Do Tinospora cordifolia Cause Hepatic Damage?

Dear Editor,

We have read the Case Report entitled “Herbal Immune Booster-Induced Liver Injury in the COVID-19 Pandemic - A case series” that appeared as a Journal Preproof on the website of Journal of Clinical and Experimental Hepatology.^1,2 Drug from any source, if consumed inappropriately, without any supervision, may manifest adverse effects. This is equally applicable with traditional systems of medicine too.

The popularity of traditional systems is growing during these years.³ People believe that “natural” medicine is better, healthier, and safer than synthetic drugs,⁴ and thus, they frequently involve in self-medication. Further, when an herbal medication is used along with conventional drugs, they may manifest as adverse reactions due to drug interactions. Thus, for the overall health and quality of life of patients, increasing awareness about potential harms, if taken inappropriately, should be initiated.

Tinospora cordifolia (TC) has been reported to prevent hepatotoxicity,⁵ whereas other species like Tinospora crispa may be associated with hepatotoxicity.⁶ Thus, consumers might develop hepatic injury without correctly identifying the plants that they are consuming. Having proper identification of the source plant becomes a mandate before its use.

In the case series by Nagral et al, only a few forms of hepatitis, including alcoholic, viral hepatitis, and Wilsons’s disease, were excluded. All the four women patients reported in this case had other comorbidities such as hypothyroidism and/or diabetes mellitus. It is also unclear from the description for what purpose the herb was being used and in what dose. The other drugs being used by these patients were also unclear. Possibility of herb-drug interaction cannot be excluded. Thus, the causality cannot be completely attributed to the TC.

TC, a popularly known herb for its immense therapeutic applications in traditional systems of medicine and has been used in the management of COVID-19.^{7, 8, 9}

The authors might have reported such observations to the pharmacovigilance program of the Drugs Controller General of India (DCGI) that would have analyzed and recommended possible regulatory interventions.

Although case reports have importance, they provide the lowest level of causality association with the reported adverse effects. Hence the possible adverse effects of TC, as stated by Nagral et al, have several confounding elements like the presence of comorbidities, which may have contributed or predisposed to DILI. A pragmatic approach restricting the over-the-counter sale of CAM preparations, the establishment of correct dose formulations, prevention of harmful self-medication, and pharmacovigilance of all classes of drugs, herbal, and allopathic is the need of the hour.

Conflicts of interest

The authors have none to declare.