Introduction: Since the publication of the Women's Health Initiative (WHI) trials, there has been a decline in the use of hormonal replacement therapy (HRT). The risks outweighed the benefits in the WHI trials, and therefore women are seeking alternative treatments including herbal remedies to HRT for mitigation of postmenopausal conditions. The authors report a case of drug-herb interaction between black cohosh (Cimicifuga racemosa) and atorvastatin leading to elevation in liver enzymes.Case summary:A 53-year-old woman with a past medical history significant for atypical chest pain, family history of coronary artery disease, and menopause discontinued oral HRT and started black cohosh for treatment of her menopausal symptoms. The patient also reported taking atorvastatin, aspirin, glucosamine/chondroitin, and vaginal estradiol (Vagifem®). Routine lab results revealed an acute elevation of her liver enzymes. At this time, additional blood tests were performed to rule out other plausible causes of acute elevation in liver enzymes, which did not reveal other etiologies. It was recommended that she discontinue the black cohosh immediately due to a potential drug-herb interaction. Following the patient's discontinuation of black cohosh, her liver enzymes decreased within 1 week and completely returned to normal within 1 month. Discussion:Several case reports have associated black cohosh with hepatotoxicity. It was reported that a commercially available formulation of black cohosh may potently inhibit human cytochrome (CYP) 3A4. Inhibition of CYP3A4 by black cohosh could possibly elevate levels of atorvastatin, causing an elevation of liver enzymes. To the authors' knowledge, they report the first case report of drug-herb interaction with use of the black cohosh and atorvastatin.Conclusion:The use of black cohosh concomitantly with atorvastatin may potentially lead to a drug-herb interaction resulting in an elevation of liver enzymes. According to the Naranjo probability scale, there was a possible drug-induced adverse event. Black cohosh should not be routinely recommended for treatment of menopausal symptoms. However, if a patient chooses to use black cohosh against medical advice, particular attention should be given to the potential CYP3A4 drug interactions.
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