value initially including exact date and normal range	□	□	□
ALP values during dechallenge up to 180 d, and later on, with exact dates	□	□	□
ALP values during dechallenge to exclude a second peak, with exact dates	□	□	□
ALP normalization with exact date and actual value	□	□	□
AST value initially including normal range	□	□	□
Laboratory criteria for definition of hepatotoxicity	□	□	□
Laboratory criteria for injury pattern	□	□	□
Liver and biliary tract imaging including hepatobiliary sonography, CT, MRT, MRC	□	□	□
Color Doppler sonography of liver vessels	□	□	□
Unintended reexposure	□	□	□
Known hepatotoxicity caused by the herb	□	□	□
Consideration and exclusion of other possible causes	□	□	□
Hepatitis A	□	□	□
Anti-HAV-IgM
Hepatitis B	□	□	□
HBsAg, anti-HBc-IgM, HBV-DNA
Hepatitis C	□	□	□
Anti-HCV, HCV-RNA
Hepatitis E	□	□	□
Anti-HEV-IgM, anti-HEV-IgG, HEV-RNA
CMV	□	□	□
CMV-PCR, titer change for anti-CMV-IgM and anti-CMV-IgG
EBV	□	□	□
EBV-PCR, titer change for anti-EBV-IgM and anti-EBV-IgG
HSV	□	□	□
HSV-PCR, titer change for anti-HSV-IgM and anti-HSV- IgG
VZV	□	□	□
VZV-PCR, titer change for anti-VZV-IgM and anti-VZV-IgG
Other virus infections	□	□	□
Specific serology of Adenovirus, Coxsackie-B-virus, Echovirus, Measles virus, Rubella virus, Flavivirus, Arenavirus, Filovirus, Parvovirus, HIV, and others
Other infectious diseases	□	□	□
Specific assessment of bacteria, fungi, parasites, worms, and others
AIH type I	□	□	□
Gamma globulins, ANA, SMA, AAA, SLA/LP, anti-LSP, anti-ASGPR
AIH type II	□	□	□
Gamma globulins, anti-LKM-1 (CYP 2D6), anti-LKM-2 (CYP 2C9), anti-LKM-3
PBC	□	□	□
AMA, anti-PDH-E2
PSC	□	□	□
p-ANCA, MRC
AIC	□	□	□
ANA, SMA
Overlap syndromes	□	□	□
See AIH, PBC, PSC, and AIC
NASH	□	□	□
BMI, insulin resistance, hepatomegaly, echogenicity of the liver
ALD	□	□	□
Patient’s history, clinical and laboratory assessment, sonography
DILI	□	□	□
Patient’s history, clinical and laboratory assessment, sonography, use of the CIOMS scale
Cocaine, ecstasy and other amphetamines	□	□	□
Toxin screening
Rare intoxications	□	□
Toxin screening for household and occupational toxins
Hereditary hemochromatosis	□	□	□
Serum ferritin, total iron-binding capacity, genotyping for C2824 and H63D mutation, hepatic iron content
Wilson’s disease	□	□	□
Copper excretion (24 h urine), ceruloplasmin in serum, free copper in serum, Coombs-negative hemolytic anemia, hepatic copper content, Kayser-Fleischer-Ring, neurologic-psychiatric work-up, genotyping
Porphyria	□	□	□
Porphobilinogen in urine, total porphyrines in urine
α1-Antitrypsin deficiency	□	□	□
α1-Antitrypsin in serum
Biliary diseases	□	□	□
Clinical and laboratory assessment, hepatobiliary sonography, endosonography, CT, MRT, MRC
Pancreatic diseases	□	□	□
Clinical and laboratory assessment, sonography, CT, MRT
Celiac disease	□	□	□
TTG antibodies, endomysium antibodies, duodenal biopsy
Anorexia nervosa	□	□	□
Clinical context
Parenteral nutrition	□	□	□
Clinical context
Cardiopulmonary diseases with shock liver (cardiac hepatopathy, ischemic hepatitis)	□	□	□
Cardiopulmonary assessment of congestive heart disease, myocardial infarction, cardiomyopathy, cardiac valvular dysfunction, pulmonary embolism, pericardial diseases, arrhythmia, hemorrhagic shock, and various other conditions
Addison’s disease
Plasma cortisol	□	□	□
Thyroid diseases
TSH basal, T4, T3	□	□	□
Grand mal seizures
Clinical context of epileptic seizure (duration > 30 min)	□	□	□
Heat stroke
Shock, hyperthermia	□	□	□
Polytrauma
Shock, liver injury	□	□	□
Systemic diseases
Specific assessment of M. Boeck, amyloidosis, lymphoma, other malignant tumors, sepsis and others	□	□	□
Other diseases
Clinical context	□	□	□

For each listed item, detailed results obtained for the individual patient are to be supplemented within the checklist. BMI: Body mass index; ALT: Alanine aminotransferase; ALP: Alkaline phosphatase; AST: Aspartate aminotransferase; CT: Computer tomography; MRT: Magnetic resonance tomography; MRC: Magnetic resonance cholangiography; HAV: Hepatitis A virus; IgM: Immunoglobulin M; HBsAg: Hepatitis B antigen; HBc: Hepatitis B core; HBV: Hepatitis B virus; HCV: Hepatitis C virus; HEV: Hepatitis E virus; IgG: Immunoglobulin G; HIV: Human immunodeficiency virus; CMV: Cytomegalovirus; PCR: Polymerase chain reaction; EBV: Epstein Barr virus; HSV: Herpes simplex virus; VZV: Varicella zoster virus; AIH: Autoimmune hepatitis; ANA: Antinuclear antibodies; SMA: Smooth muscle antibodies; AAA: Anti-actin antibodies; SLA: Soluble liver antigen; LP: Liver-pancreas antigen; LSP: Liver specific protein; ASGPR: Asialo-glycoprotein-receptor; LKM: Liver kidney microsomes; CYP: Cytochrome P450; PBC: Primary biliary cirrhosis; AMA: Antimitochondrial antibodies; PDH: Pyruvate dehydrogenase; PSC: Primary sclerosing cholangitis; p-ANCA: Perinuclear antineutrophil cytoplasmatic antibodies; AIC: Autoimmune cholangitis; NASH: Non alcoholic steatohepatitis; ALD: Alcoholic liver disease; DILI: Drug induced liver injury; CIOMS: Council for International Organizations of Medical Sciences; TSH: Thyroid stimulating hormone.

Table 3 Methods of causality assessments for suspected herbal hepatotoxicity

Methods of causality assessment	Specific criteria of various causality assessment methods
	Expert based	Structured	Qualitative	Quantitative	Liver specific	Liver validated
Prospective evaluation
CIOMS scale	No	Yes	No	Yes	Yes	Yes
MV scale	No	Yes	No	Yes	Yes	Yes
Naranjo scale	No	Yes	No	Yes	No	No
KL method	No	Yes	Yes	No	No	No
Ad hoc approach	No	No	No	No	No	No
Retrospective evaluation
DILIN method	Yes	Yes	Yes	No	Yes	No
WHO method	Yes	Yes	No	No	No	No
Expert opinion	Yes	No	No	No	Yes	No

Compilation of details are derived from previous reports[2,3,60-62,76-79,81,89,102]. Council for International Organizations of Medical Sciences scale (CIOMS scale) refers to both the original scale[60] and its update (Tables 5 and 6)[62]. Liver-specific and liver-validated criteria reflect hepatotoxicity criteria. Expert based criterion refers to the requirement of several experts for the actual case under consideration. MV scale: Maria and Victorino scale; KL method: Karch and Lasagna method; DILIN method: Drug Induced Liver Injury Network method; WHO method: World Health Organization method.

Table 5 Updated Council for International Organizations of Medical Sciences scale for the hepatocellular type of injury with items required for causality assessment in herb induced liver injury cases

Items for hepatocellular injury	Possible score	Patient’s score
Time to onset from the beginning of the herb
5-90 d (rechallenge: 1-15 d)	+2
< 5 or > 90 d (rechallenge: > 15 d)	+1
Alternative: Time to onset from cessation of the herb
≤ 15 d (except for slowly metabolized herbal chemicals: > 15 d)	+1
Course of ALT after cessation of the herb
Percentage difference between ALT peak and N
Decrease ≥ 50% within 8 d	+3
Decrease ≥ 50% within 30 d	+2
No information or continued herbal use	0
Decrease ≥ 50% after the 30th day	0
Decrease < 50% after the 30th day or recurrent increase	-2
Risk factors
Alcohol use (drinks/d: > 2 for women, > 3 for men)	+1
No alcohol use (drinks/d: ≤ 2 for women, ≤ 3 for men)	0
Age ≥ 55 yr	+1
Age < 55 yr	0
Concomitant herbs(s) and drug(s)
None or no information	0
Concomitant herb or drug with incompatible time to onset	0
Concomitant herb or drug with compatible or suggestive time to onset	-1
Concomitant herb or drug known as hepatotoxin and with compatible or suggestive time to onset	-2
Concomitant herb or drug with evidence for its role in this case (positive rechallenge or validated test)	-3
Search for non drug causes
Group I (6 causes)
Anti-HAV-IgM
HBsAg, anti-HBc-IgM, HBV-DNA
Anti-HCV, HCV-RNA
Hepatobiliary sonography/colour Doppler sonography of liver vessels/endosonography/CT/MRC
Alcoholism (AST/ALT ≥ 2 IU/L)
Acute recent hypotension history (particularly if underlying heart disease)
Group II (6 causes)
Complications of underlying disease(s)
Infection suggested by PCR and titre change for
CMV (anti-CMV-IgM, anti-CMV-IgG)
EBV (anti-EBV-IgM, anti-EBV-IgG)
HEV (anti-HEV-IgM, anti-HEV-IgG)
HSV (anti-HSV-IgM, anti-HSV-IgG)
VZV (anti-VZV-IgM, anti-VZV-IgG)
Evaluation of group I and II
All causes-groups I and II- reasonably ruled out	+2
The 6 causes of group I ruled out	+1
5 or 4 causes of group I ruled out	0
Less than 4 causes of group I ruled out	-2
Non herb cause highly probable	-3
Previous information on hepatotoxicity of the herb
Reaction labelled in the product characteristics	+2
Reaction published but unlabelled	+1
Reaction unknown	0
Response to readministration
Doubling of ALT with the herb alone, provided ALT below 5N before reexposure	+3
Doubling of ALT with the herb(s) and drug(s) already given at the time of first reaction	+1
Increase of ALT but less than N in the same conditions as for the first administration	-2
Other situations	0
Total score for patient

The compilation of the individual items is adapted from the updated version of the Council for International Organizations of Medical Sciences (CIOMS) scale[62] and the original CIOMS scale[60]. The above items refer to the hepatocellular type of injury, whereas items for the cholestatic (± hepatocellular) type are presented in Table 6. Regarding risk factor of alcohol use, 1 drink commonly contains about 10 g ethanol[2,3,90]. Total score and resulting causality grading: ≤ 0, excluded; 1-2, unlikely; 3-5, possible; 6-8, probable; ≥ 9, highly probable. HAV: Hepatitis A virus; IgM: Immunoglobulin M; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; CMV: Cytomegalovirus; CT: Computer tomography; EBV: Epstein Barr virus; HBc: Hepatitis B core; HBsAg: Hepatitis B antigen; HBV: Hepatitis B virus; HCV: Hepatitis C virus; HEV: Hepatitis E; HILI: Herb induced liver injury; HSV: Herpes simplex virus; MRC: Magnetic resonance cholangiography; N: Upper limit of the normal range; VZV: Varicella zoster virus.

Table 6 Updated Council for International Organizations of Medical Sciences scale for the cholestatic (± hepatocellular) type of injury with items required for causality assessment in herb induced liver injury cases

Items for cholestatic (± hepatocellular) injury	Possible score	Patient’s score
Time to onset from the beginning of the herb
5-90 d (rechallenge: 1-90 d)	+2
< 5 or > 90 d (rechallenge: > 90 d)	+1
Alternative: Time to onset from cessation of the herb
≤ 30 d (except for slowly metabolized herbal chemicals: > 30 d)	+1
Course of ALP after cessation of the herb
Percentage difference between ALP peak and N
Decrease ≥ 50% within 180 d	+2
Decrease < 50% within 180 d	+1
No information, persistence, increase, or continued herbal use	0
Risk factors
Alcohol use (drinks/d: > 2 for women, > 3 for men) and pregnancy	+1
No alcohol use (drinks/d: ≤ 2 for women, ≤ 3 for men)	0
Age ≥ 55 yr	+1
Age < 55 yr	0
Concomitant herbs(s) and drug(s)
None or no information	0
Concomitant herb or drug with incompatible time to onset	0
Concomitant herb or drug with compatible or suggestive time to onset	-1
Concomitant herb or drug known as hepatotoxin and with compatible or suggestive time to onset	-2
Concomitant herb or drug with evidence for its role in this case (positive rechallenge or validated test)	-3
Search for non drug causes
Group I (6 causes)
Anti-HAV-IgM
HBsAg, anti-HBc-IgM, HBV-DNA
Anti-HCV, HCV-RNA
Hepatobiliary sonography/colour Doppler sonography of liver vessels/endosonography/CT/MRC
Alcoholism (AST/ALT ≥ 2 IU/L)
Acute recent hypotension history (particularly if underlying heart disease)
Group II (6 causes)
Complications of underlying disease(s)
Infection suggested by PCR and titre change for
CMV (anti-CMV-IgM, anti-CMV-IgG)
EBV (anti-EBV-IgM, anti-EBV-IgG)
HEV (anti-HEV-IgM, anti-HEV-IgG)
HSV (anti-HSV-IgM, anti-HSV-IgG)
VZV (anti-VZV-IgM, anti-VZV-IgG)
Evaluation of group I and II
All causes-groups I and II- reasonably ruled out	+2
The 6 causes of group I ruled out	+1
5 or 4 causes of group I ruled out	0
Less than 4 causes of group I ruled out	-2
Non herb cause highly probable	-3
Previous information on hepatotoxicity of the herb
Reaction labelled in the product characteristics	+2
Reaction published but unlabelled	+1
Reaction unknown	0
Response to readministration
Doubling of ALP with the herb alone, provided ALP below 5N before reexposure	+3
Doubling of ALP with the herb(s) and drug(s) already given at the time of first reaction	+1
Increase of ALP but less than N in the same conditions as for the first administration	-2
Other situations	0
Total score for patient

The compilation of individual items is adapted from the updated version of the Council for International Organizations of Medical Sciences (CIOMS) scale[62] and the original CIOMS scale[60]. The above items refer to the cholestatic (± hepatocellular) type of injury, whereas items for the hepatocellular type are presented in Table 5. Regarding risk factor of alcohol use, 1 drink commonly contains about 10 g ethanol[2,3,90]. Total score and resulting causality grading: ≤ 0, excluded; 1-2, unlikely; 3-5, possible; 6-8, probable; ≥ 9, highly probable. ALP: Alkaline phosphatase; N: upper limit of the normal range; HAV: Hepatitis A virus; IgM: Immunoglobulin M; HBsAg: Hepatitis B antigen; HBc: Hepatitis B core; HBV: Hepatitis B virus; HCV: Hepatitis C virus; CT: Computer tomography; MRC: Magnetic resonance cholangiography; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; PCR: Polymerase chain reaction; CMV: Cytomegalovirus; EBV: Epstein Barr virus; HEV: Hepatitis E virus; HSV: Herpes simplex virus; IgG: Immunoglobulin G; VZV: Varicella zoster virus.

Table 4 Details of the various causality assessment methods for herb induced liver injury

Assessed items with specific scores	CIOMS	MV	Naranjo	KL	Ad hoc	DILIN	WHO	Expert opinion
Time frame of latency period (score)	+	+	0	0	0	0	0	0
Time frame of challenge (score)	+	+	0	0	0	0	0	0
Time frame of dechallenge (score)	+	+	0	0	0	0	0	0
Recurrent ALT or ALP increase (score)	+	0	0	0	0	0	0	0
Definition of risk factors (score)	+	0	0	0	0	0	0	0
Verified alternative diagnoses (score)	+	+	0	0	0	0	0	0
Assessed HAV, HBV, HCV (score)	+	+	0	0	0	0	0	0
Assessed CMV, EBV, HSV, VZV (score)	+	+	0	0	0	0	0	0
Liver and biliary tract imaging (score)	+	0	0	0	0	0	0	0
Liver vessel Doppler sonography (score)	+	0	0	0	0	0	0	0
Assessed preexisting diseases (score)	+	0	0	0	0	0	0	0
Evaluated cardiac hepatopathy (score)	+	0	0	0	0	0	0	0
Excluded alternative diagnoses (score)	+	+	+	0	0	0	0	0
Comedication (score)	+	0	+	0	0	0	0	0
Prior known herbal hepatotoxicity (score)	+	+	+	0	0	0	0	0
Searched unintended reexposure (score)	+	+	+	0	0	0	0	0
Defined unintended reexposure (score)	+	+	0	0	0	0	0	0
Unintended reexposure (score)	+	+	0	0	0	0	0	0
Laboratory hepatotoxicity criteria	+	+	0	0	0	+	0	+
Laboratory hepatotoxicity pattern	+	+	0	0	0	+	0	+
Liver specific method	+	+	0	0	0	+	0	+
Structured, liver related method	+	+	0	0	0	+	0	0
Quantitative, liver related method	+	+	0	0	0	0	0	0
Validated method for hepatotoxicity	+	+	0	0	0	0	0	0

Items lacking specific scores were not considered, with the exception of the last six features. The data of the Drug Induced Liver Injury Network method are derived from the report of Rockey et al[102], references for the other methods are found in the text. Latency period indicates time from herb start to symptoms, alternatively to abnormal liver tests. The symbol + shows that this item is present and the symbol 0 indicates lack of this item. ALT: Alanine aminotransferase; ALP: Alkaline phosphatase; HAV: Hepatitis A virus; HBV: Hepatitis B virus; HCV: Hepatitis C virus; CMV: Cytomegalovirus; EBV: Epstein Barr virus; HSV: Herpes simplex virus; VZV: Varicella zoster virus; CIOMS: Council for International Organizations of Medical Sciences scale; MV: Maria and Victorino scale; KL: Karch and Lasagna method; DILIN: Drug-Induced Liver Injury Network method; WHO: World Health Organization method.

Table 7 Council for International Organizations of Medical Sciences scale as an example with items required for causality assessment in a patient with herb induced liver injury by four Indian Ayurvedic herbs

Items for hepatocellular injury	Possible score	Psoralea corylifolia	Acacia catechu	Eclipta alba	Vetivexia zizaniodis
Time to onset from the beginning of the herb
5-90 d (rechallenge: 1-15 d)	+2
< 5 d or > 90 d (rechallenge: > 15 d)	+1	+1	+1	+1	+1
Alternative: Time to onset from cessation of the herb
≤ 15 d (except for slowly metabolized herbal chemicals: > 15 d)	+1
Course of ALT after cessation of the herb
Percentage difference between ALT peak and N
Decrease ≥ 50% within 8 d	+3	+3	+3	+3	+3
Decrease ≥ 50% within 30 d	+2
No information or continued herbal use	0
Decrease ≥ 50% after the 30th day	0
Decrease < 50% after the 30th day or recurrent increase	-2
Risk factors
Alcohol use (drinks/d: > 2 for women, > 3 for men)	+1
No alcohol use (drinks/d: ≤ 2 for women, ≤ 3 for men)	0	0	0	0	0
Age ≥ 55 yr	+1	+1	+1	+1	+1
Age < 55 yr	0
Concomitant herbs(s) and drug(s)
None or no information	0
Concomitant herb or drug with incompatible time to onset	0
Concomitant herb or drug with compatible or suggestive time to onset	-1	-1
Concomitant herb or drug known as hepatotoxin and with compatible or suggestive time to onset	-2		-2	-2	-2
Concomitant herb or drug with evidence for its role in this case (positive rechallenge or validated test)	-3
Search for non herb causes
Group I (6 causes)
Anti-HAV-IgM		-	-	-	-
HBsAg, anti-HBc-IgM, HBV-DNA		-	-	-	-
Anti-HCV, HCV-RNA		-	-	-	-
Hepatobiliary sonography/colour Doppler sonography of liver vessels/endosonography/CT/MRC		-	-	-	-
Alcoholism (AST/ALT ≥ 2 IU/L)		-	-	-	-
Acute recent hypotension history (particularly if underlying heart disease)		-	-	-	-
Group II (6 causes)
Complications of underlying disease(s)		-	-	-	-
Infection suggested by PCR and titre change for
CMV (anti-CMV-IgM, anti-CMV-IgG)		-	-	-	-
EBV (anti-EBV-IgM, anti-EBV-IgG)		-	-	-	-
HEV (anti-HEV-IgM, anti-HEV-IgG)		-	-	-	-
HSV (anti-HSV-IgM, anti-HSV-IgG)		-	-	-	-
VZV (anti-VZV-IgM, anti-VZV-IgG)		-	-	-	-
Evaluation of group I and II
All causes-groups I and II-reasonably ruled out	+2	+2	+2	+2	+2
The 6 causes of group I ruled out	+1
5 or 4 causes of group I ruled out	0
Less than 4 causes of group I ruled out	-2
Non herb cause highly probable	-3
Previous information on hepatotoxicity of the herb
Reaction labelled in the product characteristics	+2
Reaction published but unlabelled	+1	+1
Reaction unknown	0		0	0	0
Response to readministration
Doubling of ALT with the herb alone, provided ALT below 5N before reexposure	+3
Doubling of ALT with the herb(s) and drug(s) already given at the time of first reaction	+1
Increase of ALT but less than N in the same conditions as for the first administration	-2
Other situations	0
Total score for each individual herb used by the patient		+7	+5	+5	+5

The data of the patient with severe hepatotoxicity by four different Indian Ayurvedic herbs are derived from a published report[58], using the updated Council for International Organizations of Medical Sciences scale for the hepatocellular type of liver injury (Table 5). The symbol - signifies that this particular item has been evaluated and no abnormality was found. Regarding risk factor of alcohol use, 1 drink commonly contains about 10 g ethanol[2,3,90]. For the four herbs, the total score was either 5 (possible causality) or 7 (probable causality). ALT: Alanine aminotransferase; N: Upper limit of the normal range; HBsAg: Hepatitis B antigen; HBc: Hepatitis B core; HAV: Hepatitis A virus; IgM: Immunoglobulin M; HBV: Hepatitis B virus; HCV: Hepatitis C virus; CT: Computer tomography; MRC: Magnetic resonance cholangiography; AST: Aspartate aminotransferase; PCR: Polymerase chain reaction; CMV: Cytomegalovirus; EBV: Epstein Barr virus; HEV: Hepatitis E virus; HSV: Herpes simplex virus; VZV: Varicella zoster virus.