July 2023

The Indian government has embarked on a no-holds-barred giloy promotion spree in the last two years, through the AYUSH and health ministries. According to doctors, giloy is forbidden for people who suffer from autoimmune disorders, and can lead to death if it is consumed in sufficiently large quantities. But no government agency has warned that people with autoimmune disorders should avoid giloy – a reckless position exacerbated by uncritical media coverage. New Delhi: The Ministry of AYUSH published a statement on February 16, 2022, on giloy – a plant that features in many Ayurvedic recipes. The ministry, and the Indian government by extension, has widely publicised this herb as an “immunity booster” during the COVID-19 pandemic. “Certain sections of the media have falsely linked … giloy/guduchi with liver damage,” the ministry statement read. “The Ministry of AYUSH reiterates that giloy/guduchi (Tinospora cordifolia) is safe and as per available data, guduchi does not produce any toxic effect.” Curiously, there have been no recent media reports criticising giloy. The most proximate event The Wire Science could find was a list of questions The Wire Science had sent to the Ministry of AYUSH, seeking its response to a study that had criticised the willy-nilly consumption of giloy as an “immunity booster”. Nonetheless, several media outlets reported the statement, many verbatim. Some people consume the herb raw. Others prefer Ayurvedic ‘preparations’ in the form of capsules, powders or juices. Whenever giloy has propped up in a negative context in the past, the AYUSH ministry has been quick to issue a statement defending it. The first such release appeared on July 7, 2021. It was responding to a scientific study published in the Journal of Clinical and Experimental Hepatology on July 2. The study revealed that the mindless consumption of giloy was contributing to liver toxicity, specifically drug-induced liver injury (DILI). The study’s findings were based on detailed case studies of six people who had consumed giloy and developed DILI. According to the study paper: “Tinospora cordifolia (giloy) consumption seems to induce an autoimmune-like hepatitis or unmask an underlying autoimmune chronic liver disease, which may support its immune stimulant mechanism. However, the same mechanism can cause significant liver toxicity, and we recommend that caution be exercised in the use of this herb, especially in those predisposed to autoimmune disorders.” The government’s immediate reaction was to completely dismiss the study. In its statement, the AYUSH ministry said: “The authors of the study have not analysed the contents of the herb that was consumed by the patients… In fact, there are many studies that point out that identifying the herb not correctly could lead to wrong results. A similar looking herb Tinospora crispa might have a negative effect on the liver.” That is, the government wanted to know if the authors knew whether the six people had consumed Tinospora cordifolia or Tinospora crispa. The latter is poisonous. The ministry suggested the researchers consult an expert in botany. It’s a known fact that the two plants are impossible to tell apart with the naked eye. Even Ayurveda experts can’t do so. And both are available in the market, often labelled ‘giloy’. More than six months after the study was published, The Wire Science spoke to Dr Aabha Nagral, one of the study’s authors and a senior hepatologist . She said that of the six patients, four had consumed the raw herb: “Our follow-up research has proved that the four consumed Tinospora cordifolia only,” she said. Dr Nagral also said she and her colleagues will soon be publishing a paper that demonstrates this fact: that the patients in question didn’t consume a known poisonous substance, yet suffered liver toxicity. “The two others had taken giloy as part of a concoction of immunity-boosting products from two popular companies,” she added. “So legally, those companies couldn’t have mixed the poisonous form.” Update, November 14, 2022, 10:24 am: Abha Nagral’s findings, which she had shared with The Wire Science in February 2022, were published by the Journal of Clinical and Experimental Hepatology on November 6. A botanical analysis plus other studies confirmed that all their study subjects who had suffered serious liver injuries had indeed consumed Tinospora cordifolia and not Tinospora crispa. A Hyderabad-based hepatologist also said he has encountered many such patients in the last two years. “Forget about these researchers – do I tell a patient who comes to me with DILI symptoms to bring the herb on the next visit? Even if she does, how am I supposed to distinguish between the two forms?” he asked. He didn’t wish to be named because he feared reprisal by the Ayurveda industry. “We are trolled on social media. We are served legal notices just for speaking our minds. It is too much trauma to take,” according to him. Indeed, it wasn’t just the ministry that went after Dr Nagral and her colleagues. The journal’s editor also received numerous letters from Ayurveda medical colleges and companies manufacturing supposedly Ayurvedic drugs. These included the Patanjali group; the JSS Medical College, Mysore; the State Ayurvedic College, Lucknow; and the All India Institute of Ayurveda, Delhi. They all case doubt on the research paper on various pretexts. The most common argument was “giloy has traditionally proven safe”. The Ayurveda proponents also claimed that a thyroid drug or a fungal infection could have caused the toxicity. The journal published all these responses. At the same time, many hepatologists reported to the same journal that they were seeing patients with DILI after they had consumed giloy. Also read: Face It: The Indian Government Is Peddling Pseudoscience Sandeep Kumar, 32, is a resident of Simariya village in Ambedkarnagar district, Uttar Pradesh. His family of eight consumed giloy as kaadha during the second wave of India’s COVID-19 outbreak. His father, aged 58, took it everyday, first thing in the morning. He was diabetic and had high blood pressure. “We had read in a newspaper that giloy was good at preventing coronavirus infections,” Kumar told The Wire Science. “Our neighbours also took it.” Two months later, his father developed jaundice and was admitted to King George’s Medical University (KGMU), Lucknow, and soon after died there. Doctors told Kumar that his father died due to excessive consumption

Itching without any sign of rash or allergy is one of the early symptoms of a liver disorder A constant and prolonged itch without any visible rash on the skin may not always be just an allergic reaction. It could be an indicator of an underlying liver condition such as hepatic cholestasis (caused by reduced secretion of bile juice). Itching, one of the primary symptoms of liver complications, could start on the palm or soles of the feet and then slowly spread to the rest of the body. Link between itching and liver health Dr Chetan Kalal, program director, transplant medicine, Nanavati Max Super Speciality Hospital, Mumbai, says the medical term for itching is pruritis and it is caused by an excess build-up of bile salts in the skin. This occurs when the liver is unable to clear toxins and excess salts from the body. “Itching (pruritus) can occur in the early stages of liver conditions like primary biliary cholangitis [in which the bile ducts are slowly destroyed], primary sclerosing cholangitis [bile ducts become inflamed, scarred and get blocked] and even in intrahepatic cholestasis of pregnancy [a liver complication that develops during pregnancy],” says Dr Sudeep Khanna, senior consultant, gastroenterologist, Indraprastha Apollo Hospitals, New Delhi. People with already existing liver conditions may also experience an incessant itching and require treatment. Another reason for itching could be obstructive jaundice, in which the bile duct gets blocked and bile is unable to flow from the liver to the small intestines. Science behind the itching signs According to a research article published in the August 2015 edition of Clinical Medical Journal, the disruption in the expulsion of bile from the liver triggers the release of pruritogens (that cause itching). These pruritogens accumulate in the blood plasma and other tissues that stimulate neural itch fibres in the skin. These neural fibres then transmit the stimulus to the spinal cord. The stimulus is decoded by the brain and makes people reach out and scratch the spot where they feel the itch. Dr Kalal says the pathological mechanism for itching is not fully understood. “Usually, this itching is caused due to changes in the nerve signal pattern due to the underlying liver disease, altered immune response and high levels of enzymes like alkaline phosphatase (ALP) and lysophosphatidic acid (LPA),” he says. Excess of ALP and LPA indicates impaired liver function. Symptoms of liver-related pruritus Unlike other skin conditions, itching related to liver disease is different, says Dr Kalal. He adds that other skin-related conditions with itching usually present themselves with rashes or skin lesions, but in the case of itching triggered by liver damage there will not be any external marks. According to Dr Khanna, cholestatic pruritus can affect the day-to-day life of people with the condition. “Most people with pruritus experience this incessant itch at night, which also affects and disturbs their sleep,” he says. Pruritus and liver conditions Primary biliary cirrhosis: This chronic inflammation in the liver can cause bile duct damage and irreversible scarring of liver tissue (cirrhosis) which may progress into liver failure. Primary sclerosing cholangitis: This is a chronic liver disease in which the bile ducts of the liver become inflamed and scarred and get narrowed or blocked. “When this happens, bile builds up in the liver and causes further liver damage,” says Dr Kalal. Intrahepatic cholestasis of pregnancy: Many hormonal changes take place in the female body during pregnancy. Sometimes high estrogen and progesterone levels can cause salts in the bile to build up and enter the bloodstream. “This can cause severe bouts of itching,” says Dr Kalal. Benign recurrent intrahepatic cholestasis is a condition in which different episodes of liver dysfunction occur and the liver is unable to produce bile. “These episodes can happen of and on, last from weeks to months and are typically seen in young adults and adolescents. [They] usually begin with severe itching.”  Progressive familial intrahepatic cholestasis: Pruritus is also seen in another hereditary disorder called progressive familial intrahepatic cholestasis that causes progressive liver disease. Sometimes viral hepatitis A and hepatitis E can also present with itching when they reach cholestatic state, although it is very rare. Drug-induced liver injury: This is usually triggered as a result of a severe adverse reaction to either natural or synthetic liver medicines and supplements. Treatment “Typically, the treatment involves addressing the underlying liver problem and methods to reduce the build-up of bile salts under the skin,” says Dr Kalal. Though anti-itch medication and antibiotics are given for relief from skin abrasions, liver conditions should be addressed without fail. Sometimes UV light therapy is also given in cases of unmanageable itching. “By exposing the affected area of the skin to light we can convert these insoluble toxic bile salts into more soluble bile salts, and these could be expelled into urine, thereby reducing the itching,” says Dr Kalal. Using topical creams and moisturisers, apart from maintaining good hydration, helps the skin. The affected people are also asked to avoid hot showers. “After a shower the affected person should make it a point to pat the skin dry and not rub it with a towel,” cautions Dr Kalal. Intake of alcohol should be limited or completely avoided. It is most important to go for a liver test and get the diagnosis of the underlying condition. “The improvement of liver function through treatment of underlying liver disease can often alleviate itching symptoms,” says Dr Khanna. Dr Kalal says plasma exchange therapy or plasmapheresis is also used as a rescue therapy which helps remove the bile salts, pruritogens, chemical mediators or other toxins responsible for itching. Takeaways Intense itching (pruritus) sensation without any rash on the skin could be one of the earliest signs of liver trouble, according to experts. This is mainly caused due to the inability of the liver to clear out bile. This causes accumulation of bile salts in the skin, triggering an itching sensation. Hepatologists say that it is essential to get a liver function test done to ascertain whether liver failure is the cause of the

World Hepatitis Day: With the theme ‘Bringing hepatitis care closer to you’ WHO wants to raise awareness and promote global action on viral hepatitis. The aims is to raise awareness about the need to simplify and bring hepatitis care to primary health facilities, community-based venues and locations beyond hospital sites, so that care is closer to communities and people wherever they are. What is Hepatitis Hepatitis is an inflammation of the liver. There are five main types of the hepatitis virus – A, B, C, D and E. Hepatitis B and C lead to chronic disease in hundreds of millions of people globally, and together are the most common cause of liver cirrhosis, liver cancer and viral hepatitis-related deaths. July 28 is celebrated every year as World Hepatitis Day. According to the doctors, this chronic disease of liver can be prevented and cured. Let’s take a look what the doctors have to advise about precautions and treatment of the Hepatitis. Dr Anil Arora, HOD, Gastroenterology, Sir Ganga Ram Hospital “It is advisable to avoid the usage of contaminated water. Boil your water and then drink if you can, maintain personal hygiene, wash your hand, get yourself vaccinated if you haven’t yet. Also, maintain dental, ear, nasal hygiene as Hepatitis is dangerous than Covid.” Dr. Rajesh Upadhayay, Senior Director, Gastroenterology, Max Super Specialty Hospital, Shalimar Bagh His advice is to get vaccines for hepatitis A and hepatitis B. “Choose safe food and water, practice good personal hygiene, avoid alcohol which is the most effective strategy to prevent alcoholic hepatitis,” he advised. According to him the treatment of viral hepatitis depends on the type and stage of the infection. “However, if you have severe hepatitis, you may need to see a doctor. If you are suffering from severe hepatitis, then within a few weeks the symptoms start to subside and the patient can get relief. You can easily reduce this infection by improving diet and lifestyle,” he added. In case of chronic hepatitis, medicines need to be taken and people who have alcoholic hepatitis, they need to stop drinking, added Dr Upadhyay. Dr. Bir Singh Sehrawat Director and HOD Gastroenterology Marengo QRG Hospital, Faridabad  He says Hepatitis is an inflammation of the liver mainly caused by a viral infection. He said fever, jaundice, dark urine, fatigue, nausea or vomiting, abrupt weight loss, loss of appetite and pain in the right upper abdomen are considered the major symptoms for hepatitis. As a precaution Dr Sehrawat advised, “Newborns should be vaccinated for hepatitis B. Avoid street food. Only drink bottled water or RO water. Avoid spicy, junk, oily, and canned food to keep this liver related fatal disease at bay. Try to eat meals in smaller proportions for easy digestion. Opt for bland foods like bananas or rice. Don’t share your toothbrush, needle with others. Have safe Sex. Drink plenty of water to keep yourself hydrated. Quit alcohol or limit its use to keep your liver healthy.” Dr .Chetan R. Kalal , First DM Hepatologist of Maharashtra, Chief Hepatologist and Liver Transplant Physician, Masina Hospital, Mumbai “Hepatitis A and E are primarily caused by consuming contaminated food and water. Hepatitis B, C, and D are typically caused by contact with infected blood and bodily fluids.” In India, viral hepatitis is a major cause of health-care burden and is now regarded as a threat comparable to the “big three” communicable diseases: HIV/AIDS, malaria, and tuberculosis. Dr Alisha Chaubal- Consultant – Hepatology and Liver Transplant at Global Hospital, Parel Mumbai “Apart from viral hepatitis there are other causes of liver disease like alcohol, medicine or toxin induced, fatty liver, autoimmune and genetic diseases. In our country fatty liver disease is on the rise especially in patients with obesity, diabetes, cholesterol, thyroid problems and should not be ignored as it can cause liver damage or cancer. Also one should avoid taking over the counter medications as several herbal and allopathic medicines can cause liver injury.” She added, “Most important is the avoidance of unnecessary medications. Acetaminophen / Paracetamol and medication against vomiting should not be given. These types of hepatitis can be diagnosed by simple blood tests and an abdominal sonography. A non-invasive test called liver elastography or fibroscan can let us know the exact extent of liver damage without resorting to a liver biopsy.” Dr Praveen Jha, MD, DM, Consultant Gastroenterology, Regency Hospital “It is very important for everyone to get tested for hepatitis at least once a year. We sometimes suggest even some healthy people for hepatitis B infection tests because the virus can damage the liver before showing signs and symptoms. We get many such cases in a year in which people have got hepatitis B and now they are being treated for liver damage.”