Okay, good morning, everyone, and welcome to the American Association for the Study of Liver Diseases, Hepatotoxicity, special interest group, what a mouthful, seminar series on drug-induced liver injury, all things hepatotoxicity, and sometimes even beyond all things liver, we like to talk about here. I am Lily Dara from USC. I'm the chair of the SIG and Dr. Jim Luyendyk. The vice chair of our SIG is from Michigan State University. He's going to introduce our speakers today. This is a special series that came out of the Hepatotoxicity SIG steering committee. It was Dr. David Kleiner's suggestion, actually, and has been successful so far. This is the case-based discussion number two, where we present a case of hepatotoxicity, have a little presentation regarding the disease process, and then have an open discussion. As you know, this is very informal. Turn on your mic at the end. You can speak. If you have questions, it's just easier if you put it in the chat so I can call on people in the order that they ask their questions. So, Jim, please take it away. Yeah, you bet. So we have three stellar guests and I was asked to do introductions based on biographies that were a pleasure to read. It's like you know you have the experts together when you get biographies and it's three pages. So, forgive me, what I've done is I've kind of condensed this into the things that I thought were exciting. So I'll introduce Dr. Kleiner, who is currently a senior research physician and chief of the postmortem section of the Laboratory of Pathology at NCI. He has a particular excitement for liver pathology, and based on that, his skills are highly sought after by multiple NIDDK-sponsored study networks. He's actually so famous that he apparently may literally get called out to work during his talk. And as you might anticipate, Dr. Kleiner's credentials, his training, and accolades are outstanding. We also have Dr. Iqbal Khan, who's the director of the National Center for National Products Research, director of an FDA Center of Excellence, and professor at the National Center for Natural Products Research at the University of Mississippi. Dr. Khan is meaningfully engaged with centers, universities, regulatory agencies around the world, is the recipient of numerous awards, has an extensive list of service activities, and amidst all that, has an incredibly strong research program and an interest on analytical fingerprinting for standardization of herbal products, as well as bioanalytical approaches for the improvement of product safety and quality. We also have Dr. Dina Halegua-DiMarzio, who is a transplant hepatologist and associate professor of medicine at the Sidney Kimmel Medical College at Thomas Jefferson University, completed her residency in internal medicine fellowships in gastro and transplant hepatology at Thomas Jefferson. She actually developed and currently directs the first adult fatty liver center in the Delaware Valley and also serves, she's busy, as the director of GI research at Thomas Jefferson, is the associate chief for the division of gastro and hepatology. I really like that she's an award receiving educator and also currently serves as the co-chair for the Dillon subcommittee on herbal and dietary supplements. So, with all that in mind, I promise you, you have the experts here to, who can focus on the topic at hand. And one other thing that I wanted to point out is, while I didn't focus on numbers, between them, our guests today have published approximately 1,300 peer-reviewed publications. So, welcome to all three of you and I'll let you kick it off. Great. Well, thank you so much. And I'm honored to be here and it's such a great company. Let me go ahead and we'll get, jump right actually into our case discussion. So, this is a case of a 35-year-old male who presented to the emergency department with two weeks of fatigue, itching, and jaundice. And I'll also start with just telling you, this is actually one of our cases from our series that was published from the Drug-Induced Liver Injury Network. So, I'll show you a little bit more data on that later. When he presented, he really wasn't feeling well. He was having some nausea, vomiting, dark urine, subjective fevers, he noticed light stools and paritis that had worsened over the last three days before he came to the emergency department. In the emergency department, he was noted to be ectaric. An initial lab showed a total bilirubin of 12.5, ALT 2014, AST 796, and alkaline phosphatase of 125. R-value at this time was 42.8, representing a hepatocellular pattern. Overall, a pretty healthy gentleman. His biggest ailment was L5-S1 disherniation. He had no past medical history of liver disease except for a diagnosis of Jilbert syndrome. He was not taking any prescription medications and had no allergies. In terms of social history, he did report drinking about two alcoholic drinks about eight days per month. So, further history in discussing with him what supplements he was taking, over the past nine months, he had started taking multiple over-the-counter supplements. So, just to give, you know, kind of the lay of that, he was taking, and we'll go into this in more detail, Nature's Lab Turmeric Extract. He started that about 60 days before presenting to the ER. He was also taking Arazo Nutrition Joint Support, started that about nine months before the presentation. He was taking collagen peptides about 100 days before, vitamin D3 46 days before, wild Alaskan fish oil nine months before, and then proteolytic enzyme about 117 days before. He also was taking ibuprofen about two to three times per week, but over the last 60 days was having worse back pain and was taking it daily. So, let's take a look at these products. I know often they have, you know, these names and it's hard to really understand what's in them, and Dr. Khan is going to go into this in more detail, but just looking at the label of these two supplements. So, as I mentioned, he had started more recently taking this Nature's Lab supplement, and as you can see, the ingredients we have listed here included both a turmeric extract and also a black pepper extract, pepperine, which will become important, and then had started that while he was already taking for nine months this joint support supplement, which had glucosamine chondroitin, but also, as you can see listed here, contained turmeric as well. So, in terms of initial workup, I've listed serologies here of note. His ANA was positive at a titer of 1 to 80 at initial presentation. Two months later, it increased to 1 to 60, but then subsequently was negative on follow-up, and his anti-smooth muscle antibody was negative at presentation, but about four months later was slightly positive at 1 to 20. You can see otherwise, though, viral serologies and some genetic testing negative. And then here's his lab trend. So, you can see June 16, 2020, that was his initial presentation with the labs that I reviewed with you earlier, and we're going to take a look at the liver biopsy that he had, but a little bit of an interesting course, and you can see specifically around June 28, his bilirubin actually, although things were initially getting better, bilirubin increased and stayed there for a few days until over the next two months coming down, eventually with normalization after stopping the tumor-containing supplements. We could talk a little bit more about that. I wonder if that delay and improvement was somehow related to his history of Jill Bears, but an interesting course there. So, I'll hand it over to Dr. Kleiner to review the liver biopsy. So, you can go to the next slide. So, this is kind of a representative photo of medium power of his liver biopsy, and over on the right, you can see a portal area with mild inflammation. There are a couple of eosinophils there that are hard to pick out, but there weren't lots of them. And then over on the left, towards the bottom, there's a central vein, and above that, a little collection of pigmented macrophages and lymphocytes. But you can see that there's not a lot of inflammation, and actually, the patient, as you saw from the enzymes, was already starting to recover. So, there might have been more injury going on at the height of those enzymes in Billy Rubin. You can go to the next slide. So, this is one of the features of this gentleman's injury. So, he had duct injury, and it can be fairly subtle, but over on the left, where the arrow is pointing, there's an apoptotic cell within the wall of the bile duct. Hard to know if that was an epithelial cell undergoing apoptosis or lymphocyte, but the finding is unusual and remarkable. And then over on the right, there's a bile duct, which also shows some mild reactive changes. So, there was a little bit of bile duct injury going on. Next slide. And then around the central vein, which is sort of at the top of the photo, about two-thirds of the way along on the right, there was more inflammation. So, you can see more lymphocytes and macrophages, some of which are pigmented. Within the circle is an apoptotic hepatocyte, so a little bit of acidophil bodies scattered around the biopsy. And then the arrows indicate cholestasis, so they're dilated canaliculi that have this pigmented material in it, which is bile. And that's the easiest way to identify cholestasis in a liver biopsy, because there are other pigments that can show up in other cells. So, not much else shows up in the canaliculi. So, next slide. Just another slide of another central vein. There was a little bit of hemorrhage around this vein. You can see the red cells near the tail of the arrow. And then again, the arrow is indicating a dilated canaliculus with bile in it. So, overall, we have a cholestatic hepatitis with both cholestatic visible bile features as well as a mild degree of hepatitis. And if you go to the next slide, we have some other features here. So, there was a little bit of steatosis. Not a lot, very mild. And then on the right, you can see little collections of macrophages that are pigmented. And these may be containing bile or they may just contain cellular debris from hepatocytes that have been phagocytized. So, next slide. So, just to recap. So, the liver biopsy showed normal architecture, canalicular cholestasis, and other relatively mild inflammation with a little bit of bile duct injury and then scattered apoptotic bodies and mild steatosis. And there was no fibrosis in this case. Great. Thank you. And the MRI was also negative without any biliary obstruction. All right. So, just to go back to the case, kind of a summary of events and follow-up for this patient. So, you can see, you know, time of two months. So, starting the second supplement, time zero there, the initial labs. Given the slightly positive ANA, anti-smooth muscle, he was tried on methylpregnisolone for six days. There was no improvement in the bilirubin, and this was just discontinued after six days, did not seem to have any benefit. But over the two months after stopping the supplement, his labs continued to improve and to normalize. Slightly sluggish bilirubin improvement began with the history of Gilbert's, and he was just treated symptomatically with cholecyramine for pruritus. And then on one year post follow-up, liver tests remained normal. So, just another interesting point that I wanted to talk about, you know, spin on this case. So, with some further genetic testing, we found actually that this patient was a heterozygote for HLA subtype B3501. And when we looked at our series of patients published with this type of injury, seven of the 10 patients actually also, we'll talk a little bit more about the B3501, had this pattern. But also, we did see that there were some autoantibodies in these patients. But interestingly, immunoglobulin levels were normal, and the patients all normalized without need for immunosuppressive therapy. So, a little bit more on B3501. This is a class one HLA allele that has been previously implicated in green tea, garcinia, and polygonum hepatotoxicity, which so this was kind of exciting to also see this with tumeric hepatotoxicity. This allele is carried by 5 to 15 percent of the US population, so not rare. But the lowest rates are in Asian Americans, intermediate in European African Americans, and modestly higher in Hispanics. So, the thought is that, and the suggestion is that there's a common susceptibility in patients carrying this HLA type that may make them more sensitive to multi polyphenols. And just from the paper, a table kind of breaking those patients down in terms of if they were a carrier of this HLA type or not. And interestingly, those who did carry this 3501 had a very similar course and more classic course in terms of their average ALT elevation and presentation, where those who are negative had a much more variable course. So, you know, just some additional thoughts here, you know, with this patient, and we can talk a little bit more, obviously, about that. But so what happened here? Was it when he started taking a second tumeric containing supplement that he didn't realize that now he was taking two supplements with this? Or is it the effect of peperine increasing tumeric bioavailability? And just again, to kind of give you a summary, this was just one of those cases that in our series, but again, a good, I think, showing a good variety of patients very similar to him. Although in our series, there were more males than females, but very similar presentation, and specifically the mild elevation in the autoantibodies. So these are some photos of two other cases that we presented as part of this study. We had only a few liver biopsies to look at. This one, and in both of these cases, neither one showed cholestasis, so they were more just purely inflammatory. So this was the worst one. You can see on the left, the portal area is expanded by inflammation. There's a lot of interface hepatitis. And on the right, there's a collection of plasma cells right in the middle of the portal area. So, I mean, at least histologically, you could raise the question of autoimmune hepatitis. And then if you go to the next slide. Thank you. So this was the other case that we had. Also purely inflammatory, no cholestasis, but this one had more eosinophils, and you can see them, some of them anyway, pointed out by the arrows, as well as spotty lobular inflammation and hepatocyte apoptosis. But overall, it was a milder case than case three, and also just purely hepatocellular or hepatitic injury in this one. Great. So just to wrap up this case, and then I'm going to hand it over to Dr. Kahn to talk a little bit more about him and what his team did, which was really key to this. We know that turmeric is being widely used as an herbal product and promoted for a number of uses. Interesting to us was we were seeing this increase in cases coming into Dillon around the time of COVID. So people using this as a potential preventative treatment for COVID. The pattern seems to be hepatocellular with a latency of one to four months and this linkage to HLA-B3501. But the increase, it's unclear exactly why we're now seeing this, is it increased usage, or this potential combination with peppering, which may increase absorption. So with that, I'll turn it over to Dr. Kahn. Thank you very much. So you got all the work done. And now, before I talk about turmeric, I want to tell you a little bit, because I know that most of the clinicians are used to single ingredient pharmaceuticals, and they can link with the dosage and the effect or side effects. But we assume the supplement contain what the label says. And the first thing is not true. And we will be showing what we do about it. So first thing is, if it is not what it says on the label, it can be anything. So that creates another problem. So in order, why it's so important to know that you can link the presence of like turmeric or any other ingredient to the liver injury, but you have to know what is inside the bottle. And we will show the example what's happened. So how we go about it, because this is open field, you have to look at the label first. So we approach it, next slide. We start with chemical analysis, we look at the label, what it says, then we can go for quality, which means just want to figure it out whether everything is there, what says on the label. And then we will go and quantify how much is there. And there is a targeted, non-targeted, and I will explain what it means. Next slide. So first thing is, there's also a variation in pharmaceuticals. If anytime they want to really come up with a new formulation, they have to go through a whole nine-hour testing. But in dietary supplements, when you say you are taking turmeric, in what form and shape people are taking it, I mean, that changes a lot of bioavailability issues as well. So it can be gummies, tea bags, a gummy is a new one right now, oils, liquors, and there's a lot of other formulations that come up with the liposomes and increasing the bioavailability, but everything, the sample prep itself is keep changing. And that changes actually the bioavailability later on. So we deal with a lot of different formulation or sometime it can be simple powder. Then we come up with the instrumentation and the instrumentation we are using is a high-resolution mass spec, which can give us information about the molecular weight, and we can figure it out what molecules they are. So we do that. Mass spec is the one that we generally use for that one. And over the years, we have developed a database, which is really very unique. We have close to 15,000 natural products presented in this all mostly traditional medicine and dietary supplement present. So we go and check against this database. Next slide, please. So we do targeted and untargeted analysis, and this is the flow chart, what we go. If it is known, it's in the database, we know the molecular weight, we can identify it as a caffeine or not. If we see some peaks and we don't know what it is, then we have to go and do further studies, try to get the molecular formula and try to find out what these molecules it might be. And sometime if it is not, then we have shown examples. Turmeric is a different one, but like steroids that are not reported in the natural databases, then we go and try to find out what this molecule might be. And sometime we are lucky to find out based on the molecular structure, but sometime we have to, in fact, go and isolate it and confirm the structure and determine what this molecule is. Next, please. So we have targeted analysis and untargeted analysis. So let's talk about the targeted one that is listed next. So we look at like toxic compounds. So we use a database of pharmaceuticals. We use like aflatoxins. Pyrolizidine alkylides have been known in this area for a long, long time. So we want to make sure that none of them pyrolizidine containing or it got into through the process. Some of the compounds like anthraquinones, which generally cause the liver injuries and they are available, in fact, in also in aloe vera. Now we have ECGC and other anabolic steroids. So we, this is what we want to make sure that none of these are present. So that's, we do the targeted analysis. The next one, the untargeted one, this is also a list of targeted one that we emphasize on that one. Can you go on to next slide? So just talk about the turmeric. So we all know turmeric as she said it in the last slide that is commonly used, is present. But what turmeric we are talking about, turmeric has been used traditionally. I mean, long history of that one. It has been traditionally used. But when we come up with the turmeric, are we talking about curcumin or turmeric? That's what I was talking about, not knowing what it is. So turmeric is long history of use, is present, is standard in pharmacopoeias. The molecules, it depends, they can change from one to another form. It depends what formulation you have. The next thing is, next slide please. So turmeric has been reported in pharmacopoeias and they have like percentage, all the pharmacopoeias, they talk about 1% curcumin, for example, in Chinese pharmacopoeia, they talk about 1.5% in Indian pharmacopoeia. But here we are talking about turmeric. Okay. So the thing is when people say it's long use and it has been traditional usage, but look at the percentage. And when you saw on the product, 100 milligram, and you convert into the real turmeric that people are consuming is going to be in grams and huge amount that generally people do not consume. So the first time you see is that really become multiplied because you do the pure compound. And we don't know the side effect of it because people really consume as a turmeric, not curcumin. Now on top of it, they identified a molecule, which is curcumin. It's the same thing like ECGC in green tea. And they go up to 50 to 60% of this compound and sometimes 100 milligram of it is really very high amount. So now this, even though people claim that it has been traditionally used, but really not in that form and shape that has ever been used. So now we are dealing with a totally different problem that we are not, and it has a lot of activities. People say curcumin is good for you, but how much is there? There is no what side effect it has. There is no data on it, but making relevant generally when people talk is good for you in what form and shape that you refer to that's really taken out of context in my opinion. Next slide. So they have a lot of studies in this slide is show you the maximum you will get naturally available is up to 10%. And this theme you will see again, again, in several other slides, kava, kava, green tea, people are really taking a huge amount, even though in nature is present up to 10, 12%. But you see a very huge amount of these pure compounds are being used without looking at the safety profile of that one. And safety is not only the amount of the compound, but also what they put with it. Next slide. So when we analyze our turmeric product, in this case, we had a 47 products. The one product did not contain any turmeric. And the 33 product was tested for curcumin. But 14 product tested negative for few ingredients from each product. What is claimed like about 10 to 60% ingredient claim failed in each product, whether they're high or they're low, it's not what is written in the bottle. Nine products in the detective for the presence of piperine. Piperine has been used and is being commonly used to increase the bioavailability. And there is a patent on that one. Piperine, it does help in bioavailability in other cases as well. And top of it, two products contain unclaimed piperine. It was there, but it was not claimed. And also has a green tea extract, which was not on the label. So when you look at the label and say, oh, this is a turmeric product, it really doesn't mean anything unless we have this analysis done. And we have found other contamination as well. So this is, so you talk about the effect, which one, what product they're taking variability and curcumin does have, depends what form and shape you're taking. It does have an effect. So this is what the analysis we found in especially in turmeric product. Next slide. Bioavailability of curcumin. So when you talk about turmeric, and if you know the Indian curry, you won't see any precipitate, but they talk about the bioavailability of that one. Now, instead of going the natural way, people have gone and they're trying to put piperine in it. They come up with liposomes, curcumin, myceles, lecithin base. So what they are trying to do is increase the bioavailability. So they are using first very high amount of curcumin, which is compared to turmeric is really huge amount. Plus they're trying to increase the bioavailability, which really what it does, they just make it more bioavailable. What are the side effects? What's happening? It's really not reported and it starts being considered. But that's one thing that also, which is a different in that it supplements every formulation. You can just can't compare it with anyone because what it does, how much is bioavailability. And we have some research going on in that area as well, because some of the products can be very viable, bioavailable, and some of them probably not going to do anything. And some formulation is really don't even disintegrate your stomach. I call it the safest product. The next slide. They do have hypertrig interaction. That's another thing that when people take multiple things, they do have SIP inhibition and what SIP inhibition does. And we, especially when you are taking piperine, which has also SIP inhibition and this activity in on top of what people are taking pharmaceuticals, what it does is really not explained. And you don't know what people are taking for how long they're taking for what other medicine they're taking with. And that gets very complicated. And that needs to be really, we are doing some work on that one, but that's really, you find very sporadic. And even you do this kind of work, then you are not relating to the particular product that in question, because there's so many different products. But this is a common knowledge that curcumin does cause SIP inhibition. And also the next slide will show you more interaction. It has GCT, PGP, so this kind of drug infraction always reported. So when you take all this mixture, and these are the things that we try to address writing a grant to NIDDK, that this, this will be very valuable information for you to move forward. Okay. They have taken curcumin with piperine, and maybe that is more likely, or it does increase. So next time we see that kind of a signal, but that information in between is really missing and it needs to be done. And we're trying to make a good case, but we will not succeed. But I think that will be helpful for you, all of you to really look at it, chemical analysis and what is available in particular products. So with that one, I will stop and take any questions. Okay. A bunch of questions in the chat. This was fantastic. Um, there's, it's, there's so much nuance to, to this issue of turmeric that, um, thank you for going through all that. I have questions in the chat and so I'm going to go in order, uh, Dr. Chowdhury. Yeah. So I, I'm just, when you were describing his, um, sort of past medical history, he seemed very healthy, but he was taking very high dose of non-steroidals and why had he started all of these supplements to begin with? So I was just curious if there was an underlying arthritis that was perhaps immune mediated. Again, he did show some, you know, obviously didn't look like RF was, uh, rheumatoid factor was checked, but I'd just be curious if this was somebody with an underlying arthropathy of some sort that may have been immune mediated. So that was my only question comment. Oh yeah. Good question. He had, um, some severe low back disease that had a disherniation. Yeah. So it was really treating that, but yeah, great, great thought. Was there something else going on, but it seemed like he was really taking things to try to treat his symptoms from that. Okay. Thank you. Um, so, you know, David, I, you know, I struggle with a lot, I struggle with terminology all the time. Like, you know, me, I was like chronic dilly. What do you mean by chronic dilly? Right. What do you mean by, so, so the term cholestatic hepatitis, for example, that I've seen you use histologically and I saw you show it and I get it. Um, do you, do you have any idea, um, uh, you know, what the disconnect is with us not seeing this biochemically. So, um, so we actually looked into that in, in the, the histology paper that we wrote a number of years ago, there is not a lockstep relationship between what you see under the microscope and what the enzymes show. And so you can have people with cholestatic injury under the microscope who have only AST, ALT elevations or with minimal changes in the cholestatic enzymes and vice versa. So you can have somebody with kind of just the inflammation and nothing else going on and they can have relatively this ratio, more cholestatic. So while those enzymes give you kind of a general impression of what's going on, you can't necessarily equate them to what's going on in the liver. So, you know, there is a certain amount of false positive or false negative. I have a lot of interest in this because I'm very interested in the variant syndromes and autoimmune hepatitis PBC and that whole spectrum of these. And we've looked at it in our autoimmune hepatitis cohort and very clearly we see that AST, ALT does not correlate to disease activity in the liver. Others have shown this, HALT-C showed this with hepatitis C. But it's very interesting to see it also with alkaline phosphatase. And this patient clearly had, you know, pruritus, you know, and I don't, you know, so it's a clearly features of cholestasis. So that was just totally fascinating to me. I'll let Ashley ask her question and then I have a question for Iqalus. Go ahead, Ashley. Sure, thank you. That was a lovely presentation. Whoop, and that is the wrong video I'm looking at. I was just wondering, as David mentioned that there were some changes of duct injury, apoptotic cells reaction. And sometimes when I see that, obviously we look for duct loss, but I wonder if those patients are going to evolve into more of a chronic cholestatic injury or a vanishing bile duct syndrome. Have you seen that with this? Not in our case series. And I don't think that I have seen this in the literature documented, although I might be wrong because these things get published as case reports and it's easy to miss them. My general impression is that any drug that causes this sort of cholestatic hepatitis in a minority fraction will cause duct loss. So just about any antibiotic that gives us, and antibiotics are a good example of this kind of injury, almost all of them that cause cholestatic hepatitis, a few percent will have vanishing bile duct syndrome. And so my answer is probably yes, it's out there somewhere. Maybe we just need enough cases to show it. Thank you. There's a lot more cases floating around. Probably, yes. They don't all look the same. Not being diagnosed. Totally. Ashley, nice to see you in person. I know you're from Twitter. At liver path. So next question. Oh, it's me again. Oh, Nicholas, it's very interesting because I'm always thinking about how do I model this stuff in the lab, right? Like what can I study in the lab that idiosyncratic is such a pain in the neck? So do you think this is like a threshold issue of the amount you need to absorb, like the whole 50 milligram story, and you need to absorb beyond a certain amount to get idiosyncratic reaction? Or do you think actually curcumin, I don't know if you've done these experiments, if it's toxic to hepatocytes directly? No, I don't think it's a toxins, but everyone, all of us in this case, if you are predisposed of something, you are ready for it. So that's the thing where the threshold of the dose will play a role. So if you are taking other medications, are predisposed, how much you are taking, and this is something that Victor and we were trying to really address this question, also the bioavailability. So even it has 100,000 milligram of curcumin, how much is bioavailable to you, it depends on the formulation. So these are the questions that you cannot correlate it, but as a general toxin, curcumin is not a general toxin. Same thing with ECGC is not a general toxin. So because otherwise everybody should be seeing some effect. And so that's not the case here. But those people who are predisposed because of genetic or some indication, it doesn't have to be genetic. It can be you are already predisposed, you have this liver issues, and you take a huge amount, then the amount will play a role. But yeah, we will be happy to work. Any of you are interested in exploring more variability, we will be happy to work with you. Fantastic, I may reach out to you. Mark, actually, this is something we haven't published yet, but with the Dillon, Herb had this idea to look at the antihypertensives, okay? And we recently ran the HLA, had a meeting with Paola last week. Alpha-methyldopa, lisinopril, also have HLA-B3501. So A, either this is honestly, either 3501 is nonsense, right? We're just picking it up where it's so common or something. There's something about 3501, or this can't be a groove kind of peptide interaction. And I've been in contact also with Elizabeth Phillips and there's actually 3501 has showed up with immune checkpoint inhibitors too. Right, so I suspect it's real. I think it's actually quite interesting. And a number of years ago, actually, I don't know if you remember, Michael Norcross showed that with abacavir, there was actually peptide, the abacavir immunoreaction that's well-known. Actually, the HLA association with 5701, actually the peptide was not the abacavir-derived peptide, but it's actually an endogenous peptide that he was able to isolate in a nice experiment. So that actually the immune adaptor reaction is not actually responding specifically, necessarily to a chemical constituent of the exogenous molecule, but rather there's a stimulation maybe, and maybe that's the dose-related effect that's common across all these herbals. Because it's very curious with these different molecules that you get an exposure-related effect across different molecules that are also HLA-associated, and there's a common HLA isoform. So I actually think that this is actually an important discovery to be made from what I see, because with the herbals, we see across many herbals and these liver reactions, a dose-related effect. CBD is another example, cannabidiol is another example. There's little known about what is the actual mechanism of this adaptive immune reaction. It seems to be an adaptive immune reaction that has features, clinical features of that. So I think it's still to be determined, and if there is a common pathway with an endogenous peptide that is then stimulated and then presented by particular HLAs, then that's an important concept to either exclude or include, because that would have an effect on modeling these reactions and also managing them in terms of predicting the exposure-related effects. So that's more of a question. What do others in this group think about that? The other thing to add here is that actually B3501 has been associated with autoimmune hepatitis in Han Chinese, and also in another population. And so, and also I was looking this up the other day. I got really, went down the rabbit hole with this, because I saw it with two different drugs that have nothing to do with each other, and I knew Dino's work, and I know the Polygonum paper showed it, and the EGCG paper showed it. The other thing is apparently 3501 has, but there's some link to ER peptide processing. So I'm trying to understand if this is that second hit we talk about. I talked to Paola that maybe we need to go back and then look at all the drugs in the database that are 3501 and see if we can find a connection there. So she's trying to kind of figure out how to do that. But yes, I'm very open to thinking, to see it. I mean, it'll be very exciting if there's a common mechanism or a common sort of step that's shared between all these different herbals, irrespective of the details of their structures. I mean, as opposed to that there's a common, like an alkaloid, like papiridine or something like that, that's a contaminant that's commonly shared between the formulations. Those are very different mechanisms. No, lisinopril is positive for 3501. Alpha-methyldopa is showing 3501. Right, right, right. We don't have an HLA-specific person here to help us navigate this. Let's see, Raquel Pinto. Raquel, are you here still? Yeah. She's asking, is there a place for the use of ursodiol in this type of dilly, Dina? In this, this wasn't really used in our case series. I mean, I think in cholestatic dilly, it's something I will sometimes use. Although I don't know if there's any data that really shows, somebody else here might know if there's any data that it helps to improve the patient. But I know something that even beyond all we know about ursodiol may have some role in especially cholestatic dilly. I don't use it. But I know some people do. There's not a lot of harm, I would guess. Yeah, really no harm. But yeah, in this series, we didn't. I mean, it is a choleretic, right? So it would increase bile acid dependent bile flow. But I think the issue, I don't know. I don't know if there's any data, Dina. Yeah, I don't know. I know a lot of people just throw it on to help with bile flow, but it's a little bit voodoo almost. I don't know, other clinicians on here, Skip, Neil, I don't know. No, I think I'd agree with everything. I think the question is, if it's like an androgen injury, the question will be the new IBATs, right? Could you use them temporarily and help the paritis? It makes sense, it might. That's the question I think comes up. But I did have a question for Iqalus about the pyrine. It's a nanoparticle. So do you have to, in a dedicated fashion, take it to the lab and chemically load it with whatever you're trying to get absorbed more? Or is it more nonspecific, like you can just add it into the mix and it will just sort of self-load and start letting things be absorbed more? Because I think it's a big deal. In other words, I mean, they can just start adding pyrine, just anybody could add it into their herbal mix and see what happens. Or do you have to do it in the lab? No, actually there is a patent from India that they use, they develop pyrine for loading, reducing the amount of antibiotics. Okay, so you do have to do it somewhere in the lab and chemically load your thing onto that nanoparticle to make it work, is that right? Yeah, nanoparticle has to be made differently, but pyrine came out of this patent that pyrine does increase the bioavailability for antibiotics, so you can use the less amount and then reduce the dose. And that science has been just taken away from that particular application and people are putting in everything. Pyrine is coming from black pepper, so which is commonly used as a spice, so the thing is safe, and they're trying to make bioavailability. And I think that FDA is struggling, especially with this question of formulation of what does it mean? I mean, more bioavailability is good or bad, what does it do? And like any other thing, this science is not being done. And so that's the question that needs to be addressed. The same thing goes with the new technology, liposomes, people are making in different kind of nanoparticle. I don't know why you want to make a nanoparticle out of herbal thing anyway, but this is more marketing thing they do in the lab, they make a nanoparticle, which become more bioavailable and it can cause severe problem. But yeah, this is not based on science like they did in antibiotics, they just add more and sometimes they just add more and more. And so this certainly is gonna impact the bioavailability. And I'm sorry, I'll take one more question real quick. This is the first time I didn't know this, it actually has SIP inhibition. And so how much of the papyrin itself gets absorbed on its own? And how much do you need to create a drug-drug interaction problem? Exactly, this is, you remember that when we put proposal together, it should have considered all this formulation first and then drug interaction, which really didn't go through. But these are the things actually to me that will bridge and help all of you to make a decision if we can provide that data in one place, that yes, papyrin is not only turmeric, is fuel fine, commonly available in many, many product, they just put it there. So what it does, I think these are the questions that needs to be answered by somebody and needs to be done with a systematic research, not on the basis of product, but the question you are asking, how much papyrin does what? And then we will see how much is added and what the role is in different products. It, in general, it has to be really looked at it. The other thing is we are finding this, some of the product needs to be benign like ECGC or curcumin or cavein. Why people are getting affected is the question asked, whether it's a dose only or is something to do with genetics? I think those has a role to play in it, but nobody has a data which how much is safe. These are the things information is not there, but it needs to be generated. I think it will help all of you to make your decision easier if we have all this basic information we're discussing is available. Yeah. Thank you. Thanks. Absolutely. Dominique, I know you're mentioning, it's funny in French, everything's backwards, UDCA, A-U-D-C. You use URSO. Yes. Hi. Hi, everyone. So we do use A-U-D-C in case with prolonged cholestasis beyond the end of treatment, especially in some case with checkpoint inhibitors and it turned out, so then it turns that it seems to have good results, but obviously it's not a controlled study, of course. So, but anyway, we do it in some cases. That is interesting to note. Any, yeah, I just haven't used it. I don't think there's any harm, especially short-term to use it. We usually just wait it out. I think that concludes the session. There are no more questions. Thank you for the interaction and for all the wonderful questions. We learned a lot. Skip. Yeah, thank you very much. No, I was just to say, that's great. I did learn a lot. So I appreciate it. I always like to see slides. Anyone would like to experiment more in their labs with the curcumin and vibranium and all these things, we will be happy to work with you all. Fantastic. That sounds great, Iqbal. Hopefully, are you coming to the face-to-face in May? Yes. Okay, maybe we can carve some time and discuss what we could do. Thank you. Absolutely. Thank you so much. Great presentations, everyone. Bye. Thank you. Bye, Jim.

drug-induced liver injury

DILI

turmeric supplements

hepatotoxicity

cholestatic hepatitis

HLA genotyping

piperine

genetic predisposition

herbal supplements