key: cord-0766765-spzjz2q4 authors: Rastogi, Sanjeev; Pandey, Deep Narayan title: ‘Herbal Immune Booster-Induced Liver Injury in the COVID-19 Pandemic – A cautious interpretation is desired before any generalization is attempted’ date: 2021-08-14 journal: J Clin Exp Hepatol DOI: 10.1016/j.jceh.2021.08.006 sha: e821193cb403798103957b3fa432cf38cd8e8eab doc_id: 766765 cord_uid: spzjz2q4 nan We read with great interest an observational study on 'Herbal Immune Booster-Induced Liver Injury in the COVID-19 Pandemic -A case Series' by Nagral et al. published Experimental Hepatology. 1 Raising the concern about possible adverse effects associated with any unsupervised use of herbal/CAM or modern medicines should be welcomed by all .Indeed, Ayurveda recognizes the fact of drug related adversities depending upon their processing, dose, intake methods, and strategy of administration. 2 Naturally a drug from any source, natural or synthetic, if taken unsupervised, may cause adverse effects. 3 While we agree with the authors that a common belief about the safety of drugs of natural origin added with their easy OTC access and guided by unreliable resources often leads to self-medication 4 adverse effects have been observed in all drug classes used in the COVID-19 pandemic . 5 Thus, increasing the awareness about the mechanisms of drug effects, and their potential harms, if taken unsupervised, should be undertaken by practitioners, manufacturers and regulatory authorities. 6 Despite agreeing to these generic observations made by the authors, however, we disagree with the generalization that has been attempted by the authors by finding a commonality in all cases clubbed together in the series. Table 1 shows the dose frequency and duration of use of TC used in the study and the associated co morbidities. . Authors own statement that 'most drug induced autoimmune liver injuries are an acute idiosyncratic reaction supported by the fact that one patient taking the drug for only 3 weeks on alternate days', is in variance to another case having a history of 7 month regular consumption of the drug in the same series. Similarly two cases who have consumed commercially available syrup containing TC / 15 ml per day and TC in the form of commercially available tablet raises a concern about other ingredients of the compound formulations which may have contributed to the net adversity . 10 It has also been used successfully in the treatment of COVID-19 and other clinical conditions without any adversity as is evident from the results of many clinical trials and case studies. 11, 12 A study in a mouse model has showed that TC treatment did not display clastogenicity and DNA damaging effect in bone marrow erythrocytes and peripheral blood lymphocytes respectively. 13 There is clinical evidence for protective effects of Tinospora cordifolia on hepatic and gastrointestinal toxicity due to alcoholism. 14 Herbal Immune Booster-Induced Liver Injury in the COVID-19 Pandemic -A case series Charak Chandrika Hindi Commentary on Charaka Samhita, 1 st ed, Chaukhambha Surbharati Prakashan Poor quality and improper use: A review of common reasons of possible adversity in Ayurvedic practice, International journal of risk and safety in medicine Ayurveda formulations: A roadmap to address the safety concerns Caution and clarity required in the use of chloroquine for COVID-19 Why and how? Addressing to the two most pertinent questions about pharmacovigilance in Ayurveda Levothyroxine-induced liver injury followed by complete recovery upon cessation of the drug: a case report Cheng2 Liver injury induced by levothyroxine tablets in a patient with hypothyroidism A Cohort Study of the Incidence of Serious Acute Liver Injury in Diabetic Patients Treated With Hypoglycemic Agents COVID-19 pandemic: A pragmatic plan for Ayurveda intervention A Pilot Clinical study of an add on Ayurvedic formulation containing Guduchi and Pippali in mild to moderate Covid -19 Randomized placebo-controlled pilot clinical trial on the efficacy of ayurvedic treatment regime on COVID-19 positive patients Tinospora cordifolia, a safety evaluation Protective Effects of Tinospora cordifolia on Hepatic and Gastrointestinal Toxicity Induced by Chronic and Moderate Alcoholism