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LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-.

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LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet].

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Shou Wu Pian

Last Update: January 2, 2014.



Shou Wu Pian is an herbal product derived from the root tuber of Polygonum multiflorum, which has been used for centuries as a treatment for a wide range of conditions including backache, dizziness, graying of the hair and constipation. Shou Wu Pian has been implicated in several reports of clinically apparent acute liver injury.


Shou Wu Pian (Polygonum tablets) is a commonly used and ancient Chinese herbal remedy prepared from the root of the tuber, Polygonum multiflorum, known as the Chinese climbing knotweed (Fo Ti). Fo Ti is a plant native to China, but has been cultivated widely elsewhere. Extracts of the roots of Polygonum multiflorum have been used for centuries in traditional Chinese medicine for a multitude of conditions and as an agent to prevent aging. Some of the historical uses include cancer, tuberculosis, diabetes, hypertension, infections, erectile dysfunction, infertility, and muscle soreness. It is also used as a tonic in liver and kidney conditions and to fortify muscles and bones. The extract has been marketed as a pill and claimed to be beneficial for headache, dizziness, graying of the hair, constipation and liver disease. Shou Wu can also be brewed in teas, and extracts are used in topical creams or ointments for skin conditions and muscle soreness. The active components of Shou Wu Pian are believed to be anthraquinones including chrysophanol, emodin and rhein. Anthraquinones may also account for its effect in constipation, but may also account for its hepatotoxicity. Various oral formulations are available and it is also taken as a tea using extracts of dried Polygonum roots. Common side effects are abdominal pain, diarrhea, nausea and vomiting.


Several published cases and a large case series of clinically apparent acute liver injury have been attributed to use of Shou Wu Pian (Polygonum multiforum). The latency to onset is usually short, but ranges from a few days to as long as 6 months. The pattern of serum enzyme elevations is typically hepatocellular or mixed and the clinical presentation resembles acute viral hepatitis with onset of fatigue, nausea and right upper quadrant pain followed by jaundice. Immunoallergic features are rare as are autoantibodies. Liver biopsy shows changes typical of acute hepatitis. The course is usually self-limited, resolving rapidly once the herbal is discontinued, but at least two cases have been fatal or led to emergency liver transplantation. Recurrence upon reexposure with a more rapid time to onset has been reported.

Mechanism of Injury

The mechanism of hepatotoxicity of Shou Wu Pian is not known, but the injury is usually attributed to the anthraquinones (such as emodin) which are major constituents in Polygonum multiflorum. In a single report, the major compound identified in the recovered tablets was a stilbene glycoside, tetrahydroxystilbene-glucopyranoside.

Outcome and Management

Hepatotoxicity from Shou Wu Pian is usually self-limited, but can be prolonged and is occasionally fatal. Recurrence with restarting the herb is common and rechallenge should be avoided. There is little evidence for cross sensitivity to the hepatotoxic effects of other herbal medications.

Other Names: Fo Ti, Chinese knotweed, Chinese cornbind, Ho Shou Wu, Shen Min, Zi Shou Wu

Drug Class: Herbal and Dietary Supplements

Other herbals in the Subclass Chinese and Other Asian Herbal Medicines: Ba Jiao Lian, Bol Gol Zhee, Chi R Yun, Jin Bu Huan, Ma Huang/Ephedra, Sho Saiko To and Dai Saiko To


Case 1. Recurrent hepatitis due to Shou Wu Pian.

[Modified from: Panis B, Wong DR, Hooymans PM, De Smet PAMG, Rosias PPR. Recurrent toxic hepatitis in a Caucasian girl related to the use of Shou Wu Pian, a Chinese herbal preparation. J Pediatr Gastroenterol Nutr 2005; 41: 256-8. PubMed Citation]

A 5 year old girl developed jaundice and dark urine 4 months after her parents started her on Shou Wu Pian (3 tablets daily) for hair loss. She was otherwise healthy, with normal growth and development and no history of liver disease or risk factors for viral hepatitis. She was taking no conventional medications and her family initially did not mention the herbal use. Physical examination showed jaundice and mild hepatomegaly without fever, rash, abdominal tenderness or splenomegaly. Laboratory results showed raised serum bilirubin levels (4.9 mg/dL), and elevations in serum aminotransferases (ALT 1543 U/L, AST 1938 U/L) and gamma-glutamyl transpeptidase levels (GGT 67, normal <17 U/L). Tests for hepatitis A, B and C were negative as were tests for cytomegalovirus and Epstein Barr virus infection. Abdominal ultrasound showed normal liver and biliary tract. Liver tests improved without specific therapy and one month later liver tests were normal (Table). However, she returned with recurrence of jaundice 2 months later and at this point the history of herbal use was obtained. After recovering from the initial liver injury, the Shou Wu Pian was restarted at a lower dose (2 tablets per day) and she redeveloped jaundice within a month of restarting. She again began to improve once the herbal medication was stopped, but liver test abnormalities did not completely resolve until 5 months later. Analysis of residual tablets of the Shou Wu Pian demonstrated the stilbene glycoside, tetrahydrostilbine-glucopyranoside, as the major constituent with only trace amounts of anthraquinones.

Key Points

Medication:Shou Wu Pian (3 tablets daily)
Pattern:Hepatocellular (R=9.8, using GGT instead of alkaline phosphatase)
Severity:3+ (jaundice, hospitalization)
Latency:16 weeks initially, 4 weeks on reexposure
Recovery:4 weeks initially, 21 weeks on reexposure
Other medications:None

Laboratory Values

Time After StartingMonths After StoppingALT
Total Bilirubin (mg/dL)Other
Shou Wu Pian taken for hair loss for 4 months
4 months01543674.9
5 months1 months50210.4
Shou Wu Pian restarted for 1 month
7 (1) months01277983.7
(2) months1 months65230.5
(6) months5 months3590.5
Normal Values<40<17<1.2


The case history is somewhat typical of herbal induced liver injury, in that the family did not inform the physicians that the child was receiving Shou Wu Pian and did not consider it harmful or imagine that it was the cause of the hepatitis. The clinical features resembled acute hepatitis, but the recurrence (with a shorter latency) on restarting the herbal makes this a convincing case for Shou Wu Pian induced acute liver injury.



Shou Wu Pian – Generic


Herbal and Dietary Supplements


Shou Wu PianNo InformationHerbal mixtureNot applicable


References updated: 02 January 2014

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    (Expert review of hepatotoxicity published in 1999; hepatotoxicity of Chinese herbal products and teas are discussed generally without focus on Shou Wu Pian).
  • Seeff L, Stickel F, Navarro VJ. Hepatotoxicity of herbals and dietary supplements. In, Kaplowitz N, DeLeve LD, eds. Drug-induced liver disease. 3rd ed. Amsterdam: Elsevier, 2013, pp. 631-58. (Review of hepatotoxicity of herbal and dietary supplements [HDS] discusses Chinese and other Asian herbal medicines including Shou Wu Pian)
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    (46 year old woman developed pruritus and jaundice 2 weeks after starting Shou Wu Pian [bilirubin 12.6 mg/dL, ALT 876 U/L, Alk P 185 U/L], resolving within a month of stopping).
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    (78 year old man developed jaundice 1 month after starting Shou Wu Pian for chronic prostatitis [bilirubin 25.5 mg/dL, ALT 1276 U/L, Alk P 409 U/L], resolving rapidly upon stopping).
  • Panis B, Wong DR, Hooymans PM, De Smet PAMG, Rosias PPR. Recurrent toxic hepatitis in a Caucasian girl related to the use of Shou-Wu-Pian, a Chinese herbal preparation. J Pediatr Gastroenterol Nutr 2005; 41: 256-8. [PubMed: 16056110]
    (5 year old girl developed jaundice 4 months after being started on Shou Wu Pian [bilirubin 4.9 mg/dL, ALT 1543 U/L, Alk P normal], resolving within 5 weeks and recurring within 4 weeks of restarting, resolving this second time only after 5 months: Case 1).
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    (35 year old man developed jaundice “several months” after starting “NuHair” [containing Polygonum multiflorum] for hair loss [bilirubin 4.6 rising to 13.7 mg/dL, ALT 2714 U/L, Alk P 137 U/L, INR 1.3], resolving 4 months after stopping).
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    (30 patients with drug induced liver disease seen at a single medical university in Shanghai between 2000-2008, of which 12 were attributed to Chinese herbs, but specific agents not discussed, 9 were jaundiced, 6 hepatocellular, 3 cholestatic and 2 mixed).
  • Cho HC, Min HJ, Ha CY, Kim HJ, Kim TH, Jung WT, Lee OJ, Bae IG. Reactivation of pulmonary tuberculosis in a patient with Polygonum multiflorum Thunb-induced hepatitis. Gut Liver 2009; 3: 52-6. [PMC free article: PMC2871557] [PubMed: 20479902]
    (34 year old man developed jaundice 30 days after starting daily use of Polygonum multiflorum tea and extract [bilirubin 25.3 mg/dL, ALT 1452 U/L, Alk P 111 U/L] with neutropenia [and pulmonary tuberculosis], liver injury resolving slowly after stopping herbal product).
  • Furukawa M, Kasajima S, Nakamura Y, Shouzushima M, Nagatani N, Takinishi A, Taguchi A, et al. Toxic hepatitis induced by show-wu-pian, a Chinese herbal preparation. Intern Med 2010; 49: 1537-40. [PubMed: 20686286]
    (53 year old Japanese woman developed fatigue after taking Shou Wu Pian for 8 months [bilirubin 1.2 mg/dL, ALT 417 U/L, Alk P 1425 U/L, ANA 1:320], resolving within 2 months of stopping).
  • Bae SH, Kim DH, Bae YS, Lee KJ, Kim DW, Yoon JB, Hong JH, Kim SH. [Toxic hepatitis associated with Polygoni multiflori]. Korean J Hepatol 2010; 16: 182-6. [PubMed: 20606503]
    (54 year old Korean woman developed fatigue 1 month after starting Shou Wu [ALT 1136 U/L, Alk P 324 U/L], resolving rapidly but recurring upon reexposure).
  • Jung KA, Min HJ, Yoo SS, Kim HJ, Choi SN, Ha CY, Kim HJ, et al. Drug-Induced Liver Injury: Twenty five cases of acute hepatitis following ingestion of Polygonum multiflorum Thunb. Gut Liver 2011 ; 5: 493-9. [PMC free article: PMC3240794] [PubMed: 22195249]
    (Case series of 25 patients with suspected hepatotoxicity from Shou Wu [Polygonum multiflorum] seen between 2007 and 2009 at a single Korean hospital; ages 24 to 65 years, presenting with jaundice after taking herbal as a tea or liquid extract for 2 to 180 days [bilirubin 1.6-32.9 mg/dL, ALT 271-1706 U/L, Alk P 81-465 U/L], injury pattern being hepatocellular [n=18] or mixed [n=7], liver biopsies showing acute hepatocellular injury, resolving in most, one died and one underwent liver transplantation, one had recurrence on reexposure).
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    (Review of current understanding of liver injury from herbals and dietary supplements focusing upon herbalife and hydroxycut products, green tea, usnic acid, Noni juice, Chinese herbs, vitamin A and anabolic steroids; Shou Wu Pian not discussed).
  • Teschke R, Wolff A, Frenzel C, Schulze J, Eickhoff A. Herbal hepatotoxicity: a tabular compilation of reported cases. Liver Int 2012; 32: 1543-56. (A systematic compilation of all publications on the hepatotoxicity of specific herbals identified 185 publications on 60 different herbs, including two reports of injury due to Shou Wu Pian: [PubMed: 22928722]
    Jung [2011] and Panis [2005]).


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