Abstract
Background:
Non-alcoholic fatty liver disease (NAFLD) is the most prevalent liver disorder in western countries and an important cause of liver cirrhosis, as well as liver failure. Up to now, 20‒40% of the individuals suffer from this disorder and its prevalence is estimated around 5‒30% in Asia. The NAFLD is one of the most prevalent causes for increases in liver enzymes and has a close relationship with obesity, dyslipidemia, hypertension, and type II diabetes. However, no definite treatment has been identified for it yet.Objectives:
The present study aimed to investigate the effect of berberis vulgaris extract in inducing changes in liver enzymes levels.Patients and Methods:
The present clinical trial was conducted on 80 patients, including 32 males (40%) and 48 females (60%), who were randomly assigned into two groups of case and control. All the patients had ultrasound evidence of lipid accumulation in the liver and increases in liver enzymes. The case group received two capsules (750 mg) containing berberis vulgaris extract every day for 3 months, while the control group was treated with placebo. The weight, liver transaminases levels and lipid profiles of the two groups were assessed before, during, and after the study.Results:
In the case group, the mean serum levels of alanine transaminase (ALT) and aspartate transaminase (AST) decreased from 49 to 27.48 and 48.22 to 29.8 u/L, respectively, which was statistically significant compared to the control group (P < 0.001, P < 0.001). In the control group, the mean of ALT and AST decreased from 50.4 to 46.8 and 45.7 to 44.9 u/L, respectively. The difference was not statistically significant. In addition, a significant decrease was observed in weight, triglycerides, and cholesterol, while no significant change was found in fasting blood sugar, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL).Conclusions:
Considering the significant decrease in the liver enzymes, triglycerides and cholesterol after using berberis vulgaris extract, further studies with larger sample sizes will identify the accurate dose as well as duration of consumption for this extract, to recommend in the treatment of patients with NAFLD.Keywords
Non-Alcoholic Fatty Liver Disease Alanine Transaminase Aspartate Transaminase Triglycerides Berberis
1. Background
Non-alcoholic fatty liver disease (NAFLD) refers to a situation in which triglycerides are accumulated in the liver cells of individuals with no history of alcohol abuse or those who use little alcohol (1). This disease is the most prevalent liver disorder in western industrial countries, and about 20‒40% of the members of these societies suffer from NAFLD, with a prevalence estimate of 5‒30% in Asia (2, 3). The prevalence of NAFLD in the general population of Iran has been reported to of about 2.1% (4). The NAFLD has a wide range of clinical presentations: several patients may only suffer from the accumulation of lipid in their liver tissue, while the disease may progress to non-alcoholic steatohepatitis (NASH) in several others (5, 6). Moreover, this disorder may lead to liver fibrosis, cirrhosis, and failure, in 20% of these patients (5, 7, 8). Up to now, the pathogenesis of NAFLD has not been identified however. It has been shown to have a close relationship with obesity, dyslipidemia, hypertension, and type II diabetes (2, 6, 8). Recently, this disorder has been considered as a major cause of liver cirrhosis and failure and is the most prevalent cause of increases in the values of liver function tests (7, 9, 10).
Up to present, due to the fact that the accurate pathogenesis of NAFLD has not been identified, no medication is available for its treatment (11). Only a limited number of studies have been conducted on the issue (12). Nevertheless, decreasing the obesity and treating hyperlipidemia as well as diabetes mellitus are the measures which can be taken toward decreasing the probability of NAFLD (11).
Nowadays, the use of herbal medicines has considerably increased in Europe and the US, leading to about 65% use of herbal medicines in these countries (13).
Berberis vulgaris belongs to the Berberidaceae family and is one of the native plants of Iran, which is widely used in traditional medicine. Almost, 22 alkaloids have been identified in the root, leaf, and fruits of this plant (13); the most important of which is berberine, which can reduce weight, improve dyslipidemia, and increase insulin sensitivity (14). Similarly, it is expected to reduce the transaminases in NAFLD.
2. Objectives
The present study was conducted to investigate the effect of berberis vulgaris on NAFLD patients in Iran.
3. Patients and Methods
In this study, a randomized controlled trial (IRCT: 201202068505N2) design was employed. After obtaining approval of the Ethics Committee (Registration Number: Ct-91-6081) of Shiraz University of Medical Sciences, Shiraz, Iran, the present clinical trial was conducted between October 2011 and May 2012 on 99 patients (42.42% male and 57.57% female), who had referred to the Motahari Clinic affiliated to Shiraz University of Medical Sciences, Shiraz, Iran, for treatment of their liver diseases. The patients were selected by purposive sampling, based on the inclusion criteria. The necessary criteria for the diagnosing NASH included having ultrasound evidence of fatty liver (grade II) and increased liver enzymes (one to three times more than the normal level). On the other hand, the exclusion criteria of the study regarded the patients suffering from liver diseases resulting from causes other than NAFLD, such as hepatitis B or C, autoimmune hepatitis and drug abuse, type I diabetes, type II diabetes with 1 year duration using glucose-lowering drugs, pregnancy, breast feeding, alcohol consumption, use of medications known to affect liver tests during the previous 2 months, and having the history of psychotic diseases or severe depression.
The study subjects were randomly assigned to the case and control groups. Simple randomization was used in this study. For the randomization, we numbered the groups (case 1, control 2) then the sequence of groups was drawn up by coin tossing. The case group received 750 mg aqueous extract of berberis vulgaris for 3 months, while the control group received placebo. Both groups received their medications in the form of capsules (with identical appearance).
After berberis vulgaris was purchased, it was confirmed by a botanist and cleaned. Then, it was extracted by a specialist in the Medicinal Plants Laboratory of Shiraz School of Pharmacy, Shiraz, Iran, then concentrated in a rotary evaporator, and dried using the freeze dryer. In addition, microbial control experiments were performed in order to ensure that pathogens, such as Salmonella, Escherichia coli, Staphylococcus, and Bacillus cereus, did not exist in the berberis vulgaris extract. The two groups' weight, total cholesterol, triglyceride, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), and fasting blood glucose (FBG) were measured before and 90 days after the intervention. Besides, the alanine transaminase (ALT) and aspartate transaminase (AST) enzymes' levels were measured before and 45 and 90 days after the intervention. It should be noted that these experiments were carried out using Biosystem kits (Biosystem S.A., Barcelona, Spain) and through the spectrophotometry method.
Both groups received two capsules every day, one before breakfast and one before dinner, and the probable complications were followed up through telephone contacts. During the first week, four cases of mild disorders were reported in the case group, three of which were diarrhea and the other one was mild constipation.
Of the total 99 patients, 19 were excluded from the study due to lack of cooperation and completion of treatment period, and finally, 40 patients were enrolled into each study group for analysis.
The collected data were analyzed in the SPSS statistical software (v. 16) (SPSS Inc., Chicago, ILL, USA) using independent sample t-test before the intervention and repeated measurement test after the intervention.
4. Results
A number of 19 patients were excluded from the study resulting in a final number of 40 subjects enrolled in each group. In the case group, 19 patients (47.5%) were male, while 21 (52.5%) were female. On the other hand, the control group included 13 males (33%) and 27 females (67%). The mean age of the patients in the case and control groups was 43.65 and 42.97 years, respectively. The mean weights of the case and control subjects were 80.24 and 83.62 kg, respectively.
Demographic Characteristics of the Two Study Groups
| Group | No. | Age, y | Female, No. (%) | Male, No. (%) | Weight, kg |
|---|---|---|---|---|---|
| Case | 40 | 43.65 | 21 (52.5) | 19 (47.5) | 80.24 |
| Control | 40 | 42.97 | 27 (67) | 13 (33) | 83.62 |
Changes in Each Variable From the Beginning to the end of the Study a
| Variable | Placebo (n = 40) | Berberis Vulgaris (n=40) | P Value | |||||
|---|---|---|---|---|---|---|---|---|
| Before Treatment | Forty-fifth day | After Treatment | Before Treatment | Forty-fifth day | After Treatment | Berberis Vulgaris vs. Placebo | ||
| Baseline | After Treatment | |||||||
| Weight, kg | 83.62 ± 9.33 | 83.52 ± 9.10 | 83.53 ± 9.31 | 80.24 ± 11.68 | 79.13 ± 11.48 | 78.71 ± 11.31 | 0.1 | < 0.001 |
| ALT, U/l | 50.40 ± 9.38 | 49.90 ± 12.17 | 46.80 ± 9.87 | 49.0 ± 11.44 | 36.42 ± 12.10 | 29.08 ± 12.99 | 0.5 | < 0.001 |
| AST, U/l | 45.70 ± 8.19 | 46.32 ± 10.08 | 44.98 ± 9.69 | 48.22 ± 9.82 | 37.02 ± 12.18 | 2748 ± 12.50 | 0.2 | < 0.001 |
| FBG, mg/dL | 91.60 ± 16.24 | 93.45 ± 13.39 | 93.62 ± 16.20 | 87.95 ± 13.65 | 86.47 ± 14.5 | 85.70 ± 15.28 | 0.2 | 0.18 |
| TG, mg/dL | 214.7 ± 55.29 | 201.47 ± 60.60 | 219.22 ± 72.14 | 167.20 ± 69.32 | 0.7 | < 0.001 | ||
| CHOL, mg/dL | 225.38 ± 43.17 | 220.80 ± 39.49 | 211.40 ± 30.93 | 186.05 ± 36.51 | 0.1 | < 0.001 | ||
| LDL, mg/dL | 139.86 ± 34.14 | 134.33 ± 30.69 | 130.68 ± 27.79 | 116.13 ± 32.47 | 0.1 | 0.054 | ||
| HDL, mg/dL | 41.05 ± 8.66 | 41.22 ± 8.34 | 36.87 ± 7.43 | 37.0 ± 7.17 | 0.1 | 0.96 | ||
According to the results, the case group's mean weight decreased from 80.24 kg at the beginning of the study to 78.71 kg at the end, which was statistically significant compared to the control group (P < 0.001). The case group's mean serum level of ALT was 49 and 27.48 u/L before and after the intervention, respectively (P < 0.001), while it was measured as 50.4 and 46.8 u/L, respectively, in the control group (P > 0.05). Also, the mean AST level of the case group was 48.22 and 29.8 u/L before and after the intervention, respectively (P < 0.001), while it was measured as 45.7 and 44.9 u/L, respectively, in the control group (P > 0.05). The mean FBG in the case group was 87.95 and 85.70 mg/dL before and after the intervention, respectively (P > 0.05), while it was 91.60 and 93.62 mg/dL, respectively in the control group (P > 0.05). Moreover, the mean level of triglycerides in the case group was 219.22 and 167.20 mg/dl before and after the intervention, respectively (P < 0.001), while it was measured to be 214.7 and 201.47 mg/dL, respectively, in the control group (P > 0.05). In addition, the mean serum level of total cholesterol in the case group was 211.40 and 186.05 mg/dL before and after the intervention, respectively (< 0.001), while it was 225.38 and 220.80 mg/dL, respectively, in the control group (P > 0.05). Furthermore, the mean serum level of LDL was 130.68 and 116.13 mg/dL in the case group (P > 0.05) and 139.86 and 134.33 mg/dL in the control group (P > 0.05), before and after the intervention, respectively. Finally, the case group's mean HDL serum level was 37.0 and 36.87 mg/dL before and after the intervention, respectively (P > 0.05), while it counted 41.05 and 41.22 mg/dL, respectively in the control group (P > 0.05). As shown, no significant difference was found between the two groups regarding the study variables before the intervention.
Acknowledgements
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