Portal de Periódicos da CAPES

Silibinin

2015; Elsevier BV; Volume: 147; Issue: 3 Linguagem: Inglês

10.1378/chest.14-2682

1931-3543

Michael E. Mullins, Evan S. Schwarz, William H. Dribben, S. Eliza Halcomb, Anna M. Arroyo-Plasencia,

Drug-Induced Hepatotoxicity and Protection

We read with great interest the recent article by Gores et al1Gores KM Hamieh TS Schmidt GA Survival following investigational treatment of amanita mushroom poisoning: thistle or shamrock?.Chest. 2014; 146: e126-e129Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar in CHEST(October 2014). While applauding the successful outcome of Amanita mushroom poisoning, it mystifies us that the authors perceived any ethical quandary concerning the use of silibinin. We would consider it more ethically questionable to deprive the patient an opportunity to receive silibinin. Silibinin is the treatment best supported by available canine2Vogel G Tuchweber B Trost W Mengs U Protection by silibinin against Amanita phalloides intoxication in beagles.Toxicol Appl Pharmacol. 1984; 73: 355-362Crossref PubMed Scopus (152) Google Scholar, 3Floersheim GL Eberhard M Tschumi P Duckert F Effects of penicillin and silymarin on liver enzymes and blood clotting factors in dogs given a boiled preparation of Amanita phalloides.Toxicol Appl Pharmacol. 1978; 46: 455-462Crossref PubMed Scopus (79) Google Scholar and human evidence.4Hruby K Csomos G Fuhrmann M Thaler H Chemotherapy of Amanita phalloides poisoning with intravenous silibinin.Hum Toxicol. 1983; 2: 183-195Crossref PubMed Scopus (113) Google Scholar, 5Enjalbert F Rapior S Nouguier-Soulé J Guillon S Amouroux N Cabot C Treatment of amatoxin poisoning: 20-year retrospective analysis.J Toxicol Clin Toxicol. 2002; 40: 715-757Crossref PubMed Scopus (311) Google Scholar, 6Ganzert M Felgenhauer N Schuster T Eyer F Gourdin C Zilker T Amatoxin poisoning—comparison of silibinin with a combination of silibinin and penicillin [in German].Dtsch Med Wochenschr. 2008; 133: 2261-2267Crossref PubMed Scopus (47) Google Scholar It has long been approved in Europe, where it is the drug of choice for amatoxin poisoning. While the market for silibinin in the United States is too small to justify efforts by the manufacturer to pursue US Food and Drug Administration approval, the drug is essentially available for compassionate use under the National Institutes of Health-registered study protocol referenced in the original case report.7National Institutes of Health Clinical Center. Intravenous milk thistle (silibinin-legalon) for hepatic failure induced by amatoxin/amanita mushroom poisoning. NCT00915681http://clinicaltrials.gov/ct2/show/NCT00915681.htmlDate: 2009Google Scholar We recognize the rationale for IV N-acetylcysteine, IV penicillin G, and multidose-activated charcoal. All three have low risk and a modest role in treatment of amatoxin poisoning, but evidence of their efficacy is weak to nonexistent. The authors seem concerned about the botanical origins of the drug. We point out that we have no anxiety about using other drugs derived from plants such as the willow and the poppy in our daily practice. Most patients with amatoxin poisoning survive, and it is impossible to say whether this patient's outcome would have been different without silibinin. Given the available evidence, we would want silibinin if we were inadvertently poisoned with amatoxin-containing mushrooms.