Phyllanthus for chronic hepatitis B virus infection

Integrative Medicine

Chronic hepatitis B virus (HBV) infection is a common disease worldwide. In 2011, CDC received 39,636 reports of chronic HBV infection, with many additional people likely unaware of their disease due to its asymptomatic nature.1 The three-dose schedule HBV vaccine is 95% effective in preventing HBV infection and provides immunity for at least 20 years.

Cytotoxic activity

Many supplements such as milk thistle are used for liver disease treatment. Lesser known plants such as Phyllanthus species are used for hepatic disorders as part of traditional Chinese medicine. In vitro studies reported that Phyllanthus species contain lignans possessing cytotoxic activity, which suppresses HBV antigen secretion. 

Two systematic reviews have evaluated Phyllanthus in HBV treatment. A 2001 review of Phyllanthus treatment in 22 randomized trials reported that the plant may be beneficial in clearing HBV markers.2 In addition, liver function tests were normalized without serious adverse effects from the plant. The studies used extracts of the whole plant Phyllanthus; only one trial indicated the specific plant species used (P. urinaris). Trials used multiple dosage forms: Phyllanthus granules were either extracted and encapsulated as an oral tablet or used to create a decoction as a tea. 

Studies had small sample sizes and a limited description of randomization and allocation procedures. This introduces bias and questionable statistical power, leading to questions about the significance of the findings. The Jadad scale was used to assess study quality, and only five were ranked high quality. 

A 2010 systematic review of the effectiveness of Phyllanthus species in chronic HBV infection evaluated data on 1,326 patients of varying ages in 16 different trials.3 Trials used multiple species—P. amarus, P. urinaria (Chamber bitter), and P. niruri—and preparations prepared in the same manner as in the 2001 review. 

This systematic review used data collection and analysis methodology based on the Cochrane Handbook of Systematic Reviews of Interventions. Fifteen trials compared Phyllanthus in combination with standard antiviral treatment versus standard antiviral therapy alone. Phyllanthus significantly reduced serum HBV DNA (a marker of efficacy) as well as HBeAg (a marker of viral replication) when combined with antiviral therapy. The summary concluded that based on current evidence, Phyllanthus may be beneficial when combined with standard antiviral therapy but has no benefit alone. 

Most trials in the 2010 review are at high risk for bias due to methods of allocation and blinding, incomplete outcome data, selective outcome reporting, and other factors. The duration of follow-up after treatment was a major limitation. One trial measured outcomes for 2 weeks, another for 24 weeks, and another for 2 years. Available studies did not provide data on the effect of Phyllanthus on morbidity and mortality. Fewer than 2% of participants experienced adverse events, which included light nausea, decreased appetite, and stomachache.

What to tell patients

Chronic HBV infection is a serious condition that may result in liver cancer or cirrhosis. HBV infection is best prevented by avoiding shared needles and unsafe sexual practices, in addition to being vaccinated against HBV. Dietary supplements are not a replacement for maintaining good liver health practices, including moderation of alcohol use.

Phyllanthus species have been promoted for their potential liver benefits. Evidence has suggested a potential benefit of Phyllanthus extracts when used with antiviral therapy. Extracts may contain different species in varied strengths. Most Phyllanthus supplements recommend one capsule with a meal two to three times daily. As always, patients should purchase supplements from reputable sources. 

References

www.cdc.gov/hepatitisStatistics/2011Surveillance/Commentary.htm

J Viral Hepatitis. 2001;8:358–66

Cochrane Database Syst Rev. 2011 doi:10.1002/14651858.CD008960.pub2