Vitamin E has been found helpful to some extent in non alcoholic fatty liver disease along with UDCA before cirrhosis has set in. It helps to reduce inflammation.After occurrence of cirrhosis its effect is minimal if not at all. Cirrhosis is a state of hyperdynamic circulation. It can produce murmurs in the pulmonary/tricuspid area. Rarely seen nowadays, long standing mitral  or tricuspid stenosis or constrictive pericarditis can produce cirrhotic changes in the liver from congestive hepatopathy. These will have their respective murmurs.

Dear Dr. Ray, I disagree with your response – as a Herpetologist, I do not recommend vitamin E nor do I recommend Urso-Deoxy Cholic Acid (UDCA) Non-Alcoholic Fatty Liver Disease (NAFLD). Yet I agree with your explanation of the associations of liver disease leading to heart murmurs and vice versa.

Why do I disagree with Vitamin E and/or UDCA as a possible treatment of Non-Alcoholic Seato-Hepatitis (NASH)? The following work has free access, and gives a good overview about this topic and the recent findings in this field:  World J Gastroentrol 2014, Non-alcoholic fatty liver disease: What has changed in the treatment since the beginning? [see link]

For UDAC the authors state: "In a pilot study, a possible benefit of ursodeoxycolic acid was suggested in the treatment of NASH. However, this was not confirmed in larger randomized controlled trials using histological assessment. According to the latest guideline issued by the AASLD, ursodeoxycolic acid therapy is not recommended for the treatment of NAFLD or NASH."

For vitamin E the authors state: "The largest randomized controlled study on vitamin E, the PIVENS trial, demonstrated a greater histological improvement in inflammation in non-diabetic patients with biopsy-proven NASH compared with the placebo and pioglitazone groups... However, it is crucial to note that there have been some serious concerns regarding the safety of long-term vitamin E treatment. Meta-analyses have reported an increase in all-cause mortality with vitamin E treatment, while other studies have not reported this association. Moreover, vitamin E at a dose of 400 IU/d has been found to be associated with an increased risk of prostate cancer."

This association of vitamin E and pro-cancerogenic effects is not that surprising. Going back to1994, the NEJM published a randomised trial named: The effect of vitamin E and beta carotene on the incidence of lung cancer and other cancers in male smokers. [conduced by] The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group (DOI: 10.1056/NEJM199404143301501). This trial did not show any benefit for neither treatment, and discussed a possible harm. These findings have triggered much response (DOI: 10.1056/NEJM199409013310912), one of the commenting authors, Dr. Marantz, recalculated the data and claimed: "What was not comprehensible, and was quite disturbing, was the irresolute manner in which the findings of the study were interpreted by its authors and those of the accompanying editorial. The authors concluded that no overall reduction in the incidence of lung cancer was found and that the study “raises the possibility that these supplements may... have harmful as well as beneficial effects.” In fact, because of its methodologic rigor, the study clearly demonstrates an increase in the incidence of lung cancer; that increase is probably around 18 percent, and one can be 95 percent certain that it is somewhere between a 3 percent and a 36 percent increase."

Feel free to follow these references to make up your own mind. I mentioned the 20 years old trial by The Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group to show that medicine often recycles approaches that failed years ago to fail again. The most disappointing issue is the fact, that I am not sure the investigators even are aware that their "brand new" approach failed in another setting decades ago.

Never the less, all the best, Bruno Strebel, MD

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4202350/

Dear Dr.Strebel,

I agree with what you have pointed out. With reference to the  discussion, I have mentioned that there is no role of the drugs in cirrhosis. The other point is that NASH by itself is not a fully curable disease and hence both UDCA and Vitamin E are given for short time periods [may 6m - 1 year] for normalisation of liver enzymes if found elevated. There is no question of giving both drugs for years together. At least I have found it extremely useful in my patients.