Silymarin (milk thistle) for liver support

NYBC provides this description of the botanical Silymarin, also known as milk thistle:

Milk Thistle: Silymarin (Silybum Marianum). A potent liver-strengthening herb, it stimulates the liver to regenerate itself by producing new liver cells as well as having strong antioxidant action to help prevent lipid-peroxidation of cell membranes. Given to seven patients receiving tuberculosis drugs (INH and ethambutol), a standardized silymarin extract normalized elevated liver enzymes after three months treatment. Many people with hepatitis C use milk thistle. It is extremely safe. Some studies suggest it may help to reverse the scarring known as fibrosis. Chilean researchers have discovered that silymarin increases glutathione [a key intracellular antioxidant] in the liver, stomach and intestines by over 50%, although it was not shown to increase glutathione levels in other organs. Milk thistle may interact with cytochrome P450–specifically the 3A4 enzyme. This is important since it is the same pathway used by many AIDS drugs. A study by Piscitelli, et al., happily, found no effect of silymarin on the plasma level of indinavir (Crixivan). Now we need a study evaluating the potential benefit against the liver toxicities of drugs like nevirapine and ritonavir (Norvir). Anecdotal reports suggest that it may delay CD4 increases with ARV.

See also entries on Dandelion Root as well as Hepato-C, Hepato-Detox and Ecliptex (Chinese Herbal Formulas).

Note: NYBC stocks Milk Thistle/Silymarin 80% (Jarrow) [150mg/200 Caps]. Each capsule contains 150 mg of Milk Thistle standardized for 120 mg of Silymarin. This brand has smaller capsules since they do not use a turmeric base. Some find this more convenient to use. PWHIV and PWHCV use 3-6/day.

Suggested Usage: Take 1 to 3 capsules daily, or as directed by your qualified health consultant.

Milk Thistle in Latin is Silybum marianum. This 30:1 concentrate is standardized to contain 80% Silymarin from Milk Thistle seeds.

Silymarin is composed of three flavonoids: primarily Silybin and minor amounts of Silydianin and Silychristin, which support liver function by raising protective glutathione levels.

Multivitamin Antioxidant Combination (MAC-Pack): a K-Pax alternative available in no-iron formula for those with liver impairment

In 2007, NYBC began offering an alternative to the K-Pax multivitamin-antioxidant supplement, which was added to some ADAP and Medicaid formularies following publication in 2006 of Dr. Jon Kaiser’s study that found CD4 increases in people with HIV taking a micronutrient combination supplement. A first reason for the NYBC alternative, called the MAC-Pack, was price: for those without access to ADAP or Medicaid programs, the double strength K-Pax cost of about $140/month was rather high, and NYBC as a nonprofit co-op was able to present a close equivalent for only $62/month.

But another rationale for introducing the MAC-Pack was its flexibility. In fact, because MAC-Pack uses the AMNI/Douglas multivitamins Added Protection as its core, it can be configured as a formula with or without iron. Having the option of an iron-free MAC-Pack is important especially to people with elevated liver enzymes, liver impairment, or hepatitis co-infection. Taking iron supplements is generally not recommended for this group, since processing the iron puts an extra strain on liver function.

Also note that the MAC-Pack provides somewhat more acetylcarnitine than the K-Pax, which may not be a bad idea, especially if you believe, as we do, that acetylcarnitine is probably a key element in the multivitamin-antioxidant combination. (Two tabs/day is sufficient if you’re just interested in matching the K-Pax formula, but three/day may be better especially for those dealing with neuropathy.)

For more information, see the NYBC entry:


Unexpected liver damage in people with HIV – a connection to ddI? And a potential antidote: NAC

The Canadian AIDS Treatment Information Exchange (CATIE) has reported on a small but significant study suggesting that exposure to the anti-HIV drug ddI (didanosine, Videx or Videx EC) may be the cause of otherwise unexplained liver damage in a small percentage of people taking it.

Researchers analysed health information, collected from three clinics, of HIV positive patients with unexplained and unexpected liver disease. All patients underwent extensive medical tests to try to find the cause of their problem(s). In total, the teams found 13 patients (2 females and 11 males) who had the following features in common:

  • all had higher-than-normal levels of liver enzymes
  • there were no obvious causes of liver problems
  • no hepatitis-causing viruses were detected
  • none of the participants were alcoholics
  • swollen blood vessels in the throat and abdomen
  • bleeding in the throat or abdomen
  • water retention in the abdomen
  • unintentional weight loss
  • black stools
  • exposure to ddI for at least two years

Researchers decided that all 13 patients should discontinue ddI and replace it with another suitable anti-HIV drug. Once this was done, liver enzyme levels fell and symptoms began to resolve.

Quite interesting was the researcher’s speculation about the cause of this liver damage:

[…] ddI may have decreased levels of a protective compound called GSH (glutathione) in cells. GSH is used to make enzymes that help detoxify harmful chemicals. Low levels of GSH may result in liver cells being susceptible to ddI-related toxicity.

The CATIE report goes on to discuss GSH deficiency in people with HIV, and the possibility that this deficiency may be in some cases intensified by ddI. As further noted in the report, the supplement NAC has been used to raise GSH levels. Perhaps NAC has a role to play in preventing the kind of liver damage discussed here? The CATIE reporter leaves the question open-ended:

Experiments with HIV positive people suggest that supplements of the amino acid cysteine (which is converted into GSH inside cells) can raise GSH levels in the blood. A formulation of cysteine called NAC (N-acetyl-cysteine) is used to help detoxify the liver in cases of overdose with the pain medication acetaminophen (Tylenol). To our knowledge, no clinical trials of NAC have been done in ddI users to assess its impact on GSH and liver health.

For NYBC’s view on NAC supplementation, see these entries:


PharmaNAC (an effervescent form of NAC, easy to take; made available in North America after some early research on the benefits of NAC supplementation for people with HIV in the 1990s)

ThiolNAC (NAC + alpha lipoic acid–another supplement recommended for liver support)

Note that NAC is also a key component in NYBC’s low-cost alternative to the K-Pax multivitamin/antioxidant combination pack:


Hepato-C from Pacific Biologic

Hepato-C is a formula based on Traditional Chinese medicine and modern clinical practice. It is specifically formulated for those with hepatitis C. The manufacturer supplies this extended description of the components and rationale for the creation of the formula:

Hepato-C: Pacific Biologic product description.

See also the NYBC entry on


and the related product from Pacific Biologic,


Many Ways to Love Your Liver

Many Ways to Love Your Liver

(reprinted from the NYBC SUPPLEMENT, Summer 2008)

Liver impairment is a frequent concern for people with HIV. There are many different causes, including co-infection with hepatitis, HIV meds that put added stress on the liver, excessive alcohol or recreational drug use, opportunistic infections, repeated resort to antibiotics, or just consuming big doses of the over-processed, nutrient-poor junk that too often passes for food these days! (By the way, we like the rule of thumb for choosing good stuff at the supermarket: if your grandmother wouldn’t recognize the item as “food”—then it’s probably not very good for you.)

The liver is crucial for processing and breaking down wastes, whether those produced by normal body functioning or those absorbed into the system in the form of drugs, alcohol, or toxins. So keeping it in good repair is essential for health. One specific strategy to support liver function is to maintain levels of the intracellular (= “found within cells”) antioxidant glutathione, which plays a key role in protecting the liver as it performs its detoxification duties. Here is a short list of nutritional supplements that are frequently recommended for this purpose: Vitamin C (2–6 grams per day, in divided doses); N-acetyl-cysteine, or NAC (500 mg, 3 times per day); alpha-lipoic acid (300-600 mg, twice daily). (Note that NAC and Lipoic can be taken in the combination form ThiolNAC, one of the key supplements stocked by NYBC.)

Another worthy option for countering stresses to the liver is an herb called Milk Thistle (Silybum marianum), which has a long tradition of use as a botanical remedy. Modern research has isolated compounds referred to as silymarin within this plant, and many studies have pointed to silymarin’s effectiveness in protecting liver cells from toxic chemicals, and even in stimulating the repair and regeneration of liver cells. In 2007, a federally funded investigation identified one component of milk thistle as a potent anti-cancer agent, and suggested that it held much promise in protecting against or treating liver cancer. Be advised that if you consult sources such as the Canadian AIDS Treatment Information Exchange (CATIE) website, you may encounter concerns about whether silymarin interferes with HIV meds. But here’s what one National Institutes of Health study concluded: “Milk thistle in commonly administered dosages should not interfere with indinavir therapy in patients infected with the human immunodeficiency virus.” This and other research, we believe, suggests that milk thistle-HIV med interference is not actually a very signficant issue.

Now here’s a rather unusual dietary supplement that has been investigated for liver health: S-adenosylmethionine (SAM-e). First isolated by Italian researchers in the 1950s, SAMe is synthesized by living cells from the amino acid methionine and can’t be supplemented from food sources. In several European studies of people living with hepatitis B or C, it has been shown to help reduce jaundice, fatigue, and other symptoms. And it’s also been applied to treating alcohol-related damage to the liver. The unusual aspect of SAMe is that there’s also a great deal of published research on its value as an antidepressant and as a treatment for arthritis—so it’s quite a versatile molecule! (See the NYBC Blog at for more details.)

Last, we note that the New York Buyers’ Club, like its predecessor DAAIR, has carefully followed the modern, US-based study and dissemination of traditional Chinese herbal remedies for liver disease. For example, NYBC stocks Pacific Biologic’s Hepato-C and Hepato-Detox, and, more recently, has added Health Concern’s Hepatoplex One and Hepatoplex Two to its product list. Both of these California-based companies have a very good reputation for quality, and both have devised blends based on Traditional Chinese Medicine as well as current clinical experience by licensed practitioners. (Please consult the NYBC website for more information about the specific herbs in these formulas, as well as recommendations for their use.) Of course we’re always interested in hearing about the experience of our members in using these products, and so we welcome your comments and questions—just email us at

Nutrients for Liver Toxicity: Practical Guide from the Canadian AIDS Treatment Information Exchange (CATIE)

CATIE provides an information sheet on liver toxicity as part of its “Practical Guide to Managing HIV Drug Side-Effects.” This info sheet suggests ways of coping with liver impairment, which is frequent in people with HIV, and may result from a variety of factors, including medication side-effects, hepatitis co-infection, repeated use of antibiotics, alcohol or drug use, or a nutrient-poor, chemically-rich diet.

Here’s an excerpt on some supplementation strategies to counteract liver impairment:

In addition to removing, as much as possible, anything that might be stressing the liver, it is very important to add the therapeutic agents that can help the liver to detoxify, repair and protect itself. There are a number of potentially useful agents, listed below:

Nutrients to Maintain Glutathione

Glutathione (GSH) is the most important intracellular antioxidant and is crucially important for protecting the liver against toxicity when it goes about its task of breaking down drugs and other toxins. Taking the following nutrients may help to maintain or increase levels of glutathione:

–vitamin C (2–6 grams per day, in divided doses)
–N-acetyl-cysteine, or NAC (500 mg, 3 times per day; always take with food because taking it on an empty stomach can cause gastrointestinal tract irritation)
–L-glutamine (5 grams per day, increased up to 30–40 grams in those who also have diarrhea or wasting). Note that anyone with seriously compromised liver or kidney function should not take glutamine without a doctor’s approval since it is an amino acid that must be processed by those organs.
–alpha-lipoic acid, or thioctic acid (300-500 mg, twice daily; take on an empty stomach with fluids). Alpha-lipoic acid is a naturally occurring fatty acid that acts as a cellular coenzyme. It is very important to the liver cell metabolic pathways and can be rapidly depleted when the liver is under stress. It appears to help boost repair when there has been either virally induced or drug-induced liver damage. Note that alpha-lipoic acid disappears from the bloodstream very rapidly, so products made in an extended-release form will last longer and work better.

For anyone with liver dysfunction or disease, the above nutrients may be very important as part of a total treatment approach.

For people with fatty livers, another important nutrient is the amino acid carnitine. Researchers say that it may help prevent mitochondrial toxicity, thus helping the body to handle fat better. Early studies of its use for non-HAART-related elevated triglycerides in PHAs did, indeed, show successful lowering of the blood fat levels. Research in animals has shown its successful use in reversal of fatty livers. The usual dosage is two capsules (500 mg each) twice daily. The alternative is Carnitor, the basic form of carnitine, available by prescription only. It is usually prescribed in doses of 3,000 mg daily (three 330-mg capsules, 3 times daily). Too-high doses can cause diarrhea, so watch for this. Doses of plain carnitine need to be higher because the acetyl-L-carnitine releases four times as much free carnitine into the bloodstream, using equivalent doses.

Note that in addition to the individual supplements mentioned above, NYBC also stocks its combination of N-acetyl-cysteine and alpha-lipoic acid, ThiolNAC.

Lark Lands on the 7 Deadly Sins for those wishing to live long and well with HIV

We’re re-printing below an excerpt from a piece Lark Lands wrote several years ago, because it still has much solid advice for people with HIV/AIDS. A medical journalist and longtime AIDS treatment educator and advocate, Lark was a pioneer in focusing attention on an integrated, “holistic” approach to HIV disease. She served as science editor for POZ magazine, and has also been a contributor to Canadian AIDS Treatment Information Exchange (CATIE) publications.

The title of this piece is “The 7 Deadly Sins for those wishing to live long and well with HIV.” This excerpt has to do with nutrient needs (but see also the other sections, including those on gastrointestinal health and maintaining muscle mass.)

Sin #2: Ignoring the nutrient needs that both the disease and the medicines create.

Whether or not you’re taking antiretrovirals, your body is fighting an ongoing battle. It needs higher levels of nutrients to do that. You can’t power the body’s immune response or build replacement immune cells without the nutrient building blocks. You need to consume:

–good levels of protein
–good levels of unrefined complex carbohydrates (brown rice instead of white; whole-grain breads, crackers, cookies and pasta instead of those made with nutrient-poor white flour)
lots of fresh fruits and vegetables
–moderate amounts of good fats every day (monounsaturated fats like olive oil are best; avoid the partially hydrogenated oils found in margarines, shortenings and many baked goods and snack foods. Read the labels!)
–lots of healthful liquids (water, juices, teas — not chemical- and sugar-loaded junk drinks)

That’s how you power your body to keep up the immense battle against HIV. Numerous studies have shown that disease progression is faster in people with low levels of nutrients, so remember, nutrients are one of your best weapons against HIV. (Always make sure that the food you eat and the water you drink is safe.)

Nutrients can also help prevent or reduce the side effects and toxicity of medications while improving their absorption. You can help your body handle all the pills you’re taking by giving it good nutrition, lots of healthful fluids, appropriate supplementation and plenty of liver and kidney support.

With liver-toxic drugs: Consider L-carnitine (or L-acetyl-carnitine), and the nutrients that maintain glutathione levels in the liver — alpha-lipoic acid, vitamin C, vitamin E, N-acetyl-cysteine (NAC) and L-glutamine. Depending on drug interactions (check!), silymarin (milk thistle extract) may also be useful.

To help with kidney stress: Drink lots of water throughout the day. Aim for a large glass every hour or so, especially each time you pop your pills.

Don’t forget that nutrient supplementation can often help reduce or possibly eliminate HIV-related symptoms such as fatigue, skin problems, diarrhea and gas, memory loss, neuropathy and more. In order to manage a difficult disease long-term, you need to feel good!