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Potential rare liver reactions to

He Shou Wu (Polygonum multiflorum)

by Subhuti Dharmananda, Ph.D., Institute for Traditional Medicine, Portland, Oregon

He Shou Wu (aka: ho-shou-wu, heshouwu, or shouwu; sometimes mistakenly called fo-ti) is a Chinese herb obtained from the tuberous roots of Polygonum multiflorum.  It is one of the more commonly used Chinese medicinal materials, and has a special reputation for preventing or delaying the graying of hair, even reverting gray hair to its original color, as well as having other benefits for the hair, such as treating alopecia.  The herb is used for a variety of other therapeutic actions related to the traditional Chinese medicine (TCM) categories of nourishing blood and yin.

Recent interest in the potential use of He Shou Wu in prevention and treatment of neurodegenerative diseases, especially Alzheimer’s disease, has stimulated further research into its active components and therapeutic actions.   The herb contains several derivatives of tetrahydroxystilbene (see image left) that are antioxidant and anti-inflammatory compounds investigated for their effects on neurons.   The red wine component resveratrol is a similar compound; it is a trihydroxystilbene.  In making dietary supplements with resveratrol (the supplements are claimed to be of potential value for cardiovascular health, prevention of Alzheimer’s, reduction of cancer risk, etc.), the common plant source is Polygonum cuspidatum, a relative of He Shou Wu (Chinese name: Hu Zhang).   A similar compound under investigation is oxyresveratrol, obtained from the mulberry (e.g., the Chinese herb Sang Bai Pi); mulberry fruit or leaf is often recommended to be used with Ho Shou Wu in preventing graying of hair.  He Shou Wu also contains the laxative compound emodin, and a number of derivatives of emodin; this accounts for a potential adverse effect of the herb: causing loose stool when consumed in quantity.  Emodin also serves as a liver-protective agent.

Ho Shou Wu is known for being a safe herb with little toxicity, and one that is typically used for a prolonged time in anti-aging formulas.  However, the Medicines and Health Care Products Regulatory Agency (MHRA) in London issued an alert about potential adverse reactions to this herb.  As part of the report, the recently introduced yellow card tracking system is mentioned.  Yellow-colored pre-printed cards are made available to practitioners who prescribe herbs in the U.K. to allow them to easily report apparent adverse reactions; the MHRA examines these to find any patterns that raise concern about particular herbs for formulas.  This is the main text of their report:

As of 30 March 2006, seven reports of suspected adverse reactions associated with Polygonum multiflorum have been reported to the MHRA through the Yellow Card Scheme. All seven reports are of liver reactions and comprise one report of abnormal liver function, 3 reports of jaundice, 2 reports hepatitis and one report of jaundice and hepatitis. The patients, 5 women and 2 men aged from 36 to 70 years old, were taking Polygonum multiflorum for hair loss (3 patients had taken the product Shen Min and 3 patients had taken the product Shou Wu Wan).  All the patients had recovered or were recovering after stopping Polygonum multiflorum.  Reports of hepatitis associated with Polygonum multiflorum have also been reported in the published literature (1–4).

There are many signs and symptoms of liver disease. These include jaundice (yellowing of the skin or whites of the eyes), dark urine, nausea, vomiting, unusual tiredness, weakness, stomach or abdominal pain, and /or loss of appetite. If you think you are experiencing any of these symptoms you should see your doctor. If a liver disorder is diagnosed it is recommended that you stop taking Polygonum multiflorum.

Anyone who has previously experienced any liver complaint or any other serious health complaint is advised not to take Polygonum multiflorum without speaking to their doctor first. It is important to always discuss all of the medication you are taking, including herbal products, with your doctor or herbal practitioner to ensure you receive the appropriate care.

1. Battinelli et al (2004) New case of acute hepatitis following the consumption of Shou Wu Pian, a Chinese Herbal product derived from Polygonum multiflorum. Annals of Internal Medicine 140: E589

2. But et al (1996) Hepatitis related to the Chinese medicine Shou Wu Pian manufactured from Polygonum multiflorum. Veterinary and Human Toxicology 38: 208-282

3. Park et al (2001) Acute hepatitis induced by Shou Wu Pian, a herbal product derived from Polygonum multiflorum. Journal of Gastroenterology and Hepatology 16: 115-117

4. Panis et al (2005) Recurrent toxic hepatitis in a Caucasian girl related to the use of Shou-Wu-Pian, a Chinese herbal preparation. Journal of Pediatric Gastroenterology and Nutrition 41: 256-258.

The four published reports cited in the alert all mention Shou Wu Pian; this is a product manufactured in Shanghai; there are also several manufacturers who have more recently copied the product.  It is reputed to contain 100% Ho Shou Wu, but the actual content in the Shanghai preparations is not known.  The report also mentions the recent cases involving Shen Min—a product made of several ingredients (including vitamins), with extract of Ho Shou Wu as a central herbal component—and Shou Wu Wan, which is a formula that is said to contain Ho Shou Wu plus a dozen other herbs.  

In addition, the MHRA noted in a May 23, 2006 letter to herb prescribers in England that five additional cases of possible liver reaction to an herbal product with He Shou Wu were reported in a Toxicology Unit in the U.K. (to follow up with any new information from MHRA, visit their website www.mhra.gov.uk and type Polygonum multiflorum in the search box that is provided). 

Liver reactions to herbs have been reported several times in recent years.  Among the well-known cases are: the herbs kava kava and comfrey; the Chinese patent remedy Jin Bu Huan (which consists of tetrahydropalmatine, an active ingredient of certain herbs); usnea, an herb used in Western and Chinese herbalism; and a Chinese herbal combination that was being used for treatment of eczema in London.   While a specific group of liver toxins—pyrrolizidine alkaloids—has been found in comfrey, and are also present in certain other herbs (including some infrequently used Chinese herbs), in the other cases the reactions appear to be idiosyncratic responses to substances that have little or no inherent toxicity for the liver.  

There is one piece of evidence recently relayed (personal communication) that supports the concept that He Shou Wu is the causative agent, rather than another ingredient in a product or a coincidental finding of hepatitis with use of a common herb.  In one young girl who had an apparent reaction to treatment with the herb, the single herb was given a couple of months later and she immediately developed a hepatic reaction with more severe symptoms than before.  This strongly suggests a hypersensitivity reaction (rare idiosyncratic response) rather than a toxic effect.  Since He Shou Wu is extensively used, practitioners of Chinese medicine should be on the alert for patient reports of symptoms that might indicate liver reactions, and consider the possibility that the ingredient He Shou Wu could be a cause if it is among the ingredients that were ingested.

June 2006

Appendix. Ho-shou-wu in the ITM Formulary

*by listing these applications, it is not intended to suggest that these herb combinations are effective for such uses; rather, when prescribed by licensed practitioners of Chinese medicine, these formulas may be deemed an appropriate component of a comprehensive regimen for the conditions noted.

Resources. For additional information about ho-shou-wu in traditional Chinese medicine, see:

Ho-shou-wu: What’s in an herb name? http://www.itmonline.org/arts/hoshouwu.htm

For more information about herbs suspected of causing liver reactions, see:

Safety Issues Affecting Chinese Herbs: The Case of Dictamnus and Herbs for Skin Diseases http://www.itmonline.org/arts/dictamnus.htm

Safety Issues Affecting Herbs: The Case of Kava: http://www.itmonline.org/arts/kavasafe.htm

Kava Update: http://www.itmonline.org/arts/kavaupdate.htm

Safety Issues Affecting Herbs: Pyrrolizidine Alkaloids: http://www.itmonline.org/arts/pas.htm

Safety Issues Affecting Herbs; Usnea: an herb used in Western and Chinese medicine: http://www.itmonline.org/arts/usnea.htm