What’s in a name?

Warren Bell

I am astonished that you published the Case Report entitled “Exacerbation of hemochromatosis by ingestion of milk thistle.”1

This brief report is actually not about milk thistle at all; it is about the devastating effects of untreated hemochromatosis. In this tale, the ingestion of milk thistle simply amounts to an inconsequential sidebar.

The author’s experience with herbal remedies appears to be limited. For example, she does not note, in her lengthy description of the milk thistle preparation in question, whether “200 mg” refers to the active ingredient (silymarin) or to the powdered plant. Whichever is the case, the amount taken by her patient was subtherapeutic. The usual therapeutic dose is 160 to 320 mg of silymarin twice daily.

In the sixth paragraph, the author notes that her patient’s liver function tests normalized after stopping the milk thistle preparation, coincident with stopping the “moderate amounts of acetaminophen” she was ingesting. Acetaminophen is a known hepatotoxin; I have treated a number of patients in our emergency room for acetaminophen overdose, and our first concern is always hepatic damage.

Moreover, I have had patients on recommended doses of acetaminophen (4 g or less daily) who have shown signs of hepatotoxicity. In someone whose liver is already significantly damaged, the presumption that withdrawal of a known hepatotoxin is irrelevant, whereas the cessation of a known hepatoprotective substance is pivotal, stretches credulity beyond the breaking point.

At the very least, this kind of sketchy evidence should have warranted a question mark at the end of the title! In fact, an altogether more fitting title would have been “Lack of a hepatoprotective effect of milk thistle in a case of severe hemochromatosis.” Frankly, I have never heard (even in herbal medicine circles) of someone seriously considering milk thistle in this situation. The treatment of advanced hemochromatosis is always, and always has been, reduction of iron load—period. I refer your readers to a summary of the beneficial and other effects of milk thistle, written by pharmacist Wendell Combest, PhD, at www.uspharmacist.com/oldformat.asp?url=newlook/files/alte/acf3007.htm.

I note that this article was peer reviewed. I would be interested to know if any of your reviewers have extensive clinical experience with the use of herbal medicines or are familiar with the literature of pharmacognosy.

The biggest problem I have with this article is that it will now go into the melting pot of PubMed citations. There, authors who have an ideological problem with herbal remedies will find it and cite it (unwittingly or otherwise) as “evidence” of yet another “bad” effect of a plant remedy. It might even be used as an excuse by some regulatory agency to ban the use of milk thistle entirely, thus removing one of the few hepatoprotective substances now available to clinicians from the therapeutic stage.

I invite—I implore!—researchers to scrutinize and analyze the effects of every single remedy in the complementary and alternative medicine repertoire. If $1 out of every $10 spent on researching often trivial pharmaceutical products was devoted to good research on complementary and alternative medicine, there would be a tsunami of valuable studies, many of which would indicate new and useful therapeutic opportunities.

But I hope, just as fervently, that visible and decisive titles of articles like this are reworked carefully so that they reflect the radically more ambiguous content.