Perspectives of Indian Medicinal Plants in the Management of Liver Disorders

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Resurgence of global interest in medicinal potential of plants during the last few decades has evoked tremendous efforts in exploring traditional systems of medicine resulting in generation of scientific data for validating claims of therapeutic efficacy and safety of medicinal plant based drugs especially for the diseases of public health importance.

The Council initiated a programme on integration of data from ancient knowledge, modern system of medicine and evidence generated through scientific studies on medicinal plant monographs on diseases of public health importance such as diabetes, malaria, filaria and liver disorders. The envisaged monographs incorporate information on the diseases (including etiopathogenesis) of public health importance and the plant drugs as given in the ancient texts of indigenous systems and allopathic system of medicine as well as the multidisciplinary research data generated through various scientific studies on such plant drugs with focus on pharmacological toxicological, clinical, phytochemical and pharmacognostic studies with complete references on the work cited.

Under this endeavour of the council, first in the series is the monograph on liver disorders entitled "Perspectives of Indian medicinal plants in the management of liver disorders". This specialized monograph may provide an insight of the liver disorders from the point of view of Ayurveda, Unani and Allopathic systems of medicine, rationale of use of plant drugs of traditional Indian systems of medicine, strengthen claims with respect to IPR/patents for global acceptability, give an insight in systematic and planned evaluation of plant drugs, basic and applied research and modern drug design, leading eventually to concepts of therapy and therapeutic agents for liver disorders.

I trust that this initiative of the Council will be of immense use to researchers, academicians, scientific bodies, drug industry, hepatologists, clinicians of different systems of medicine and other interested in medicinal plants.

I deeply appreciate the efforts of the Chairman and the members of the Scientific Advisory Group and Technical Review Committee.

Medicinal plants are a well spring of traditional medicines, household remedies, phytopharmaceuticals, drug intermediates, modem allopathic drugs, nutraceuticals, food supplements widely accepted all over the globe. Liver disorders have been recognized world wide as an important cause of morbidity and mortality in all age groups. Ayurvedic scriptures, nighantus, monographs and other literature cite many medicinal plants and their formulations as being useful in liver disorders. Caraka, Susruta, Kasyapa, Vagbhata and Chakradatt have described several remedies; some of these are still being used and investigated too. Some of the medieval literature on liver diseases and their treatment hold interesting possibilities for modem scientific research. In the year 1868, the British ruled Government of India, published Indian Pharmacopoeia which included monographs on many Indian medicinal plants. Several hepatoprotective medicinal plants were also included in the Pharmacopoeia.

Under the ICMR programme on preparation of medicinal plant monographs on diseases of public health importance, a project was sanctioned on the preparation of medicinal plants monograph in the area of liver disorders with the objective of listing medicinal plants and products reported to have been used in traditional Indian systems of medicine as well as in folklore and compilation of detailed consolidated scientific information on selected medicinal plants reported to have been used in traditional systems of medicine and investigated for hepatoprotective activity using modem scientific methodology.

This publication after giving an overview of liver biology, provides perception of liver disorders as de cribed in Ayurvedic, Unani and Allopathic systems of medicine followed by management of liver diseases under these systems covering clinical correlates of different kinds of liver disorders, differential diagnosis and management of the disorders by use of plants, classical formulations, modem drugs and dietary management. Listing of medicinal plants and classical formulations containing medicinal plants used in liver disorders have been separately given. Selected 12 medicinal plants used in liver disorders and investigated with modem approach have been thoroughly reviewed giving botanical description, Ayurvedic properties, traditional uses, chemical constituents, standardization and quality control, hepatoprotective/choleretic activity, clinical trials, dosage, toxic/adverse effects etc.

In order to encourage research work in the area of hepatoprotective plants, a full chapter has been devoted to methods and parameters of hepatoprotective evaluation of medicinal plants. In India, lot of work is done at various institutes on screening of medicinal plants for hepatoprotective activity and there are interesting leads available which need to be pursued to logical ends. Hope this publication will be of help to researchers, academicians, hepatologists and clinicians interested in liver protecting drugs from plants.

Inspite of tremendous advancement in medical and pharmaceutical sciences and improvement in the living conditions of human beings, there are certain ailments for which satisfactory cure or management is not yet available. One of such diseases is liver disorders which is one of the most prevalent causes of human sufferings and death. Living in a world of inadequately controlled environmental pollution and expanding therapy with potent drugs, the liver, being the key organ of metabolism and excretion, is continuously exposed to a variety of xenobiotics and therapeutic agents. Thus, the disorders associated with this organ are numerous and varied. There exists tremendous knowledge in our ancient scriptures on traditional systems of medicine regarding liver disorders, their management and cure. Modem medical science exhibits considerably advanced knowledge about this vital organ, its varied functions and disorders attributed to wide range of causes providing limited therapeutic agents but still liver disorders remain a wide spread disease of public health importance.

The Indian Council of Medical Research initiated a programme on integration of data from ancient knowledge, modem system of medicine and evidence generated through scientific studies on medicinal plant monographs on diseases of public health importance such as diabetes, filarial, malaria and liver disorders. Under this endeavour of the Council, first in the series is the monograph on "Perspectives of Indian medicinal plants in the management of liver disorders". This specialized monograph provides an insight of the liver and its disorders from the point of view of Ayurveda, Unani and Allopathic systems of medicine, rational use of plant drugs of traditional Indian systems of medicine, provides systematic and planned evaluation of plant drugs. It also contains in depth information on various aspects of twelve most important medicinal plants with all the scientific work done on hepatoprotective activity and their use in traditional systems of medicine.

The compilation consists of nine Chapters and three Appendices. Each Chapter is having all the relevant references. The sources of information include survey of literature from ancient scriptures, published literature including primary, secondary and tertiary sources, besides the literature made available by various scientists, academicians, research institutions and universities involved in activities related to medicinal plants/Indian systems of medicines in liver disorders. The Sanskrit slokas taken from various Ayurvedic publications bear exact reference to the original source of information. Each Sanskrit sloka is followed by English transliteration. Exact translation of the slokas is not provided to avoid any controversy rather entire essence of each sloka has been expressed in the text.

Introductory first Chapter includes concepts and prevalence of liver disorders, current management and its limitations followed by potential of medicinal plants in liver disorders. An overview of biology of liver giving gross anatomy, histology, functions and biochemistry of liver besides molecular hepatology, immunity and liver imaging are given in Chapter two. The third Chapter is on the perception of liver disorders as per Ayurvedic, Unani and Allopathic systems of medicine. Under the Ayurvedic system, liver disorders such as pandu (anaemia), kamalaUaundice), raktapitta (haemorrhagic disorders), sotha (inflammation/oedema), yakrtadalyudara (hepatomegaly) and b slagraha roga (liver disorders in children) have been discussed. Under the Unani system, liver disorders have been given under two categories viz: Yarqan-e-Ghair Suddi (non-obstructive jaundice) and Yarqan-e-Suddi (obstructive jaundice). Four kinds of the first category include Yarqan-e-Bohrani (jaundice by lysis), Yarqan-e-Mizaji (jaundice due to altered temperament), Yarqan-e-Mutaadi (infective jaundice), Yarqan-e-Sammi (jaundice due to toxic substances). Five kinds of liver disorders in the second category include Suddah- e-Jigar (intrahepatic obstruction), Suddah-e-Mirara (cholecystitis), Suddah-e-Majra- e-Safravi kabidi (obstruction in hepatic duct), Suddah-e-Majra-e-Safravi mushtarak (obstruction in common bile duct) and Yarquan-e-Qulanji (obstruction of intestine). Under the Allopathic system, the liver disorders described include hepatitis due to viruses (A,B,C,D,E and beyond A to E), due to drugs and toxins, alcoholic hepatitis, autoimmune hepatitis; metabolic diseases of the liver; liver cirrhosis; liver cancers; abnormality of liver functions in liver disorders besides immunologic derangements in liver disease and pathology.

Management of liver disorders as per Ayurvedic, Unani and Allopathic systems of medicine have been discussed in Chapter fourth. Under the Ayurvedic system clinical correlates of different kinds of kamala like kostha-kamala (haemolytic jaundice) and sakhasrita-kamala (hepatocellular jaundice) and viral hepatitis have been given. Plants used in liver disorders, nidana parivarjana (avoidance of causative factors), dietary regimen and Ayurvedic compound formulation for the treatment are described. Similarly in Unani system are given clinical features and diagnosis, formulations used and dietary regimen prescribed. Under the Allopathic system, signs and symptoms, differential diagnosis and management of all types of liver disorders have been described.

The Chapter fifth is devoted to medicinal plants and formulations used in liver disorders. Medicinal plants with their botanical and common names used in Ayurveda, Unani, Siddha and in folklore are given in tabular form. Classical compound Ayurvedic formulations have been given in different categories such as avaleha, kvatha Carna, ghrta (snehakalpa), carna, taila, vatiand gutika, bhasma, rasa-yoga and lauha as described in Ayurvedic Formulary of India. Similarly, unani compound formulations and common unani remedies containing medicinal plants used in liver disorders are given.

Medicinal plants used in liver disorders and investigated with modem approach given in Chapter six include Andrographis paniculata, Boerhavia diffusa, Cichorium intybus, Curcuma longa, Eclipta alba, Glycyrrhiza glabra, Phyllanthus amarus, Picrorhiza kurrooa, Plumbago zeylanica, Silybum marianum, Swertia chirayita, Tinospora cordifolia. Each plant has been dealt with in-detail under the following subtitles:

Other names of the plant given are in Sanskrit and other Indian regional languages. Botanical description gives the part of the plant used, its diagnostic macroscopic and microscopic features. Ayurvedic description includes Ayurvedic properties such as rasa, guna, virya, vipaka as well as Ayurvedic actions which are given along with English equivalence. Traditional uses of the plant drug are given for the management of liver disorders. Well characterized chemical constituents of the plant part used are given along with chemical structures of the most important chemical constituents. Under standardization and quality control, methods reported in the literature are given with some details and all references. Hepatoprotective activity is thoroughly reviewed and given in detail. Clinical trials wherever reported for hepatoprotective efficacy evaluation have been described. Doses and toxicology/adverse effects as per literature reports are given and pharmacokinetic studies wherever conducted have been also incorporated.

Methods and parameters of hepatoprotective evaluation of medicinal plants are given in Chapter seven. Hepatotoxins for experimental models described include carbon tetrachloride, d-galactosamine, paracetamol, ethanol, a-naphthylisothiocyanate, dimethylnitrosamine, amatoxin, lanthanum, antitubercular drugs, aflatoxin and Plasmodium burghei. Serum constituents and liver enzymes affected by hepatotoxins have been tabulated.

In vitro technique of isolation of hepatocytes, their viability test and biochemical parameters affected by drug under test are given.

Choleretic, anticholestic and antifibrotic activities of medicinal plants are also given.

Discussion and future approach elaborated in Chapter eight and Summary is given in Chapter nine.

The first Appendix includes detailed references on hepatoprotective activity of medicinal plants other than those 12 medicinal plants which have been exhaustively reviewed under Chapter six. The plants have been arranged genus wise alphabetically.

The second Appendix lists additional references relevant to hepatic disorders and hepatoprotection. These references have not appeared in any of the chapters of the monograph.

The third Appendix lists 130 proprietary commercial poly herbal formulations claimed useful in liver disorders in Indian market. Botanical names with family of individual plants involved in each formulation are given in tabular form. Inclusion of the names of these commercial formulations in this monograph does not indicate any claim of efficacy or safety or quality of these formulations, therefore no commercial organization should use this inclusion as a parameter of their sale promotion. The purpose of having this listing done was merely to know the medicinal plants involved.

The indices included are those on Medicinal Plants (botanical name with authority), Chemical constituents, Classical Ayurvedic formulations, Classical Unani formulations, Other names of the plants.

This monograph provides comprehensive information on liver disorders and their management as described in Ayurvedic, Unani and Allopathic systems of medicine with major focus on medicinal plants used in the traditional systems of medicine and those which have been scientifically evaluated. Hope this publication would be useful for clinicians of traditional and Allopathic systems of medicine, researchers, academicians engaged in medicinal plant research and hepatologists.