With few medicines developed to treat liver problems, doctors in Asia regularly turn to supplements and natural remedies for a range of liver conditions, from fatty liver and hepatitis to cirrhosis, unlike many of their counterparts in the West.

While some of the treatments that have been used in Asia for generations might not be readily available in Europe and the US, a more fundamental reason they are shunned is that Western doctors tend to want to see well-published evidence before reaching for the prescription pad.

Doctors in Asia, however, are more inclined, and perhaps less restricted, in considering the natural remedies their grandparents probably used.

In contrast, Western physicians are often tied down by what the evidence says when it comes to age-old supplements, says Dr Prabhjot Singh Sidhu, consultant gastroenterologist and hepatologist at Ara Damansara Medical Centre in Kuala Lumpur. They want evidence to show that a treatment works so they can justify prescribing it, rather than looking back at what was used by our ancestors, though he does
agree that the specifics of those remedies can be difficult to tease out.

“Let’s be honest, evidence-based medicine is an excellent practice that places priority on patient safety. That’s how I was trained, practice now and will continue to practice,” he said. “But just because the published evidence isn’t there, it doesn’t mean that it doesn’t work—it just means that we haven’t studied it well enough yet. When dealing with a critically ill patient, should we forego these remedies simply because someone hasn’t done the work?”

Dr Sidhu stresses that he is not advocating throwing out the text books in favour of herbs and spices but simply wants physicians to keep them in mind when treating liver patients. Moreover, these remedies are already widely available in health stores and, like it or not, many people are already on them.

“After working in the UK and coming back here, I see all these supplements that people are using and it worried me,” he said. “By ‘using’ I actually mean dishing them out like its going out of fashion. What are these things? Almost every other person I speak to is on one or knows someone taking a liver supplement.”

According to Dr Sidhu, in England, steroids are available for patients with alcoholic hepatitis and N-acetylcysteine drips are used for paracetamol overdose (e.g., Panadol). But apart from treatments for viral hepatitis (infection of the liver) and primary biliary cholangitis (an autoimmune disease of the liver), there is not much else by way of evidence-based drugs.

“Otherwise you treat the source of the disease, not the liver itself. In Malaysia, doctors are more likely to prescribe supplements at the early stages of liver conditions, whether medicines are available or not,” he explained.

The best known of these goes by the brand name Heptral, which at Dr Sidhu’s hospital is classified as a drug, but elsewhere is mostly considered a dietary supplement. It contains ademethionine, a component that the body needs to make glutathione, an antioxidant in the liver that is often lacking in patients with chronic liver disease.

Another popular natural supplement is milk thistle, a herb that has been used for thousands of years to treat liver disorders, though it is never prescribed in the West. Classed as a supplement and available at health food stores, it is an antioxidant and an anti-inflammatory that prevents free radical formation, helps regulate liver cell walls, and stabilises membranes while helping liver regeneration.

Tulsi, also known as holy basil, is another commonly prescribed supplement in Asia. Some studies show that tulsi, combined with silymarin from the milk thistle seed, can protect the liver from damage caused by drugs and alcohol. In the UK, tulsi is never prescribed, according to Dr Sidhu.

Another popular supplement, the long pepper, a Chinese herb used in traditional medicine, has been shown in research papers to have antioxidant properties that help control free radicals. It is widely available over the counter.

But the most heavily used supplement is coffee, which can protect against liver cancer and is associated with lower levels of liver enzymes since it acts as a hepatoprotective agent. Studies have shown links between its use and the slowing of the progression of alcoholic cirrhosis and hepatitis C.

“The interesting thing is that no one actually prescribes coffee or takes it for their liver. We just enjoy having it and fortunately it has benefits,” said Dr Sidhu.

But some physicians, such as Dr Steve Ryder, a consultant hepatologist in Nottingham, take a more circumspect view of natural remedies. He is adamant that evidence needs to be found before a supplement can be prescribed or evenrecommended.

“From a UK perspective, prescribing is very, very tightly controlled,” he stressed.

“There are a lot of medicines freely available in many other countries that are not found in the UK. And that, I think, sets the framework for a doctor’s ability and willingness to prescribe outside particular areas.
“As with all these things, there is going to be a cultural element to it, a training element to it, and a regulatory element as well. As a hepatologist, I have occasionally seen the downside of some herbal remedies, like acute liver failure, so they are not necessarily risk-free substances.”

While in Malaysia not all doctors will automatically prescribe natural remedies, they are still worth considering once the limited medicinal options available to treat the liver directly have been exhausted, Dr Sidhu said.

“I trained in the West, so I like evidence to say that this is why we do these things and here are the hard facts. Again, I’m not pro-supplements and certainly have my reservations about them,” he said. “I have seen patients suffer from significant liver impairment from taking unspecified herbal remedies, with some even ending up on the liver transplant list.

“But what about the patient who is desperate for something, anything, that might help? Should we tell him that there are supplements, though the evidence is not strong? There are many things we don’t know about fully, and with that there is risk. But at least we have some evidence of their safety. I think the jury is still out.”

I have occasionally seen the downside of some herbal remedies, like
acute liver failure, so they are not necessarily risk-free substances