WHAT is the deal with Milk Thistle?
WHY is it used to treat liver disease?
HOW does it work?
DOES it work?
ARE you ready for a #tweetorial?
🧵 #medtwitter#livertwitter
Milk Thistle, a history:
1⃣Use to treat snake bites (Dioscorides)
2⃣To carry off bile (Pliny the Elder)
3⃣Great for liver disease (1500's: Otto Brunfels)
4⃣In 19th Century 🇺🇸, the 'Eclectics' popularized herbology, especially milk thistle, for the liver
Fast forward to today:
1⃣Herbal supplements are a multibillion dollarindustry
2⃣A quarter of the population takes an herbal supplement
3⃣~5% of the US population is using Milk Thistle, including 12% of people with liver disease
What do they get out of it?
What does it do?
It has been shown in numerous mouse and cell-culture studies that Milk Thistle can stop lipid peroxidation and has both anti-oxidant and anti-fibrotic properties
But we are neither mice nor clumps of cells
So does it help actual people?
Milk thistle has been used to treat Amanita mushroom poisoning which can lead to acute liver failure.
But the bigger the study, the weaker the effect. Pool them together and the effect overall is no improvement.
Next slide, please
Interestingly, in this (open label) RCT, there was a decrease in blood sugar and insulin needs among patients with alcohol-related cirrhosis and diabetes who got milk thistle
So this leads me to...
Milk thistle for fatty liver?
Two RCTs show there is no improvement in liver inflammation. But one had reduced fibrosis.
Is this a false discovery? Cause for celebration? Or a reason for future studies?
I took an uber to Pearson airport at 3am recently. And my driver asked me what I do. The next question was whether he should take Milk Thistle for his fatty liver. My answer is no. But he made me want to understand how Milk Thistle use is so common
Summary
⭐️Milk thistle has been used to treat liver disease for centuries.
⭐️12% of people with liver disease take it
⭐️Benefits unclear but harms unlikely.
This concludes a #tweetorial on the history and uses of Milk Thistle for chronic liver disease inspired by a midnight uber ride. I hope you enjoyed
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We found that broad testing didn’t add much costs but increased false positives, especially when pretest probability of NAFLD was high
Then, In this RCT, John Dillon comparing usual care to broad evaluation of elevated liver enzymes, the cost per incremental diagnosis was 284💷 but was def cost-effective
This is a powerful method. But poorly understood, often maligned. My goal is to improve critical appraisal and help good analyses get the appreciation they deserve
All CEA begins with a clinical decision where we are uncertain about the best path forward. Nevertheless, when we face patients we must do something, even if that something is nothing. CEA brings our dilemma to life. Helping us quantify trade offs
Usually we compare a fair description of usual care to an alternative - make sure you agree the choice is fair, realistic, and represents an actual clinical dilemma
There's lots of tests you can order.
But most diagnoses are made in the H+P
Like this one
In fact, in this case, my attending said the diagnosis was obvious from the beginning
Just not to me
When I meet someone with ALT>1000, I think:
1⃣Ischemic hepatitis. Right 🫀failure? 🫀-genic shock? Cool legs?
2⃣Biliary 🪨. Pain? imaging!
3⃣Drug induced liver injury. Tylenol? Run every med through livertox.gov
4⃣Viral hep. Hep A/B/C
First, the lactate is up. Take this patient seriously
Second, the obvious clues are lower hemoglobin, platelet consumption.
Third, the ammonia is crazy high. This seals the deal for variceal bleeding.
The answer is hemoglobin and albumin are isoleucine-poor. This means that when our blood enters the gut, it is not a nutritious source of protein. It gets broken down for waste. That waste, my friends, is ammonia