Evaluation of efficacy and safety of Liv.52 DS tablets in acute viral hepatitis:
A prospective, double-blind, randomized, placebo-controlled,
phase III clinical trial

Dr. Rajiv Baijal, M.D., D.N.B.1, Dr. Nikhil Patel, M.D.,2 and Dr. S. A. Kolhapure, M.D.3* 1Gastroenterologist, 2Research Associates, Department of Gastroenterology,
Jagjivanram Western Railway Hospital, Mumbai Central, Mumbai, India. 3Senior Medical Advisor, R&D Center, The Himalaya Drug Company, Bangalore, India

Table 12: Improvement in WBC (cells/cu.mm.) levels at baseline and after 4th month Parameter Liv.52 DS Placebo Day 0 4th month Day 0 4th month Minimum 4800 4000 4000 4000 Maximum 11900 10000 10000 10000 Mean 8057 7332 7378 7117 Std. Deviation 1673 1494 1632 1636 Std. Error 334.5 298.8 340.2 341.1 Lower 99% CI 7121 6496 6419 6156 Upper 99% CI 8992 8168 8337 8079 Mean of differences 724.8 260.9 99% CI -214.9 to 1665 -143.5 to 665.2 R2 0.1624 0.1307 t value 2.157 1.819 p value p=0.0412 p=0.0826 p value summary *Significant Non-significant Table 13: Improvement in serum hemoglobin (gm/dl) levels at baseline and after 4th month Parameter Liv.52 DS Placebo Day 0 4th month Day 0 4th month Minimum 8.6 10 9 10 Maximum 16.9 15.1 18.2 17.2 Mean 12.96 13.15 13.37 13.08 Std. Deviation 1.978 1.364 2.424 1.847 Std. Error 0.3957 0.2728 0.5054 0.3851 Lower 99% CI 11.85 12.39 11.95 11.99 Upper 99% CI 14.07 13.91 14.8 14.16 Mean of differences 0.192 0.295 99% CI -0.8016 to 0.4176 -0.2955 to 0.8868 R2 0.03133 0.08287 t value 0.881 1.41 p value p=0.3871 p=0.1725 p value summary Non-significant Non-significant

overall compliance to the drug treatment was found to be excellent. These beneficial clinical efficacies of Liv.52 DS in acute viral hepatitis might be due to the synergistic action of its ingredients, which had been well documented in various experimental and clinical studies by various researchers. Khanfar et al. isolated and identified the active ingredients of Capparis spinosa as beta-sitosterylglucoside-6'-octadecanoate and 3-methyl-2-butenyl-beta-glucoside.7 p-Methoxy benzoic acid isolated from Capparis spinosa was found to possess potent hepatoprotective activity against CCl4, paracetamol (in vivo) and thioacetamide, galactosamine (in vitro) induced hepatotoxicity.8 Al-Said et al. demonstrated the strong anti-inflammatory activity of Capparis spinosa, which was comparable to oxyphenbutazone.9-10 Bonina et al. documented a significant antioxidant activity of Capparis spinosa and also identified flavonols (kaempferol and quercetin derivatives) and hydroxycinnamic acids (caffeic acid, ferulic acid, p-cumaric acid, and cinnamic acid) as major antioxidants from Capparis spinosa.11 In another study, Germano et al. observed the antioxidant activity of Capparis spinosa using tests such as lipid peroxidation, bleaching of free radicals and autoxidation of iron ions.12 Mahasneh et al. observed potent antimicrobial and antifungal activity of Capparis spinosa.13,14 He et al. isolated 2,3,4,9-tetrahydro-1H-pyrido- (3,4-b) indole-3-carboxylic acid, azelaic acid and daucosterol as the major constituents of Cichorium intybus.15 and Du et al. identified the other chemical constituents as alpha-amyrin, taraxerone, baurenyl acetate and beta-sitosterol.16 Aktay et al. and Zafar et al. observed the hepatoprotective effect (confirmed by histopathological examination) of Cichorium intybus against CCl4-induced hepatotoxicity and reported significant prevention of the elevation of malondialdehyde formation (plasma and hepatic) and enzyme levels

(AST and ALT).^17,18 Ahmed et al. screened Cichorium intybus for antihepatotoxic activity and measured the degree of protection using biochemical parameters (AST, ALT, ALP and TP). Potent antihepatotoxic activity (comparable to the silymarin) was observed with almost complete normalization of the tissues (as neither fatty accumulation nor necrosis was observed on histopathological study).19 Kim et al. studied the effects of Cichorium intybus on the immunotoxicity of ethanol and reported significant increase in the number of circulating leukocytes, the weights of concerned organs (liver, spleen and thymus), number of splenic plaque forming cells, hemagglutination titers and the secondary IgG antibody response. There were also significant increases in delayed-type hypersensitivity reaction, phagocytic activity, natural killer cell activity, cell proliferation and interferon gamma secretion.20 Sultana et al. reported that the presence of Cichorium intybus in the reaction mixture (containing calf thymus DNA and free radical generating system) protects DNA against oxidative damage to its deoxyribose sugar moiety.

Table 14: Total platelet count (cells) at baseline and after 4th month Parameter Liv.52 DS Placebo Day 0 4th month Day 0 4th month Minimum 150000 150000 140000 140000 Maximum 360000 360000 320000 320000 Mean 229200 243600 236400 240000 Std. Deviation 41120 34750 37740 36380 Std. Error 8224 6949 8046 7757 Lower 99% CI 206200 224200 213600 218000 Upper 99% CI 252200 263000 259100 262000 Mean of differences -14400 -3636 99% CI -28390 to -407.5 -16340 to 9072 R2 0.2566 0.0303 tvalue 2.878 0.8101 pvalue p=0.0083 p=0.427 p value summary Non-significant Non-significant

All these studies suggest that the observed hepatoprotective effect of Cichorium intybus might be due to its ability to suppress the oxidative degradation of DNA in the tissue debris.21 El et al. and Papetti et al. documented the antioxidative activity (radical scavenging effects, inhibition of hydrogen peroxide, and iron chelation) of Cichorium intybus.22,23 Gurbuz et al. observed significant cytoprotection against ethanol-induced damage and these results were further confirmed by using histopathological techniques.24 Amirghofran et al. reported the capacity of Cichorium intybus to enhance the proliferation of lymphocytes after stimulation with the allogenic cells.25 Kim et al. investigated the effect of Cichorium intybus on mast cell-mediated immediate type allergic reactions and observed inhibition of systemic anaphylactic reaction, reduction in the plasma histamine level.26 Ikeda et al. identified saponins (nigrumnins I and II) as the active ingredients of Solanum nigrum.27 Solanum nigrum was investigated for its

hepatoprotective activity against CCl4-induced hepatic damage and Raju et al. observed remarkable hepatoprotective activity confirmed by evaluated biochemical parameters (AST, ALT, ALP and TB).28 Sultana et al. demonstrated that Solanum nigrum protect DNA against the oxidative damage and the results suggest that the observed hepatoprotective effect of Solanum nigrum might be due to the ability to suppress the oxidative degradation of DNA in the tissue debris.29 Moundipa et al. studied the effects of Solanum nigrum on hepatotoxicity and reported increased activity of aminopyrine N-demethylase, uridine diphosphate glucuronyltransferase and glutathione S-transferase, without any alteration in levels of ALP, ALT and gamma-glutamyltransferase levels in the serum.29 Son et al. reported Solanum nigrum as a potent scavenger of hydroxyl radicals and diphenylpicrylhydrazyl radicals.30 Prashanth Kumar et al. tested in vitro Solanum nigrum for its cytoprotection (against gentamicin-induced toxicity) and observed significant inhibition of cytotoxicity, alongwith hydroxyl radical scavenging potential, which might be the mechanism of cytoprotection.31 Similarly, Akhtar et al. observed gastric mucosal cytoprotection offered by Solanum nigrum against aspirin-induced gastric ulcers.32 Qureshi et al. reported the antifungal activity of Solanum nigrum.³³


Upadhyay et al. identified arjunetoside, oleanolic and arjunic acids as active ingredients from Terminalia arjuna.34 Munasinghe et al. reported the potent antioxidant activity of Terminalia arjuna, which might be due to its effects on lipid peroxidation.35 Ali et al. demonstrated that arjunaphthanoloside from Terminalia arjuna inhibits nitric oxide production36 and terminoside A isolated from Terminalia arjuna decreases inducible nitric oxide synthase levels in lipopolysaccharide-stimulated peritoneal macrophages.37 Cheng et al. observed potent antiviral activity by virtue of inhibition of viral attachment and penetration by Terminalia arjuna.38 Perumal Samy et al. demonstrated the potent antibacterial activity of Terminalia arjuna.³⁹

Jafri et al. reported significant hepatoprotective effects of Cassia occidentalis in chemically induced liver damage.40 Bin-Hafeez et al. showed that Cassia occidentalis modulates hepatic enzymes and provides hepatoprotection against induced immunosuppression.41 Samy et al. reported antimicrobial properties of Cassia occidentalis comparable with standard reference antibiotics.42 Perez et al. reported strong antibacterial activity of Cassia occidentalis against Salmonella typhi.43 Tona et al. reported the inhibitory effect of Cassia occidentalis on Plasmodium falciparum growth.44 Caceres et al. and Graham et al. observed the antifungal activity of Cassia occidentalis.^45,46


Harnyk et al. documented the clinically beneficial effects of Achillea millefolium in the treatment of chronic hepatitis.47 Krivenko et al. reported similar clinical improvements in chronic hepatocholecystitis and angiocholitis with Achillea millefolium.48 Lin et al. observed anti-hepatoma activity of Achillea millefolium.49 Candan et al. and Bezic et al. reported the antioxidant and antimicrobial activities of Achillea millefolium.^50,51


Devarshi et al. studied Mandura bhasma for the hepatoprotective property in hepatitis induced by CCl4 and observed prevention of CCl4 mediated changes in the enzyme activities, which suggest the hepatoprotective role of Mandura bhasma.⁵² Therefore, as discussed above, these synergistic actions (hepatoprotective, antimicrobial, antioxidant and anti-inflammatory) exhibited by the ingredients of Liv.52 DS might explain the beneficial mechanism of action of Liv.52 DS in acute viral hepatitis.