“HEPATITIS”

SYED ASIF RAZA ZAIDI

B.pharm,MBA
Student of M.Pharm
(Pharmacognosy)

University of Karachi, Pakistan 2009 ©

What is it ?
Any Guess !
Disease that impairs liver function either temporarily or
permanently even leading to death.

Acute Hepatitis < 6 month caused by hepatitis any virus.

Chronic Hepatitis >6month caused by Hepatitis B,C,D
Viruses.
Alcoholic Hepatitis, hepatocytes swelling due to heavy
drinking,
Autoimmune Hepatitis , Chronic hepatitis with high serum
globulin usually in young women's, positive antinuclear
antibody ( ANA) & smooth muscle antibody is most
common type
Drug Induced , The liver helps the body break down
certain drugs. However, the process is slower in some
people, which can make them more likely to get liver
damage. Even small doses of certain drugs can cause
hepatitis
Viral Hepatitis
Lets have a look ;
• VIRUS
VIRUS & ITS GLOSSARY
A group of infectious agents characterized by their inability to reproduce
outside of a living host cell. Viruses may subvert the host cells' normal
functions, causing the cell to behave in a manner determined by the virus.

• VIROLOGY
The study of viruses and viral disease.
VIREMIA.
The presence of virus in the blood
• VIROID
A very exotic type of virus-like particle that only infects plant cells and
consists of a group of membraneless circular RNAs that neither code for
nor contain any structural protein. They replicate without other viruses
being present.
• VIRION
A virus particle existing freely outside a host cell.
• VIRULENCE
Refers to the ability of a microorganism to produce serious disease.
Tuberculosis is a virulent organism. Some nontuberculous mycobacteria
are virulent (e.g., M. kansasii), while others (e.g., M. gordonae) are not.
(PATHOGENICITY is a related--though not identical--concept.)
 Hepatitis B virus Hepatitis Virus Hepatitis E virus

Hepatitis C
Hepatitis A virus Hepatitis Delta agent
Single stranded RNA & Double Stranded Circular
DNA genome, envelope Single stranded RNA virus
Non Envelope.
contains a surface antigen
HBsAg.

Small Single
Single Stranded RNA Single stranded RNA
stranded RNA
virus. Virus.
,Composed
HBsAg
 HAV HBV HCV HDV HEV
Picornavirus Hepadnaviri Flaviviridae Delta Agent
28nm dae 30 - 60nm 40nm Hepeviridae
40nm 30 - 35 nm

Incubation Incubation Incubation Incubation Incubation

period is 30 period is 120period is 60 period is 90 period is 40
days. days. days. days. days.
Fecal/Oral Parenteral,s Parenteral,se Parenteral, Fecal/Oral
route, exual, xual, Sexual route,
contaminate Infected Infected contact HDV contaminate
d food & mother to mother to person., d food &
water, new born. new born. water,
person person
contact contact
Mortality Mortality Mortality High to very 1-2% High in
rate <0.5% rate 1%-2% rate 0.5%-1% high Pregnancy.

Mild Severe, Severe, Severe, Acute

Severity and Acute and Acute & high Acute and Hepatitis.se
Acute Chronic Chronic Chronic vere in
 HGV Now GBV-C

• GB virus C (GBV-C),
• Parenteral, sexual and vertical
formerly known as transmission of GBV-C have all
been documented, and
Hepatitis G virus because of shared modes of
transmission, individuals
(HGV), infected with HIV are commonly
co-infected with GBV-C. Among
• Flaviviridae family people with HIV infection, the
prevalence of GBV-C viraemia
which has not yet been ranges from 14 to 43%.
assigned to a genus, is
known to infect • Some studies have suggested
humans, but is not that co-infection with GBV-C
will actually slow the
known to cause human progression of HIV disease
disease.
How we can find
virus & what is
there
Geographical
location !!!
• The electron microscope negative-
contrast method makes it possible to
detect virus particles directly.
• Considering the course of the disease
and other investigations, results often
lead to a definite diagnosis very
quickly. In contrast with many other
diagnostically methods, electron
microscopy is not limited to the
detection of one specific, previously
known pathogen. This is why it plays
such a key role in the detection of
new viral pathogens as well.
• Searching for virus particles in
samples of organs, excretions or
cultured media usually takes place at
a magnification of 40 000x.
• In order to identify the characteristic
structural features of the virus
reliably, the scientists use higher
magnifications - i.e., ranging from 150
000 to 300 000x. This would not be
feasible using a light microscope as it
can only magnify up to 1000x.
Hepatitis G virus (HGV)
has been recently documented in
the Americas, Europe, and
Australia. Distinct risk populations
from North Africa, South America,
and Southeast Asia were screened
for HGV, in addition to hepatitis B
and C viruses. First time
recognition of HGV is described
from Egypt and Indonesia. Notable
is the high proportion of HGV
positive individuals among multiply
transfused children, ranging from
24% of those sampled from Egypt
to 32% in Indonesia. Also, data from
Peru suggest the likely association
of HGV infection with progressive
liver disease. Hepatitis G virus
should be considered a world-wide
health concern.
We need a cure!
But first we shall looks towards
sign & symptom's
 Sign & Symptoms
Intermittent
nausea

flu •Jaundice - yellowing of skin, eyes, nail beds

•Dark urine
Fever
•Fatigue •Abdominal pain & Malase
 Laboratories
Findings
Tests include:

• Liver Function Tests

• History and Physical Exam
• Serum Alanine Aminotransferase (ALT) Level Test
• SerumAspartate Aminotransferase (AST) Level Test
• Serum Bilirubin Test
• Serum Gamma-glutamyl Transferase (GGT) Test
• Serum Albumin Test
• Serum Alkaline Phosphatase (ALP) Level Test
• Acute Hepatitis Panel
• Total Hepatitis A Antibody Level Test
• Hepatitis A Antibody Test
 Precautions !!!

is s i o n
r a n s m
l -o r a lt u s e
c a u g
1. Fe e n o u s d r
e d B l o o d
r a v e c t
2. Int u r e t o In f
d In t a k e
x p o s F o o e
3. E m in a t ed
e r In t a k
tr ie s
t a a t un
4. Con minated W ffected co cretions
C o n t a i tin g a i ly S e
5. r s v is d B o d
r a v el e n f e ct e
6 . t r e t o I
x p o s u
7. E
 Drug Induced Hepatitis :
• Drugs that can lead to liver inflammation include:
• Amiodarone
• Anabolic steroids
• Birth control pills
• Chlorpromazine
• Erythromycin
• Halothane
• Methyldopa
• Isoniazid (used to treat tuberculosis)
• Methotrexate
• Statins
 Drug Induced Hepatitis :

Exams and Tests

Blood tests will be done to check liver function. Liver Enzymes
may be increased.
A physical exam may reveal an enlarged liver and abdominal
tenderness in the right upper part of the belly area.
Treatment
There is no specific treatment for most cases of drug-induced
hepatitis other than stopping the drug that is causing the problem.
The exception is acetaminophen. Treatment should be started as
soon as possible after you take excessive doses of acetaminophen
and have developed hepatitis. Outlook (Prognosis)
Usually, drug-related hepatitis goes away within days or weeks after you
stop taking the drug that caused it.
Possible Complications
Liver failure is a possible but rare complication of drug-induced hepatitis.
Treatments
Options!
L-ornithine-L-aspartate for Hepatic
Encephalopathy

Hepatic encephalopathy. Abnormal ammonia metabolism is one of

several possible mechanisms for hepatic encephalopathy. In
cirrhosis,impaired hepatic metabolism and blood flow lead to raised
serum and CNS ammonia concentrations.
Ornithine and aspartate are important substrates in the metabolic
conversion of ammonia to urea and glutamine, respectively.
Ornithine aspartate thus provides for both of these ammonia
detoxification pathways. Controlled clinical trials suggest that
ornithine aspartate, significantly reduce ammonia levels and have
useful therapeutic effects in patients with cirrhosis and mild hepatic
encephalopathy.
(3g active ingredient) which is dissolved in water for oral
administration. The dose is one or two sachets
three times a day.
 Anti-Virals
All medication duration depends on the severity of disease.

• MEDICINES • DOSSAGE
• Entecavir 0.5mg in • Once Daily.
chronic Hep B.
• Acyclovir 200-800mg. • 5 times daily .
• Adefovir Depivoxil 10 • 1 tab daily.
mg.
• Ribavarin.200- • Twice daily
600mg.in combination
with interferon , Hep C.
 Treatment & Prevention:
There is no specific treatment for Hepatitis A . However, the most common
treatment. are bed rest , drink a lot of fluids .Prevention is by Immune
globulin and Hepatitis A vaccine.
Immuno globulin 0.02ml/kgIM is protective and recommended dose.
Vaccine dse is 1ml 0r 0.5ml IM followed by a booster dose at 6-12 months .
For treating hepatitis B there are 2 drugs approved: interferon and lamivudine.
The therapy with interferon lasts from 6 to 12 months and it has many side
effects. The therapy with lamivudine lasts for at least one year and it
could have lower effects than the therapy with interferon.
For treating hepatitis C there are 3 drugs approved: interferon alfa, pegylated
interferon (recently introduced) and ribavirin.
The treatment varies with the form of the infection with hepatitis D virus. In the
acute stage, the treatment is identical with the one from the other types of
hepatitis: rest in bed as needed, balanced diet and avoiding alcohol. The
situation regarding the chronic infection with hepatitis D virus is more
complicated.
Liver transplantation is an option in cases of largely destroyed or stopped
functioning liver. Liver transplantation has been helpful for treating
fulminant acute and end-stage chronic hepatitis.
Hepatitis E can be prevented by Bed rest and taken lot of fluids.
There is no treatment available for hepatitis G . Prevention is same as other
Hepatitis viruses.
 Chemoembolization
• Chemoembolization is most beneficial to patients whose disease is limited to the
liver. Some success has been demonstrated with patients whose cancer has
spread to other areas. Patients with kidney disease, blood coagulation problems,
or known allergies to contrast agents are not good candidates for this procedure.

• The chemoembolization procedure takes place in a hospital setting. The actual

procedure depends on the embolizing agent being used. Such issues as drug
administration, anesthetic requirements, length of time of procedure, and
potential side effects differ with each agent.

• Chemoembolization is considered to be a relatively safe and effective method of

treating unresectable liver tumors. The overall risk of the procedure is related to
your general underlying health. People with Juandice , severe cirrhosis or kidney
failure have an increased chance of complications.

• Under x-ray guidance a small catheter is inserted into the femoral artery (located
in the groin) and advanced into the liver artery. The embolic material and drugs
are then injected through the catheter into the liver tumor. The procedure usually
lasts 2 - 3 hours.
CURE WITH !

PHARMACOGNOSY
Science of Natural Medicines
 Natural cure for HEPATITIS :

Principal Proposed Treatments = none

• Other Proposed Natural Treatments

Ayurvedic Medicines.
TCM Traditional Chinese
Medicines.
 Ayurvedic Medicine

Ayurvedic medicine, the ancient medical system of India,

has many traditional treatments for hepatitis. Some of
these have undergone scientific evaluation. One such is a
combination treatment called Kamalahar, which contains
Tecoma undulata, phyllanthus urinaria, Embelia ribes,
Taraxacum Officinale, Nyctanthes arbortristis, and
Terminalia ariuna. In a double-blind, placebo-controlled
study, 52 people with acute hepatitis were randomly
assigned to receive placebo or this combination herbal
therapy at a dose of 500 mg, 3 times daily for 15 days. The
results indicate that the herbal combination improved liver
function to a significantly greater extent than placebo
 TCM
Traditional Chinese Medicine
Licorice and Its Component Glycyrrhizin One of the
substances frequently mentioned in the Chinese literature
regarding hepatitis B is glycyrrhizin, a component of
licorice root (Glycyrrhiza uralensis is the species used in
China). Licorice was an ingredient in many of the
prescriptions used in ancient times to treat hepatitis

Hu-Chang and Its Anthraquinone ComponentsHu-chang

(Polygonum cuspidatum) refers to one of the many species
of Polygonum used by Chinese doctors. It contains
anthraquinones as main active components, as well as
resveratrol, a stilbene. The herb, used alone, or in
combination with other herbs, has been reported to cure
both acute and chronic hepatitis
Curcuma and Its Essential Oil Components Curcuma (yujin) refers
to one of three major species of curcuma used in Chinese
medicine, the other two are turmeric (huangjiang) and zedoaria
(ezhu). It contains a complex essential oil that regulates blood
lipids and treats infectious hepatitis
Ligustrum and Its Component Oleanolic AcidLigustrum refers to
the seed of Ligustrum lucidum. It is rich in oleanolic acid, a
compound that appears to be effective in treatment of liver
diseases, acting mainly as a liver-protective agent. It is reported
to be efficacious in treating both acute and chronic hepatitis, with
a cure rate of 70% for acute hepatitis and it was markedly
effective in treating 44% of cases of chronic hepatitis.
Silybum and Its Component Silymarin Silymarin is a complex
flavonoid from Silybum marianum, an herb that was initially
introduced as a therapeutic agent by European researchers, but
soon taken up by their counterparts in China as a treatment for
liver diseases
HERBAL REMEDIES FOR HEPATITIS

• Silybum marianum, milk thistle Also

known as variegated thistle regarded as
the standard amongst hepatoprotective
herbs and remains the most well studied
(up to 50 studies and clinical trials).
Constituents:
Flavonolignans. These are unusual
polyphenolic compounds referred to
collectively as silymarin. Thistle seed
preparations are ideal for chronic and
post-acute stages of hepatitis, rapidly
bringing an improvement in appetite and
well-being. It is also used in fatty
degeneration and even cirrhosis of the
liver. The seeds can be gathered (use
gloves!) and made into decoctions, or
ground up and used quite safely as foods.
 Dandelion. (Taraxacum officinalis).

• This is one of the most well known herbs and

universal weed. Dandelion has a long history of use
for liver ailments, and its nutrient content is
outstanding. While the leaves tend to act as potent
diuretics it is the roots that are used specifically to
promote bile and restore liver function.
• Constituents:
Vitamins- esp. beta carotine (vit.A) and ascorbic
acid.; minerals including potassium and calcium;
inulin and pectin; sterols.
• Actions and use:
Dandelion is classes as a choleretic, cholagogue,
diuretic and mild laxative. It increases appetite and
improves digestion. Its alkalising effect is beneficial
in all detoxification treatments. The dried roots can
be roasted and taken instead of coffee. However
unroasted roots are more therapeutic. They can be
taken in decoction form. Fresh juice of leaves and
roots can be taken in 5 ml doses. This is the most
bitter preparation.
 Artichoke. (Cynara scolymus).
• Globe artichoke is a popular food originating in Europe
which can be easily cultivated in Australia. It has a
long history of use as a bitter digestive herb and is a
major remedy for liver and gall bladder disorders. It is
the leaf that contains these properties.
• Constituents:
Cynarin and other phenolic acids; sesquiterpene
lactones; flavonoids; inulin.
Minerals, vitamins and enzymes.
• Actions and use:
Choleretic; digestive tonic; diuretic;
hypocholesterolemic; hepatoprotective.
• A safe and reliable herb for all liver disturbances
including hepatitis. Helps lower cholesterol (made in
the liver) and assists weight reduction. It can be made
into a leaf decoction and take alone or in combination
with the above two remedies. Artichoke, St.Mary's
thistle and dandelion all belong to the Asteraceae
family and work well in combination.
 Schizandra. (Schizandra sinensis).

• The dried fruits are derived from an aromatic,

woody vine that grows in China and north-east
Asia. It is a member of the Magnolia family. The
fruits are sour tasting, subsequently stimulating
bile production.
• Constituents:
Lignans known as schizandrins.
Also contains essential oil, fatty oil and mucilage.
• Actions and use:
Tonic; astringent; sedative; hepatoprotective.
• Studies show it decreases liver enzymes rapidly
in various forms of hepatitis. In mice it protects
liver cells from toxins and viruses, and promotes
liver protein synthesis.
• Schizandra is beneficial for insomnia, memory
loss and vision impairment. Chinese herbalists
make a decoction of the dried berries, though
they are sometimes eaten. The herb is generally
taken as part of a specific formula.
 Reishi Mushroom. (Ganoderma lucidum).
• This is a polyphore mushroom known in China as
Ling-Zhi. It is rated as one of the greatest of all
medicines, even rivalling the legendary ginseng. The
wild fungus is now hard to find, but extensive
cultivation occurs in many Asian countries so it is
readily available though quite expensive.
• Constituents:
Triterpenes including ganoderic acid;
polysaccharides; organic germanium; adenosine.
• Actions and use:
Antiviral; antioxidant; antitumor; immuno-stimulant;
hypoglycaemic; cardiotonic; anti-inflammatory.
Hepatoprotective action in mice. Hepatitis patients
show improved symptoms and less tiredness in
clinical trials. In China it is frequently used for chronic
hepatitis. It can be obtained in the dried form or in
tablets. Daily doses range between 2 and 10g. This
herb should to be taken under the supervision of a
suitably qualified practitioner.
 Phyllanthus. (Phyllanthus amarus, P.gasstroemii).
• Phyllanthus are low shrubs common across southern Asia
and Australia. In parts of India the herb is renowned for its
success in treating hepatitis and jaundice. It has acheived
international status since the publication of a clinical trial with
hepatitis B(HVB) patients.
• Constituents:
Ellagitannins including geraniin; lignans- phyllanthin;
flavanoids; alkaloids.
• Actions and use:
Astringent; diuretic; cholagogue; antiviral; hepatoprotective.
• Direct antiviral effects have been demonstrated in human and
animal HVB studies, which could be measured by a reduction
in the virus surface antigen. Several Australian species have
also shown antiviral properties in animal studies on HVB but
no clinical data is available. In India fresh roots are
considered the most effective for jaundice. Australian use is
restricted to prescription by medical herbalists.
 Liquorice. (Glycyrrhiza glabra).
• One of the most widely used herbs throughout the world,
liquorice is regarded by herbalists as a harmoniser or
balancing agent. It certainly improves the flavour of herbal
compounds but its properties extend much further than
flavouring.
• Constituents:
Glycyrrhizin, a triterpenoid saponin; isoflavones
• Actions and use:
Demulcent; expectorant; antiulcer; tonic; antiviral;
antiinflammatory; hepatoprotective. Chinese teaching
hospitals found its effective rate in treatments of chronic
HVB over 70%. The herb has a mineralcorticoid effect and
can cause oedema and hypertension in some people. The
popular liquorice stick candies are of little use
therapeutically, since the percentage of liquorice is small
while the sugar content is high. Pure liquorice root can be
obtained in bulk , it has a distinct yellow colour due to its
flavonoid content. Manufacturers use thick liquorice
concentrates which are included into a wide range of
products. Liquorice should not be used over long times
unless under supervision of a practitioner.
Awareness &
Media :-
Awareness &
Media :-
Further Queries:
adviapharma@aol.com
sarz_pharma@yahoo.com
genetech.laboratories@gmail.com

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© 2009 Department of Pharmacognosy, Uok, Pakistan.