Many of the stories about herbal medicines publicize their successes as remedies with little mention of their adverse effects; the word natural is equated with safety. Saw palmetto, an active ingredient in many preparations, is an extract of Serenoa repens, the American dwarf palm tree. Although it has been used for a myriad of indications as diuretic, aphrodisiac and breast augmenter, its major clinical usage is in benign prostatic hypertrophy (BPH). Its success in relieving obstruction due to BPH earned it the name plant catheter and inclusion in the US National Formulary (1906-1950).[1,2] Saw palmetto has so far been implicated in hepatitis, cholecystitis, bleeding diathesis, conduction defects, and erectile dysfunction.[3,4,5,6,7] Its mechanism of action is believed to be derived from the stimulation of estrogenic and inhibition of progesterone receptors in prostatic tissues, but it also exhibits antiestrogenic and antiandrogenic effects, inhibiting the actions of 5-alpha reductase enzyme and also the binding of dihydrotestosterone to androgen receptors.[8,9]
In 1997, Hamid et al reported a case of persistent cholestatic hepatitis following only a 2 week exposure to Prostata, an herbal preparation containing saw palmetto; there are, however, fewer reports of herbal medications causing acute pancreatitis. This may be related to the inadequate monitoring of these drugs or patients not volunteering information on their use. There is no established cause in our patient of acute pancreatitis or hepatitis apart from the fact that he takes saw palmetto. The consistent resolution of symptoms following abstinence during brief hospitalization periods (consistent with short elimination half-life of saw palmetto) and the relatively prolonged symptom-free period following complete withdrawal are pointers of potentially significant association. Furthermore, the concurrent occurrence and resolution of pancreatitis with acute hepatitis (known to be caused by saw palmetto) is indicative of common etiology. Noteworthy also is the fact that his clinical picture and the pattern of rise in his transaminases are suggestive of hepatocellular damage as well as cholestasis.
This case underscores the importance of taking a detailed medication history including herbal medicinal usage in all patients, especially in those with recurrent problems for which no explanation has been found. Highly sophisticated imaging techniques cannot substitute for this important piece of clinical data. While remote causes of pancreatitis including microlithiases may arguably play a role in this patient's symptomatology, such causes would not explain his clinical and biochemical presentation together with a quick and sustained response without surgical intervention.
Finally, the fundamental question of whether saw palmetto is indeed involved in hepatic, pancreatic and possibly other organ injury in susceptible individuals needs to be determined.
Ismaila Jibrin, MD, St. Agnes Healthcare, 900 South Caton Avenue, Baltimore, MD 21229. Email: firstname.lastname@example.org
South Med J. 2006;99(6):611-612. © 2006 Lippincott Williams & Wilkins
Cite this: Saw Palmetto-induced Pancreatitis - Medscape - Jun 01, 2006.