Home' Australian Pharmacist : Australian Pharmacist December 2015 Contents Australian Pharmacist December 2015 I © Pharmaceutical Society of Australia Ltd.
CONTINUING PROFESSIONAL DEVELOPMENT
THE COMPLEMENTARY APPROACH
1. Which ONE of the following
statements regarding the use of
Silybum marianum (St Mary’s thistle/
silymarin) is most appropriate?
a) Administration of silymarin (2000 mg
daily) during combination therapy for
HCV (IFN/RBV plus simeprevir) improves
SVR in prior non-responders and those
with advanced fibrosis.
b) St Mary ’s thistle/silymarin is the most
commonly used herbal medicine
in individuals. infected with HCV.
A substantial body of evidence
demonstrates that ongoing use results
in a significant improvement in ALT,
AST, quality of life and viral clearance
during IFN/RBV therapy. It should be
considered a first-line treatment option.
c) St Mary ’s thistle/silymarin is the most
commonly used herbal medicine in
individuals infected with HCV. While
compelling data from in vitro and
animal studies suggests that silymarin is
hepatoprotective and inhibits HCV in vitro,
clinical data are equivocal and this may
be due to heterogeneity in study design,
dose and forms used in clinical trials.
d) St Mary ’s thistle/silymarin induces
CYP3A4, a primary metaboliser of a
number of medicines including the
HCV protease inhibitors, and may result
in reduced plasma concentrations and
treatment failure. It should never be
given during HCV therapy.
2. Which ONE of the following lists
of effects has reportedly been
associated with low vitamin D status
in individuals infected with HCV?
a) Increased ALT and AST in serum, and
poor viral clearance during IFN/RBV
b) Increased risk of cirrhosis, fibrosis and
poorer response to IFN-based therapy.
c) Increased risk of cirrhosis, jaundice and
progression to liver cancer.
d) Reduced ALT and AST in serum, and
poorer quality of life.
3. Which ONE of the following
statements is true?
a) EGCG, the major flavanone found in
grapefruit, reportedly reduces HCV
secretion in infected cells, blocking the
assembly of infectious viral particles.
b) EGCG has been shown to suppress HCV
replication, reduce ALT and AST values
in serum, exert antiviral effects against
HCV and may also act synergistically
with IFN therapy.
c) Glycyrrhiza glabra (licorice) contains
compounds that have been shown to
suppress HCV replication, reduce ALT
and AST values in serum, exert antiviral
effects against HCV and may also act
synergistically with IFN therapy.
d) Naringenin, a flavonoid compound
found in green tea extract, has been
shown to inhibit the entry of HCV
into hepatocytes and may also exert
chemopreventive effects in people
at risk of liver cancer by diminishing
oxidative DNA damage.
4. Which ONE of the following concerns
exists for CAM use in individuals
infected with HCV?
a) Dose-dependent hepatotoxity has been
reported for licorice and glycyrrhizin so
further studies are required to evaluate
the potential benefits and risks.
b) EGCG inhibits CYP3A4 activity, primarily
in the small intestine rather than the
liver, and may potentially interact
with over 85 different medicines,
many of which may result in serious
c) Hypericum perforatum (St John’s wort)
induces CYP3A4 which is involved
in the metabolism of HCV protease
inhibitors so concurrent use may reduce
plasma concentrations and result in
d) Naregenin, from grapefruit, prevents
the inactivation of cortisol to cortisone
and may cause sodium retention,
hypokalaemia, fluid retention and
15. Yang Z, Zhuang L, Lu Y, et al. Effects and tolerance of silymarin
(milk thistle) in chronic hepatitis C virus infection patients: a
meta-analysis of randomized controlled trials. Biomed Res Int
16. Braun L, Cohen M. St Mary ’s thistle. In: Herbs and natural
supplements: an evidence based guide. Vol 2, 4th edn.
Australia: Elsevier; 2015:951–65.
17. Gurley BJ, Fifer EK, Gardner Z. Pharmacokinetic herb-drug
interactions (part 2): drug interactions involving popular
botanical dietary supplements and their clinical relevance.
Planta Med 2012;78(13):1490–514.
18. US Food and Drug Administration (FDA). Olysio (simeprevir)
for the treatment of chronic hepatitis C in combination
antiviral treatment. 2014. At:www.fda.gov/ForPatients/Illness/
19. Gal-Tanamy M, Bachmetov L, Ravid A, et al. Vitamin D: an
innate antiviral agent suppressing hepatitis C virus in human
hepatocytes. Hepatology 2011;54(5):1570–9 .
20. Yu LL, Yin LY, Chen W, et al. [Prospective study on the relation
between serum vitamin D levels and liver cirrhosis risk].
Zhonghua Gan Zang Bing Za Zhi 2013;21(3):202–6.
21. Petta S, Cammà C, Scazzone C, et al. Low vitamin D serum
level is related to severe fibrosis and low responsiveness to
interferon-based therapy in genotype 1 chronic hepatitis C.
22. Luo YQ, Wu XX, Ling ZX, et al. Association between serum
vitamin D and severity of liver fibrosis in chronic hepatitis C
patients: a systematic meta-analysis. J Zhejiang Univ Sci B
23. Kitson MT, Sarrazin C, Toniutto P, et al. Vitamin D level and
sustained virologic response to interferon-based antiviral
therapy in chronic hepatitis C: a systematic review and meta-
analysis. J Hepatol 2014;61(6):1247–52 .
24. Atsukawa M, Tsubota A, Shimada N, et al. Effect of native vitamin
D3 supplementation on refractory chronic hepatitis C patients
in simeprevir with pegylated inter feron/ribavirin. Hepatol Res
2015; doi: 10.1111/hepr.12575 (epub ahead of print).
25. Abd Elalim MH, Zaky DZ, Motawae IA, et al. Interplay between
vitamin D status and antiviral therapy among chronic hepatitis
C Egyptian patients. J Egypt Soc Parasitol 2015;45(1):17–22 .
26. Terrier B, Lapidus N, Pol S, et al. Vitamin D in addition to
peg-interferon-alpha/ribavirin in chronic hepatitis C virus
infection: ANRS-HC25-VITAVIC study. World J Gastroenterol
27. Coppola N, Pisaturo M, Sagnelli C, et al. Role of genetic
polymorphisms in hepatitis C virus chronic infection. World J
Clin Cases 2015;3(9):807–22 .
28. Arai T, Atsukawa M, Tsubota A, et al. Vitamin D-related gene
polymorphisms do not influence the outcome and serum
vitamin D level in pegylated interferon/ribavirin therapy
combined with protease inhibitor for patients with genotype
1b chronic hepatitis C. J Med Virol 2015;87(11):1904–12.
29. Sekine-Osajima Y, Sakamoto N, Nakagawa M, et al. Two
flavonoids extracts from Glycyrrhizae radix inhibit in vitro
hepatitis C virus replication. Hepatol Res 2009;39(1):60–9 .
30. Shibata S. A drug over the millennia: pharmacognosy,
chemistry, and pharmacology of licorice. Yakugaku Zasshi
31. van Rossum TG, Vulto AG, Hop WC, et al. Intravenous
glycyrrhizin for the treatment of chronic hepatitis C: a
double-blind, randomized, placebo-controlled phase I/II trial. J
Gastroenterol Hepatol 1999;14(11):1093–9 .
32. van Rossum TG, Vulto AG, Hop WC, et al. Glycyrrhizin-induced
reduction of ALT in European patients with chronic hepatitis C.
Am J Gastroenterol 2001;96(8):2432–7 .
33. Morris DJ, Latif SA, Hardy MP, et al. Endogenous inhibitors
(GALFs) of 11beta-hydroxysteroid dehydrogenase isoforms 1
and 2: derivatives of adrenally produced corticosterone and
cortisol. J Steroid Biochem Mol Biol 2007;104(3–5):161–8.
34. Ferrari P. The role of 11beta-hydroxysteroid dehydrogenase
type 2 in human hypertension. Biochim Biophys Acta
35. Calland N, Albecka A, Belouzard S, et al. ( -) -Epigallocatechin-3 -
gallate is a new inhibitor of hepatitis C virus entry. Hepatology
36. Luo H, Tang L, Tang M, et al. Phase IIa chemoprevention trial of
green tea polyphenols in high-risk individuals of liver cancer:
modulation of urinary excretion of green tea polyphenols and
8-hydroxydeoxyguanosine. Carcinogenesis 2006;27(2):262–8 .
37. Sarma DN, Barrett ML, Chavez ML, et al. Safety of green tea
extracts:a systematic review by the US Pharmacopeia. Drug
38. Nahmias Y, Goldwasser J, Casali M, et al. Apolipoprotein
B-dependent hepatitis C virus secretion is inhibited by the
grapefruit flavonoid naringenin. Hepatology 2008;47(5):1437–
39. Bailey DG, Dresser G, Arnold JM. Grapefruit-medication
interactions: forbidden fruit or avoidable consequences?
40. Seeff LB, Bonkovsky HL, Navarro VJ, et al. Herbal products
and the liver: a review of adverse effects and mechanisms.
41. Dick TB, Lindberg LS, Ramirez DD, et al. A clinician’s guide to
drug-drug interactions with direct-acting antiviral agents for
the treatment of hepatitis C viral infection. Hepatology 2015;
doi: 10.1002/hep.27920 (epub ahead of print).
42. Piccolo P, Gentile S, Alegiani F, et al. Severe drug induced acute
hepatitis associated with use of St John’s wort (Hypericum
perforatum) during treatment with pegylated interferon
alpha. BMJ Case Rep 2009;2009.
Links Archive Australian Pharmacist November 2015 Australian Pharmacist January 2016 Navigation Previous Page Next Page