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Medical Forum / Diseases and Disorders / Hepatitis / November 2009

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Milk Thistle?

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CatEyes - 20 Oct 2009 17:34 GMT
Almost every site I've gone to for information about Hep C mentions Milk
Thistle to help liver function.  First, does it really do anything?  Second,
how much should you take (I got a bottle of the 1,000mg and the directions
say to take 2 to 4 every day)?  Since they were fairly expensive I'm
hesitant to take 4 per day if that's just over-doing it.

Hugs,

CatNipped
M - 20 Oct 2009 18:14 GMT
> Almost every site I've gone to for information about Hep C mentions Milk
> Thistle to help liver function.  First, does it really do anything?  Second,
[quoted text clipped - 5 lines]
>
> CatNipped

I pay 1 euro and 16 euro cents for 30 capsules with 80 mg of Silimarina
and I take three capsules a day. Gonna take one right now :-) The doc
prescribed them for me and it does make a difference in that the fatigue
and lethargy goes away.

M
Waterspider - 20 Oct 2009 21:47 GMT
>> Almost every site I've gone to for information about Hep C mentions Milk
>> Thistle to help liver function.  First, does it really do anything?
[quoted text clipped - 9 lines]
> and lethargy goes away.
> M

Speaking of lethargy and fatigue, spirulina is an excellent natural
energy-booster and it worked well for me while on treatment and, before
that, for hep C symptoms. However, it's high in iron so might not be a good
recommendation for anyone with cirrhosis or more advanced liver disease.
Nyarnon - 20 Oct 2009 20:58 GMT
CatEyes schreef:
> Almost every site I've gone to for information about Hep C mentions Milk
> Thistle to help liver function.  First, does it really do anything?  Second,
[quoted text clipped - 5 lines]
>
> CatNipped

Milk Thistle seems to be a miracle if you may believe half of the
scientific reports. In Germany it has already been accepted by the
ministery of health as an official medicine. It works straight on the
center of the livercells renewing the liver from within. Last but not
least it is able to get rd of scar tissue.

I do not use any extract, most of them are on alcohol base to begin with
I also believe to use the natural product has some benefit's therefor I
buy Milk Thistle seed. This can then be grinded and added to whatever
you like. I use currently about three table spoons of it.

http://www.ahrq.gov/clinic/epcsums/milktsum.htm
http://www.hepatitis-central.com/mt/archives/2009/08/four_more_benef.html
http://sites.google.com/site/hcvmybone/files-and-documents/milkthistle.pdf?attre
directs=0


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Russian - 22 Oct 2009 09:12 GMT
> I do not use any extract, most of them are on alcohol base to begin with
> I also believe to use the natural product has some benefit's therefor I
> buy Milk Thistle seed. This can then be grinded and added to whatever
> you like. I use currently about three table spoons of it.

Well, I go a step further... I prefer to just eat raw milk thistle.
Sure, the thistles make your mouth bleed and it's really hard to
swallow, but then I know that it hasn't been contaminated with colloidal
silver....

:)
Char - 22 Oct 2009 12:51 GMT
>> I do not use any extract, most of them are on alcohol base to begin
>> with I also believe to use the natural product has some benefit's
[quoted text clipped - 7 lines]
>
> :)

That is soooo funny! LOL! Thanks for brightening my day and bringing
laughter to my lips.
Nyarnon - 22 Oct 2009 12:56 GMT
Char schreef:
>>> I do not use any extract, most of them are on alcohol base to begin
>>> with I also believe to use the natural product has some benefit's
[quoted text clipped - 10 lines]
> That is soooo funny! LOL! Thanks for brightening my day and bringing
> laughter to my lips.

http://en.wikipedia.org/wiki/Milk_thistle#Edible_Uses

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Russian - 22 Oct 2009 23:21 GMT
> http://en.wikipedia.org/wiki/Milk_thistle#Edible_Uses

Don't need to... I already know milk thistle is a good thing.

I'm just one of the very rare people who is on an unusual medication
that conflicts :(

The years I was taking it and when I stopped, it was just a suspected
benefit.

I suppose if it now has a proven benefit, I could check my heart rate
(that's what my other drug is for) 4 times a day or wear a holter
monitor, and then start on the milk thistle for a couple of weeks and
then check heart rate again.

Because measuring blood levels of the actual drug in question i believe
would be way to expensive to do as an individual outside of a funded
research study or with backing from the pharm.
Russian - 22 Oct 2009 23:15 GMT
> That is soooo funny! LOL! Thanks for brightening my day and bringing
> laughter to my lips.

You're so welcome!  Thanks for noticing....
greyhackles - 20 Oct 2009 20:59 GMT
>Almost every site I've gone to for information about Hep C mentions Milk
>Thistle to help liver function.  First, does it really do anything?  Second,
[quoted text clipped - 5 lines]
>
>CatNipped

I think the preponderance of data shows that Milk Thistle can be quite helpful
to folks battling liver inflammation caused by HCV. The problem has been (and
may still be) that because MT exists in a generally unregulated space, there
is difficulty in establishing a "standard dose", and then having all the
suppliers meet the quality and quantity specs that make up that standard. So
the quality of what is available is apparently all over the map.

Don't know how anyone deals with that and ends up with something in which they
have reasonable confidence of potency and purity...

Cheers

/greyhackles
CatNipped - 22 Oct 2009 00:26 GMT
>>Almost every site I've gone to for information about Hep C mentions Milk
>>Thistle to help liver function.  First, does it really do anything?
[quoted text clipped - 25 lines]
>
> /greyhackles

I get all my herbs and supplements from "Nature Made" - it's a large
company, its products readily available in almost any store, so I figure
they'd have a pretty standard, well, standards!  ;>

Hugs,

CatNipped
Frank - 21 Oct 2009 00:40 GMT
>Almost every site I've gone to for information about Hep C mentions Milk
>Thistle to help liver function.  First, does it really do anything?  Second,
[quoted text clipped - 5 lines]
>
>CatNipped

It's obviously effective enough to interfere with chemo for liver disease.  Although my
cancer center encourages you to take it for liver issues, it can actually cause chemo
to lose much of it's cell destroying effectiveness and told me to stop before I start
chemo.
Nyarnon - 21 Oct 2009 09:28 GMT
Frank schreef:

> It's obviously effective enough to interfere with chemo for liver disease.  Although my
> cancer center encourages you to take it for liver issues, it can actually cause chemo
> to lose much of it's cell destroying effectiveness and told me to stop before I start
> chemo.  

Hi Frank,

What you describe is a long misunderstanding about Milk Thistle from
years ago. When Milk Thistle became popular amongst Heppers and it came
in the spotlight of the doctors they where very confused about the blood
values. Some of them decided that it would be better not to use it as
they didn't know how to interpret the bloodvalues.

I have been all over the web to read up on the Milk Thistle and have not
found any authoritive paper stating that the Thistle would interfer with
treatment. That said I will issue a word of warning. Any supplement you
use you should talk about with your doctor and unless your really sure
of yourself you should go by his decission.

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Russian - 22 Oct 2009 09:15 GMT
I took Milk Thistle from those guys who host one of the first decent HCV
websites.  However, Milk Thistle effects the metabolism (slows it down)
of drugs that are processed by a certain specific enzyme.

So I look through the short list of drugs that might be better without
milk thistle, mostly really obscure stuff, and wham, there is a drug I
have taken every day for 10 years.

Milk Thistle could potentially cause the levels of that drug to be
higher than expected and excreted much more slowly.

So even for "good" drugs you have to take standard precautions.
Cactus Jammies - 25 Oct 2009 18:43 GMT
> Almost every site I've gone to for information about Hep C mentions Milk
> Thistle to help liver function.  First, does it really do anything?
[quoted text clipped - 5 lines]
>
> CatNipped ...............................................
Hi,
 I am relapsed geno 1b.  I have been taking eight capsules of Milk Thistle
(80% silymarin) extract 200mg/500mg MT powder and eight capsules of Reishi
Mushroom 4:1 extract powder (10% polysaccharides) 500 mg/200mg whole ground
mushroom for three years, along with eight teaspoons of Turmeric spice
powder per day.  I have no outward symptoms of Hepatitis C nor do I feel
'sick'.  These tonics were suggested in a book 'Herbs, Hepatitis C and the
Liver'  by H Buhner.  My blood work is all in the 'normal' range and has
been for quite a while.  I highly recommend the  book as a guide through the
maze of complementary treatments and tonics on the market.  I mail order for
the MT and Reishi from WholeHealthProducts.com  Very reasonable if you go on
the maintenance plan.
Those who know me on this group can vouch for the fact I am not a shill for
either the publishing house nor Whole Health.

cactus jammies (probably starting 72 week combo tx sometime next year)
Sara - 25 Oct 2009 18:55 GMT
On Oct 25, 1:43 pm, "Cactus Jammies" <cactusjamm...@retinalcircus.orb>
wrote:
> > Thistle to help liver function.  First, does it really do anything?
> > Second, how much should you take (I got a bottle of the 1,000mg and the
[quoted text clipped - 25 lines]
>
> - Show quoted text -

Wow, CJ, keep us posted!  It is your turn for SVR!!

Sara
Nyarnon - 25 Oct 2009 19:04 GMT
Cactus Jammies schreef:

> Hi,
>  I am relapsed geno 1b.  I have been taking eight capsules of Milk
[quoted text clipped - 10 lines]
> Those who know me on this group can vouch for the fact I am not a shill
> for either the publishing house nor Whole Health.

That you dont feel sick or your bloodworks show normal range doesn't
mean anything, thats why hepatitis is called the silent dragon. How the
state of your liver is can be seen with a soundecho and even better a
biopsy. Using herbs is in itself a good thing but I ensure you they are
quite useless without a propper treatment. You might slow progress but
it solves nothing.

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greyhackles - 26 Oct 2009 01:21 GMT
>Cactus Jammies schreef:
>>
[quoted text clipped - 19 lines]
>quite useless without a propper treatment. You might slow progress but
>it solves nothing.

CJ is a very smart dude - and there's no doubt he gets all of the tests
required to keep track of his business.

As for the blood work: generally, I'd be the first to agree with you that
blood tests (which usually means liver function tests) do not provide much
insight wrt to the state of the liver - when HCV is involved, at least.

But, CJ is a diagnosed, treatment-experienced patient, with plenty of lab
history to establish baselines for inflammation activity levels (as well as
biopsy results). If his labs have dropped from above the normal ranges into
the normal range, there is no doubt that the level of inflammation has dropped
as well. That doesn't mean everything is peachy-keen, but it does mean he's
doing better than before - and possibly much better. And that translates into
time...

Cheers

/greyhackles
Nyarnon - 26 Oct 2009 09:22 GMT
greyhackles schreef:

>> Cactus Jammies schreef:
>>> Hi,
[quoted text clipped - 21 lines]
> CJ is a very smart dude - and there's no doubt he gets all of the tests
> required to keep track of his business.

<snip>

> /greyhackles

This is not about CJ it was just an adition for people who do not
realize that it was not ment as replacement for treatment.

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Cactus Jammies - 26 Oct 2009 02:57 GMT
> Cactus Jammies schreef:
>>
[quoted text clipped - 20 lines]
> useless without a propper treatment. You might slow progress but it solves
> nothing.

sigh.
  I have had routine six-month interval ultrasound scans of my liver over
the past four years.  And a CT as well.  Nothing has progressed according to
the readings.  Yes it is still there but it is not galloping through my
liver turning it into one big mass of scars.  The ultrasound scans are
Standard Of Care (SOC).
 The effective use of Milk Thistle is to find an amount and ingested orally
that will be absorbed in enough concentration into the bloodstream to keep
inflammation of the liver static.  It's more than an number, this ALT/AST
business.  European studies have found that constant use of Silymarin will
keep the viral load down.  The key is to find an efficient way to use the
stuff.  In Europe they used IV drip.  Intravenous is a lot more efficient
that eating it, and that's why you have to eat so much and that is why the
concentration of Silymarin is so important.

cactus jammies
(I don't care for your authoritative demeanor one bit.)
Nyarnon - 26 Oct 2009 09:36 GMT
Cactus Jammies schreef:

>> Cactus Jammies schreef:
>>>
[quoted text clipped - 39 lines]
> cactus jammies
> (I don't care for your authoritative demeanor one bit.)

see what I wrote to grey the initial posting was not really clear for a
newbee could as well have been one of those alternative cure postings
thats why I responded has nothing to do with you really. Now funny that
you mention Europe, as I live there and use Milk Thistle, where did you
get that IV drip story, in Portugal f.i. they dont even know what Milk
Thistle is/does. Germany for now is the only european country that uses
it as a official med.

I f.i. use the raw seed that I grind, reason for that is that I think it
will be better. F.i. the seed also has a lot of fiber that you won't get
in the solution. Nature shows us everytime again when we rip it's
secrets apart we often forget a few things here and there.

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Cactus Jammies - 26 Oct 2009 18:04 GMT
> see what I wrote to grey the initial posting was not really clear for a
> newbee could as well have been one of those alternative cure postings
[quoted text clipped - 8 lines]
> in the solution. Nature shows us everytime again when we rip it's secrets
> apart we often forget a few things here and there.

The clinical trials were done in Austria.  I remember posting the trial
results to this group quite some time ago.  This is something a bit more
fresh but I beleive it refers to the same battery of testings.   Importance:
Concentration and amount of compound to to reach blood supply is very
important.  As you say it is important to injest the ground milk thistle
seed as well as it reduces inflammation in the liver and is a recognized
detoxifier/anti-oxidant.  I *think* that much of which we read about the
benefits of Milk Thistle are more in line with what the whole ground does
for the liver.  The same compound also exists in the food plant Artichoke.

-cactus jammies
.......................................
http://www.catie.ca/catienews.nsf/00a48c8905294f0b8525717f00661eb8/8a96f3de84f05
00b8525754b00586b59!OpenDocument


Milk thistle-hints of help for hepatitis C

The herb milk thistle has been used for millennia as part of traditional
European remedies for gastrointestinal and liver illness. This herb contains
many compounds, some of which are being studied in lab experiments with
cells. In these experiments, extracts of milk thistle appear to have
anti-inflammatory, anti-cancer and antioxidant activity. What's more, some
of the extracts have antiviral activity against hepatitis C virus (HCV). All
of these properties have stimulated further interest and research in this
herb.

Researchers in Vienna, Austria, have been conducting small clinical trials
with an intravenous formulation of a milk thistle extract-silibinin-in
people with hepatitis C who are unresponsive to standard therapy. Their
results are somewhat surprising and suggest that silibinin has potent
anti-HCV activity in some people. Much work remains to be done to confirm
and extend these findings.

Study details
For the study, 36 volunteers (5 female, 31 male) were recruited. All had HCV
mono-infection and previous standard HCV therapy-the immune booster
interferon and the antiviral drug ribavirin-had failed to cure them. Their
average age was 50 years and most had the hard-to-treat strain of HCV called
genotype 1. About 55% had moderate-to-severe liver damage.

The study team first gave participants different intravenous doses of highly
purified silibinin, sold as Legalon Sil (made by Madaus GmbH, in Köln,
Germany), for one or two weeks, followed by a combination of interferon and
ribavirin. Additionally, once participants stopped receiving IV silibinin,
they were switched to an oral formulation of a mix of concentrated milk
thistle extracts called silymarin. This oral formulation was taken three
times daily. So far, most participants have taken silymarin and
interferon-ribavirin for at least 24 weeks and the trial will continue for
an additional 24 weeks.

Results
High doses-15 or 20 mg/kg/day-of IV silibinin alone caused a significant
decline (between 100- and 10,000-fold) in HCV levels. The addition of
interferon-ribavirin resulted in a further decline in virus levels.

In two of five participants who received 15 mg/kg/day of IV silibinin, HCV
levels fell below the threshold of detection; the lower limit of
quantification of the test was 15 international units (IU). Five of nine
participants who received the 20 mg/kg/day dose also had HCV levels fall
below the 15 IU level.

After 12 weeks of combination therapy, a total of eight participants
continued to have very low levels of HCV (less than 15 IU).

Safety
In general, IV silibinin use was well tolerated. Eight participants
complained of the following symptoms (some participants had more than one
symptom), each of which they described as "mild":

abdominal pain (five people)
diarrhea (two people)
nausea (one person)
headache (two people)
joint pain (one person)
All participants receiving high doses of IV silibinin reported feeling
warmer when the herb was infused into their veins; this feeling subsided
after 30 minutes.

Intravenous vs. oral
In this study, IV silibinin appears to have potent anti-HCV activity.
However, according to the study team, oral doses of milk thistle extract did
not share this effect. The study team suspects that this is likely due to
the extensive processing and breakdown of the extracts in the intestine and
liver. Previous studies have found that oral formulations of milk thistle
result in very low levels of active extracts in the blood. These levels are
much lower than seen in lab experiments with liver cells. Taking this into
account, it is perhaps not surprising that another study has found that oral
milk thistle had no effect on HCV levels in people. Future research will
likely use highly purified milk thistle extracts given intravenously.

The current protocol used in the Vienna study is a bit
cumbersome-intravenous infusion over a period of four hours each day.
However, the Austrian research team is exploring different schedules, such
as five consecutive days weekly and perhaps repeated and longer use of IV
silibinin, in people who show a partial response to therapy. Further studies
are needed to determine the best dose of silibinin and possible interactions
with other drugs. Researchers in Austria and the United States hope to
conduct a larger study of IV silibinin followed by interferon-ribavirin
treatment in volunteers whose HCV infection was not cleared when previously
treated with standard therapy.

Notes on extracts
Silymarin is the name given to a mix of compounds called flavonoids found in
milk thistle. The chief compound in silymarin is silibinin (found as an
equal mixture of silibinin A and silibinin). Other compounds found in
silymarin include the following:

silydianin
silycristin
isosilybin A
isosylibin B
isosilycrystin
taxifolin
It is likely that other research teams will explore the activity of these
compounds for a wide range of conditions.

Acknowledgement
We thank Professor Peter Ferenci, MD, from the Medical University of Vienna
for his helpful comments and review.
Nyarnon - 26 Oct 2009 20:03 GMT
Cactus Jammies schreef:

<snip report>

Ok so it was a test trail that explain the IV. And it is indeed the
German company that is the sole producer for the German market of the as
medicine registered extract. I wonder in how far that influenced the
oral versus iv conclusion. I would love that as single producer.

Odd conclusion IMHO as it has always been used because of its benefits
for the liver long before pharma extracted what it believes to be the
(only) working compound :-)

Thanks for sharing.

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Cactus Jammies - 26 Oct 2009 23:54 GMT
> Cactus Jammies schreef:
>
[quoted text clipped - 10 lines]
>
> Thanks for sharing.

I think I remember reading somewhere that only 8% of the compound reaches
the bloodstream through the GI tract whereas the IV is far more effcient and
controlled.  The compound isolated is the one that temporarily reduces the
strength (viral concentration) in the blood stream (and hence must somehow
tie in with the liver as the blood supply passes through the liver of
course).  There are other compounds in Milk Thistle that reduce inflammation
as well.

cactusjammies
Russian - 29 Oct 2009 17:50 GMT
Where did you get your milk-thistle, CJ?
Cactus Jammies - 29 Oct 2009 20:09 GMT
> Where did you get your milk-thistle, CJ?
................................
Russian, it was above, but here it is again

****************  I have been taking eight capsules of Milk Thistle
(80% silymarin) extract 200mg/500mg MT powder and eight capsules of Reishi
Mushroom 4:1 extract powder (10% polysaccharides) 500 mg/200mg whole ground
mushroom for three years, along with eight teaspoons of Turmeric spice
powder per day.  I have no outward symptoms of Hepatitis C nor do I feel
'sick'.  These tonics were suggested in a book 'Herbs, Hepatitis C and the
Liver'  by H Buhner.  My blood work is all in the 'normal' range and has
been for quite a while.  I highly recommend the  book as a guide through the
maze of complementary treatments and tonics on the market.\\\\\

******************  I mail order for
the MT and Reishi from WholeHealthProducts.com  Very reasonable if you go on
the maintenance plan.*************

cactus jammies
Russian - 29 Oct 2009 17:46 GMT
> That you dont feel sick or your bloodworks show normal range doesn't
> mean anything,

No, it does mean something... that he doesn't feel sick... and that's
not nothing...

I think he knows that it is not diagnostic since he stated that he will
probably be starting 72 weeks of treatment next year...
greyhackles - 26 Oct 2009 01:13 GMT
>> Almost every site I've gone to for information about Hep C mentions Milk
>> Thistle to help liver function.  First, does it really do anything?
[quoted text clipped - 21 lines]
>
>cactus jammies (probably starting 72 week combo tx sometime next year)

Two things, CJ: I am *so* happy to read that your blood work and general
health are both good; and based on that, I really hope you can hold off on the
retreatment until either Telaprevir or Boceprevir are available to help with
the combo drugs...

Cheers, Bob - and keep being well!

/greyhackles
Cactus Jammies - 26 Oct 2009 03:05 GMT
"greyhackles" <greyhackles@REMOVEyahoo.com> wrote >
> Two things, CJ: I am *so* happy to read that your blood work and general
> health are both good; and based on that, I really hope you can hold off on
[quoted text clipped - 6 lines]
>
> /greyhackles
..................................................
Oh so am I, so am I.  My doc says that if there was something new that was
going to be popped into the market within the next two years, that it would
already be news in the HepMed type community of doctors and such.  According
to him Vertex or the other outfits would be out there now (in the USA)
letting them know 'it's just around the corner so hang tough'.  I don't
discuss my herbal stuff with him because his eyes go out of focus and then
he looks at his wrist watch.  Lol.
cheers to you too, Grey.  I spewed a bit in my last response to that
whomever.  Three top things that will kill you early:  Inflammation,
Oxidation and psychological stress.  (Oh and that bus you didn't see coming
when you went out in the street to pick up your daily paper.)

cactus jammies
Russian - 29 Oct 2009 17:53 GMT
> Two things, CJ: I am *so* happy to read that your blood work and general
> health are both good; and based on that, I really hope you can hold off on the
> retreatment until either Telaprevir or Boceprevir are available to help with
> the combo drugs...

I'm in that same boat... "let me make it to 2012, let me make it to 2012"...
Nyarnon - 26 Oct 2009 09:44 GMT
Cactus Jammies schreef:

>> Almost every site I've gone to for information about Hep C mentions
>> Milk Thistle to help liver function.  First, does it really do
[quoted text clipped - 22 lines]
>
> cactus jammies (probably starting 72 week combo tx sometime next year)

The book is available from Amazon also, they offer it also second hand
from 1,99$ and up.

http://www.amazon.com/gp/offer-listing/1580172555/ref=dp_olp_used?ie=UTF8&qid=12
56546432&sr=1-1&condition=used


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Waterspider - 26 Oct 2009 09:54 GMT
>> Almost every site I've gone to for information about Hep C mentions Milk
>> Thistle to help liver function.  First, does it really do anything?
[quoted text clipped - 21 lines]
>
> cactus jammies (probably starting 72 week combo tx sometime next year)

Good to hear from you, CJ.
What's this about tx next year? Will it be extended "regular" treatment or
will you be adding more ammo to the mix?

To the newbies: I'll definitely vouch for Cactus Jammies as our resident
alternative treatment expert. He's done some excellent research and has
given us all good, solid information on the use of herbals to help the liver
(not as a substitute for peg-inf/riba).
CatEyes - 29 Oct 2009 21:58 GMT
>> Almost every site I've gone to for information about Hep C mentions Milk
>> Thistle to help liver function.  First, does it really do anything?
[quoted text clipped - 21 lines]
>
> cactus jammies (probably starting 72 week combo tx sometime next year)

Thanks!  I've printed this note to put with some of the other research I've
done.  Personally I'd rather follow anecdotal recommendations than second
hand info from somebody trying to sell something (or someone with an obvious
axe to grind - or web site to promote ;>), so your post goes to the top of
the queue.

Hugs,

CatNipped
helmsman@wowway.com - 03 Nov 2009 22:52 GMT
>Almost every site I've gone to for information about Hep C mentions Milk
>Thistle to help liver function.  First, does it really do anything?  Second,
[quoted text clipped - 5 lines]
>
>CatNipped

Is there a medically recommended dose?
I am thinking of buying ground seed.
Who sells it in a ground form.
Cactus Jammies - 04 Nov 2009 05:16 GMT
get something with a blend of the extract (80% Silymarin) and the ground
seed.  Both are beneficial but the Silymarin is most important.  If you have
chronic hep c, the book I mentioned in the string (Herbs, Hepatitis C and
the Liver) recommends a certain (forgotten right now) concentration, with a
dosage of two capsules times four doses per day.  That stuff has to make it
to your blood stream and eating Milk Thistle by itself will not do the
trick.
hope this helps
cactus jammies

>>Almost every site I've gone to for information about Hep C mentions Milk
>>Thistle to help liver function.  First, does it really do anything?
[quoted text clipped - 10 lines]
> I am thinking of buying ground seed.
> Who sells it in a ground form.
 
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