Article published in Global Health and Travel Magazine 2018
Asian trust in age-old natural remedies trumps the west’s need for evidence, leading doctors to prescribe non-pharmaceuticals.
Unlike many of their counterparts in western countries; with relative few medicines available for liver problems; doctors in Asia freely turn to supplements as additional ammunition when combating conditions like fatty liver, hepatitis and cirrhosis.
Indeed, some of the treatments that have been employed in Asia and parts of Eastern Europe for generations might not be easily available to their neighbours the United Kingdom and America. This boils down to a need in the west for well-published evidence before doctors will be allowed to reach for the prescription pad.
Doctors in Asia, however, are more inclined and perhaps less restricted when considering naturally occurring remedies which their grandparents and/or ancestors probably used.
“Western physicians are often restricted by what the little available evidence says when it comes to age-old supplements”, says Dr Prabhjot Singh Sidhu, Consultant Gastroenterologist and Hepatologist at Ara Damansara Medical Centre in Kuala Lumpur. “We want well-published evidence to show that a treatment works so we can justify prescribing it. But what about looking back at what did work for our ancestors? Although I do agree with the specifics of those treatments and remedies would be difficult to tease out”.
“Let’s be honest, evidence-based medicine is an excellent practice that keeps the patient’s safety as a priority. That is how I was trained, continue to and will continue to practice, but just because the published evidence isn’t there, it doesn’t mean that these remedies don’t work—it just means that we haven’t studied it well enough yet. When dealing with a critically ill patient, should we forego these remedies simply because someone hasn’t done the work? I’m not saying that we should throw out or medical books and switch to herbs and spices but instead, maybe we should simply keep them in mind when considering the ill liver patient. Also, these things are widely available at most health stores and like it or not, many people are already on them.”
“After working in the UK and coming back here, I see all these supplements that people are “using” and it worried me.“Using” I say freely when I actually mean “dish out” like it’s going out of fashion. What are these things? Almost every other person I speak to is on one or knows someone taking a liver “supplement”
In England, he says, there are steroids for patients with alcoholic hepatitis and N-acetylcysteine through a drip for paracetamol overdose—and apart from the specifics of viral hepatitis and primary biliary cholangitis, there is not much else by way of evidence-based drugs.
“Otherwise you treat the source of the disease, not the liver itself. In Malaysia, doctors are more likely to prescribe supplements at early stages for liver conditions weather medicines are available or not.”
Dr Sidhu, who recently returned home to Malaysia after 19 years in Britain, latterly as a Consultant at Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, lists a number of natural remedies used by physicians in Malaysia to improve liver function in patients and protect from insults like drugs and alcohol.
The best known of these goes by brand names including Heptral, which at Dr Sidhu’s hospital is classified as a drug, but elsewhere is mostly considered a dietary supplement. It contains ademethionine, a component that the body needs to make glutathione—an antioxidant in the liver which is often lacking in patients who have chronic liver disease.
Elsewhere, there is milk thistle, a herb which has been used for thousands of years to treat liver disorders, though it is never prescribed in the west. Classed as a supplement and available at all health food shops, it is an antioxidant and an anti-inflammatory that addresses free radicals, and it helps regulate liver cell walls, stabilizes membranes and helps the liver regeneration.
Tulsi, also known as holy basil, which can be used in cooking, is also commonly prescribed by hepatologists in Asia. There are studies to show that tulsi, combined with silymarin, can protect the liver from insults like drugs and alcohol. In the UK, this is never given, Dr Sidhu says.
He also mentions long pepper, a Chinese herb used in traditional medicine, which has come up in research papers recently. Again, it has antioxidant properties to address free radicals and is widely available over the counter.
The most heavily used supplement of all, however, would be coffee, which can protect against liver cancer and is associated with lower levels of liver enzymes. As a hepatoprotective agent, studies have also shown links between its use and slowing the progression of alcoholic cirrhosis and hepatitis C.“The interesting thing is that no one actually prescribes coffee or takes it for their liver. We just enjoy having it and fortunately, it has said benefits”
Dr Sidhu says that his peers would probably frown at him for even talking about supplements and that he would be in the same boat before returning home to Malaysia.
“I would show them the evidence, though this is often tenuous. I would also show them evidence to show that these supplements do very little harm. Then I will let them decide on their own,” he says.
Speaking from the UK, Dr Steve Ryder, a consultant hepatologist in Nottingham, is adamant that evidence must be found before a supplement can be prescribed or even recommended.
“From a UK perspective, prescribing is very, very tightly controlled,” he says. “There are a lot of medicines that would be freely available in many other countries are not in the UK. And that, I think, sets the framework for a doctor’s ability and willingness to prescribe outside particular areas.
“As with all these things, there is going to be a cultural element to it, a training element to it, and a regulatory element as well. As a hepatologist, I have occasionally seen the downside of some herbal remedies, like acute liver failure, so they are not necessarily risk-free substances.”
Not all doctors in Malaysia will automatically prescribe natural remedies, however; I included, but they are still worth considering once the limited medicinal options available to treat the liver directly have been exhausted, Dr Sidhu says.
“I trained in the west, so I like evidence to say that this is why we do these things and here are the hard facts. I have also seen many patients suffer from significant liver impairment from taking unspecified herbal remedies and off the internet medication, some ending up on the liver transplant list. Again, I’m not pro-supplements and certainly have my reservations about them as a whole like the majority of UK trained doctors but what about the patient who is desperate for “something, anything” that might help? You have to be aware, here in Asia, they are very likely to just go to their local “herbalist” maybe take something that might put them to harm. Should we say ” there are supplements—the evidence is not strong, there are a lot of things we don’t know about them and with that there are risks but at least we have some evidence on safety”? I think the jury is still out,” he adds.
