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Shah SJ, Fine N, Garcia-Pavia P, Klein AL, Fernandes F, Weissman NJ, Maurer MS, Boman K, Gundapaneni B, Sultan MB, et al

Johns wort, garlic and germander, may mechanistically enhance the CYP system.1 An alternative mechanism by which medications may enhance APAP hepatotoxicity involves competitive utilization of the glucouronidation pathway, resulting in increased metabolism towards the CYP system and thus enhanced formation of hepatotoxic substrates.25 Importantly, opioid therapies can reduce the level of hepatic GSH and thereby potentiate APAP-induced liver injury.8 It is important to note that some natural products and remedies have been demonstrated to have protective potential against APAP hepatotoxicity.8 One proposed mechanism underlying this phenomenon is the competitive utilization of CYP 2E1 in herbal drug metabolism that would decrease APAPs conversion into its toxic metabolites, such as NAPQI.25,33,34 The Schisandra plant species, ubiquitous in its use as a traditional East Asian herb, has been used in Korea, China and Japan as a remedy for hepatitis