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Effects of Silybum Marianum on Patients With Chronic Hepatitis C

Effects of Silybum Marianum on Patients With Chronic Hepatitis C

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Published by: yigalby on Feb 12, 2012
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Received: 6.1.2011 Accepted: 27.2.2011
Associate Professor of Gastroenterology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
Associate Professor of Gynecology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
Academic Member of Medical Informatics Deptartment, School of Health Management and Information Sciences, Isfahan University ofMedical Sciences, Isfahan, Iran.
Professor of Pharmacology, Isfahan University of Medical Sciences, Isfahan, Iran.
Department of Gastroenterology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
Corresponding AuthorE-mail: shahshahan@med.mui.ac.ir
JRMS/ March 2011; Vol 16, No 3.
Original Article
Effects of silybum marianum on patients with chronic hepatitis C
Hamid Kalantari 
, Zahra Shahshahan* 
, Sayed Mehdi Hejazi 
,Taghi Ghafghazi 
, Vahid Sebghatolahi 
Silymarin derived from silybum marianum (milk thistle), a flowering member of the daisy family, maybenefit liver function in people infected with the hepatitis C virus. The aims of this pilot study were to assess the effica-cy and safety of silymarin on serum hepatitis C virus (HCV) RNA, serum aminotransferases (ALT, AST) levels, liverfibrosis and well-being in patients with chronic hepatitis C (CHC).
This prospective self-controlled trial study was conducted from March to September 2006 at Department of Gastroenterology, Isfahan University of Medical Sciences, Isfahan, Iran. 55 patients with HCV (10 female and 45 male)with a mean age of 31.8 ± 6.4 years (10-67 years) were participated in the study. Patients received 24 weeks of silymarin(630 mg/day). Baseline virological biochemical, liver fibrosis (by a serum fibrosis markers, including YKL–40 and Hyalu-ronic acid), and SF-36 questionnaire were performed with biochemical tests repeated at the end of the treatment period.
There was statistically difference in mean of ALT (108.7 ± 86.6 vs 70.3 ± 57.7) before and after the treatment(p < 0.001). The means of AST were 99.4 ± 139.7 and 59.7 ± 64.32 before and after the treatment with statistically dif-ferences (p = 0.004). After the treatment, nine patients were found with negative HCV-RNA (p = 0.004) and statistical-ly significant improvement in results of liver fibrosis markers were found only in fibrosis group (p = 0.015). Quality of life was improved significantly (p < 0.001).
This study indicated that in patients with CHC performing silymarin (650 mg/day) for 6 months, im-proved serum HCV-RNA titer, serum aminotransferases (ALT, AST), hepatic fibrosis and patient’s quality of life. Morefuture studies are warranted.
Hepatitis C Virus (HCV), Quality of life, Serum Aminotransferases.
 JRMS 2011; 16(3): 287-290
epatitis C is a major cause of liver -related morbidity and mortality.
Ri-bavirin plus interferon combinationtherapy, is presently considered the optimaltreatment for patients with chronic hepatitis C,but the recommended treatment regimen isassociated with considerable expense, adverseeffects and poor efficacy in some patients withhepatitis C. Therefore, many hepatitis C pa-tients use the herb silymarin (milk thistle), analternative therapy for hepatitis C, in additionto or instead of standard treatment for chronichepatitis C virus infection.
 Although the popularity of silymarin hasbeen increased in people with liver disease
 but a little evidences with controversial resultsexist in effect of silaymarin on chronic hepatitisC. In one study in Egypt,
a dose of 420mg/day of silymarin has been used for oneyear. The quality of life of the patients im-proved very well, but the level of liver enzymedid not change. An exhaustive search strategy
Effects of silybum marianum on chronic hepatitis C Kalantari et al
JRMS/ March 2011; Vol 16, No 3.
identified 148 papers that studied silymarincompounds in liver disease. Of these, four tri-als included patients with hepatitis C whichonly two trials reported a decrease in serumtransaminases.
 According to existence of little evidenceswith controversial results and increasing popu-larity of using silymarin in chronic hepatitis C,this study was conducted to evaluate the effectof higher doses of silymarin (630 mg/day) for6 months, on patients with hepatitis C alongwith liver biopsy.
This prospective self-controlled trial study wasconducted from March 2006 to September 2006at Department of Gastroenterology, IsfahanUniversity of Medical Sciences, Isfahan, Iran.Inclusion criteria contained confirmedchronic hepatitis C (HCV Ab (+), HCV-RNA[with PCR] (+)), normal or increased liver en-zymes (ALT and AST) and not using interfe-ron or ribavirin due to patient sensitivity ornot consenting. The pregnant patients and pa-tients with side effect which confirmed withrechallenge test were excluded. The ethicscommittee of Isfahan University of MedicalSciences approved the study and all of partic-ipants signed an inform consent after explain-ing the aims and protocol of the study tothem. The study was registered at Clinical-Trials.gov (Identifier: NCT01292161).After measuring the baseline outcomes, weperformed 630 mg/day silymarin a product ofGoldaru pharmaceutical Co. Isfahan, Iran forsix months. Following serum componentswere measured before and after the treatment:liver enzymes (ALT and AST), HCV-RNA(with PCR) and markers for liver fibrosis suchas YKL 40 and Hyaluronic Acid (HA). YKL 40was measured with YKL 40–EIA Kit, Quaildelcomp. San Diego. CA. with cut off value of284.8 ng/ml (sensitivity 80% and specificity71%)
and HA was assessed by enzyme linkedbinding protein assay (corgenix inc Denver)with the cut-off value of 110 mg/l (sensitivity79.2% and specificity 89.4%).
According to liver fibrosis markers (YKL 40and HA) results before treatment, patientswere divided into three stages:Fibrosis group: YKL 40 > 150 ng/ml and HA >60 ng/ml or YKL 40 > 150 ng/ml or HA > 100ng/ml; Non-fibrosis group: YKL 40 < 100ng/ml and HA < 20 ng/ml; Intermediategroup: the results with no agree with abovelevels.After the treatment patients were divided tothree groups according to their liver fibrosismarkers results. Fibrosis activity progressgroup: YKL 40 > 100 ng/ml or HA > 50 ng/mlmore than the level before treatment. Fibrosisactivity regression group: YKL 40 decreasedmore than 75 mg/ml or HA decreased ≥ 30ng/ml compared with before treatment levels.Fibrosis stable group: the level of liver fibrosismarkers were not agreed with above level aftertreatment. For the determination of quality oflife, we used the Iranian version of short formhealthy survey (SF-36) questionnaire
beforeand after treatment which it’s validity and re-liability was established. The SF-36questionnaire is a generic measure of healththat is used to measure quality of life. Itconsists of 36 questions (items) which alto-gether score from 0 to 100.Data were analyzed with the paired t-test,McNemar, and chi–square statistical methods.All analysis were done with SPSS v.16.
Seventy seven patients were enrolled in thestudy. One patient died and 21 patients did notparticipate in follow-up process. Finally, 55patients (10 female and 45 male) with themeans age of 31.8 ± 6.4 years (10-67 years)completed the study.The mean of ALT before and after the treat-ment were 108.7 ± 86.6 and 70.3 ± 57.7. Accord-ing to paired t-test analysis there was a statistic-al difference before and after the treatment withsilymarin (p < 0.001). The mean of AST were99.4 ± 139.7 and 59.7 ± 64.32 before and after thetreatment. According to paired t-test analysisthere was statistically different from before thetreatment with silymarin (p = 0.004).After the treatment, nine patients were found
Effects of silybum marianum on chronic hepatitis C Kalantari et al
JRMS/ March 2011; Vol 16, No 3.
Table 1.
Liver fibrosis markers (YKL 40 and HA) results before and after the treatment
GroupsBeforetreatmentProgressionafter treatmentStable aftertreatmentRegressionafter treatment
Fibrosis n (%) 42 (76%) 11 (26%) 14 (33%) 17 (40%)Non-fibrosis n (%) 4 (7%) 0 (0%) 4 (100%) 0 (0%)Intermediate n (%) 9 (16%) 2 (22%) 7 (77%) 0 (0%)
with negative HCV-RNA which in regard toMcNemar test, it was significantly difference be-fore and after the treatment (p = 0.004).The results of liver fibrosis markers areshowed in table 1. According to hi-square me-thod, there was a statistical improvement onlyin fibrosis group (p = 0.015).The means of SF-36 score were 51.06 ± 21.8and 61.49 ± 22.8 before and after the treatmentrespectively. According to paired t-test analy-sis, there was a statistical improvement inquality of life of patients (p < 0.001).
Silymarin has been claimed to have a beneficialeffect on various types of liver injury, includ-ing alcoholic liver disease, drug and toxin in-duced hepatotoxicity, and acute and chronicviral hepatitis.
Our results showed that per-forming silymarin was significantly improvedthe serum liver enzymes, HCV-RNA titer, he-patic fibrosis and patient’s quality of life.The mechanism of silymarin might be byprotecting liver cell injury with free radicalscavenging, stabilization of liver cell mem-branes, stimulation of hepatocyte protein syn-thesis, and modulation of the immune re-sponse.
Also recently determined silymarinhad antiviral effects against hepatitis C viruscell culture infection that included inhibition ofvirus entry, RNA and protein expression, andinfectious virus production.
There is a little evidence for using this drugfor hepatitis C. Previous studies
have re-ported an improvement in a number of liverchemistries, including ALT, following treat-ment with S. marianum and our results sup-ported their findings. Tanamly et al in adouble-blinded trial evaluated silymarin inpreventing complications of chronic hepatitisC. Although they showed an improvement inpatient’s symptoms and quality of life, but nosignificantly improvement in their liver en-zymes, liver fibrosis markers and HCV-RNAwas achieved. Our results were not agreedwith their findings respectively. The differencemight be because of the performed dose of si-lymarin, the study design and the genotypes ofpatients.
 Gordon et al in a randomized, double-blind,placebo-controlled, crossover study examinedthe effects of silybum marianum on patientswith chronic hepatitis C and showed no signifi-cant effect on serum HCV-RNA, alanine amino-transferase levels, quality of life or psychologi-cal well-being.
Our findings did not supporttheir findings respectively. It may be due totheir low sample size or study design whichmay influence the results.Adverse drug effects related to silymarinhave been published in studies and case reportsinvolving a total of over 7000
patients andthose confirmed that it is safe, with only threereports of significant adverse reactions.
 Thus, it seems from the current data that pa-tients with chronic hepatitis C are to benefitfrom taking salymarin.
This study indicated that in patients withchronic hepatitis C performing silymarin (650mg/day) for 6 months, improved serum HCV-RNA titer, serum aminotransferases (ALT,AST), hepatic fibrosis and patient’s quality oflife. More future studies are warranted.
This research was supported by a grant (GrantNo. 83451) from the research council of IsfahanUniversity of Medical Sciences. The authors ac-knowledge the kind assistance and financialsupport provided by the Vice Chancellor forResearch at the Isfahan University of MedicalSciences.

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