Management of Black Cohosh in Patients with Fatty Liver Disease

Patient Assessment and Risk Evaluation

• The American College of Radiology suggests that patients with nonalcoholic fatty liver disease (NAFLD) have a hepatocellular pattern of injury, characterized by mildly elevated ALT levels, typically less than 5 times the upper limit of normal, and an AST:ALT ratio less than 1, indicating a higher risk of hepatotoxicity from supplements like black cohosh 1
• The Mayo Clinic recommends considering the risk-benefit ratio in patients with pre-existing liver disease, as the baseline liver dysfunction creates vulnerability to additional hepatotoxic insults 2

Clinical Decision-Making and Management

• The American College of Radiology and Mayo Clinic Proceedings suggest that patients with NAFLD and elevated ALT have an increased baseline risk of hepatotoxicity, and black cohosh should be discontinued immediately to minimize this risk 1, 2
• The Clinical and Molecular Hepatology journal recommends addressing underlying NAFLD through weight loss, glycemic control, and cardiovascular risk modification, as these are critical components of managing the disease 3, 2
• The American Heart Association and American College of Cardiology are not mentioned, however the management of NAFLD involves optimizing lipid management, as cardiovascular disease is the leading cause of death in NAFLD patients, and statins are safe in NAFLD patients with elevated liver enzymes less than 3 times the upper limit of normal 4, 3

Monitoring and Follow-Up

• The Mayo Clinic Proceedings recommend monitoring for clinical improvement, such as resolution of fatigue or right upper quadrant discomfort, after discontinuation of black cohosh, and rechecking liver enzymes in 4-6 weeks 2
• The American College of Radiology and Mayo Clinic Proceedings suggest that if ALT remains elevated or worsens, other causes of hepatocellular injury should be investigated 1, 2