Drug and herb induced liver injury: Council for International Organizations of Medical Sciences scale for causality assessment

Table 6 Changes of the Council for International Organizations of Medical Sciences gradings with considering the risk factors

HILI study	Scored risk		CIOMS assessment with RF	CIOMS assessment without RF	Grading change	Cases with references
	Alcohol	Age	Score/grading	Score/grading
Kava	0	+	+1/Unlikely	0/Excluded	↓	Case 2[12]
Kava	+	+	-1/Excluded	-3/Excluded	0	Case 4[12]
Kava	0	+	+1/Unlikely	0/Excluded	↓	Case 10[12]
Kava	0	+	-1/Excluded	-2/Excluded	0	Case 17[12]
Kava	0	+	+8/Probable	+7/Probable	0	Case 20[12]
Kava	0	+	-1/Excluded	-2/Excluded	0	Case 24[12]
Kava	0	+	-1/Excluded	-2/Excluded	0	Case 26[12]
Kava	0	+	+5/Possible	+4/Possible	0	Case 1[46]
Kava	0	+	+6/Probable	+5/Possible	↓	Case 2[46]
Kava	0	+	+8/Probable	+7/Probable	0	Case 3[46]
Ayurvedic herbs	0	+	+8/Probable	+7/Probable	0	Case 1[30]
Black cohosh	0	+	-2/Excluded	-3/Excluded	0	Case 1[47]
Black cohosh	+	0	-2/Excluded	-3/Excluded	0	Case 2[47]
Black cohosh	+	0	-3/Excluded	-4/Excluded	0	Case 3[47]
Black cohosh	0	+	+1/Unlikely	0/Excluded	↓	Cases 4[48]
Black cohosh	+	0	+1/Unlikely	0/Excluded	↓	Case 9[48]
Black cohosh	+	0	-1/Excluded	2/Excluded	0	Case 2[36]
Black cohosh	0	+	-1/Excluded	-2/Excluded	0	Case 8[36]
Black cohosh	0	+	-1/Excluded	-2/Excluded	0	Case 10[36]
Black cohosh	+	0	0/Excluded	-1/Excluded	0	Case 16[36]
Black cohosh	+	0	0/Excluded	-1/Excluded	0	Case 17[36]
Black cohosh	+	0	-2/Excluded	-3/Excluded	0	Case 21[36]
Greater Celandine	0	+	+9/Highly probable	+8/Probable	↓	Case 2[37]
Greater Celandine	0	+	+10/Highly probable	+9/Highly probable	0	Case 5[37]
Greater Celandine	0	+	+6/Probable	+5/Possible	↓	Case 8[37]
Greater Celandine	0	+	+5/Possible	+4/Possible	0	Case 11[37]
Greater Celandine	0	+	+8/Probable	+7/Probable	0	Case 14[37]
Greater Celandine	0	+	+5/Possible	+4/Possible	0	Case 15[37]
Greater Celandine	0	+	-1/Excluded	-2/Excluded	0	Case 16[37]
Greater Celandine	0	+	+8/Probable	+7/Probable	0	Case 17[37]
Greater Celandine	0	+	0/Excluded	-1/Excluded	0	Case 18[37]
Greater Celandine	+	0	+4/Possible	+3/Possible	0	Case 21[37]
Greater Celandine	0	+	+5/Possible	+4/Possible	0	Case 4[32]
Greater Celandine	0	+	+6/Probable	+5/Possible	↓	Case 9[32]
Greater Celandine	0	+	+3/Possible	+2/Possible	0	Case 11[32]
Greater Celandine	0	+	+7/Probable	+6/Probable	0	Case 16[32]
Greater Celandine	0	+	+7/Probable	+6/Probable	0	Case 17[32]
Greater Celandine	0	+	+5/Possible	+4/Possible	0	Case 18[32]
Greater Celandine	0	+	+7/Probable	+6/Probable	0	Case 20[32]
Pelargonium sidoides	0	+	0/Excluded	-1/Excluded	0	Case 1[38]
Pelargonium sidoides	0	+	+2/Unlikely	+1/Unlikely	0	Case 7[38]
Pelargonium sidoides	0	+	+1/Unlikely	0/Excluded	↓	Case 14[38]
Pelargonium sidoides	0	+	+1/Unlikely	0/Excluded	↓	Case 2[39]
Pelargonium sidoides	0	+	+4/Possible	+3/Possible	0	Case 3[39]
Pelargonium sidoides	0	+	0/Excluded	-1/Excluded	0	Case 5[39]
Pelargonium sidoides	0	+	0/Excluded	-1/Excluded	0	Case 8[39]
Pelargonium sidoides	0	+	+2/Unlikely	+1/Unlikely	0	Case 9[39]
Pelargonium sidoides	0	+	+2/Unlikely	+1/Unlikely	0	Case 11[39]
Pelargonium sidoides	0	+	0/Excluded	-1/Excluded	0	Case 13[39]
Herbalife	0	+	+7/Probable	+6/Probable	0	Case 1[33]
Herbalife	0	+	+2/Unlikely	+1/Unlikely	0	Case 2[33]
Herbalife	0	+	+2/Unlikely	+1/Unlikely	0	Case 4[33]

Based on details described in Table 5, in all 52 patients with evident risks factors of alcohol, age ≥ 55 years, or both, scores and Council for International Organizations of Medical Sciences (CIOMS) gradings with risk factors were compared with conditions without risk factor consideration. In 9 patients, there was a CIOMS downgrading when risk factors would not have been considered. RF: Risk factor.