Legalon® SIL: The Antidote of Choice in Patients with Acute Hepatotoxicity from Amatoxin Poisoning

Abstract

More than 90% of all fatal mushroom poisonings worldwide are due to amatoxin containing species that grow abundantly in Europe, South Asia, and the Indian subcontinent. Many cases have also been reported in North America. Initial symptoms of abdominal cramps, vomiting, and a severe cholera-like diarrhea generally do not manifest until at least six to eight hours following ingestion and can be followed by renal and hepatic failure. Outcomes range from com-plete recovery to fulminant organ failure and death which can sometimes be averted by liver transplant. There are no con-trolled clinical studies available due to ethical reasons, but uncontrolled trials and case reports describe successful treat-ment with intravenous silibinin (Legalon ® SIL). In nearly 1,500 documented cases, the overall mortality in patients treated with Legalon ® SIL is less than 10% in comparison to more than 20% when using penicillin or a combination of silibinin and penicillin. Silibinin, a proven antioxidative and anti-inflammatory acting flavonolignan isolated from milk thistle ex-tracts, has been shown to interact with specific hepatic transport proteins blocking cellular amatoxin re-uptake and thus in-terrupting enterohepatic circulation of the toxin. The addition of intravenous silibinin to aggressive intravenous fluid man-agement serves to arrest and allow reversal of the manifestation of fulminant hepatic failure, even in severely poisoned pa-tients. These findings together with the available clinical experience justify the use of silibinin as Legalon ® SIL in Ama-nita poisoning cases.