TUDCA vs Essential phospholipids: what to choose and for whom

On strength-sport forums TUDCA is called the «gold standard» of liver protection, while pharmacies most often offer essential phospholipids. The editorial team examined for whom and in which situations each agent may make sense, where study data ends and marketing begins, and how not to go wrong with the choice.

First - the question, not the agent

Before comparing TUDCA and phospholipids, it is worth honestly answering why an agent is needed at all. «For prevention» is not an indication. If liver tests are normal, weight is under control, alcohol is in moderate amounts and there are no hepatotoxic drugs, extra «support» is unlikely to give a measurable benefit.

But if there are abnormalities, their nature determines the next steps. A predominant rise in ALT and AST points to damage to the liver cells, a predominant increase in alkaline phosphatase, GGT and bilirubin - to cholestasis. Fatty infiltration on ultrasound indicates a metabolic problem, which is solved mainly through lifestyle.

In people who train intensively, one more factor is added to this list: the muscular origin of ALT and AST. A study by Pettersson and co-authors showed that after a hard strength workout in healthy men these values can rise several-fold, mimicking liver injury. So before deciding to take any agent, tests should be interpreted in the context of training.

Only after it is clear what problem we are dealing with can we discuss whether an agent is needed and which one. And in most cases where there is a real disease, this is a decision for a doctor, not for a supplement buyer.

The profile of the person for whom TUDCA is considered

TUDCA is a bile acid, so it is logical to consider it where the problem is linked to bile. In a number of European countries TUDCA is registered as a medicinal product for dissolving cholesterol stones and for some cholestatic conditions. However, in clinical practice for these indications UDCA, with a larger evidence base, is used far more often.

The second group often mentioned is people with insulin resistance and obesity. A study by Kars and co-authors (2010) showed improved insulin sensitivity in the liver and muscles over four weeks. However, this is a single small study, and it gives no grounds to consider TUDCA a treatment for diabetes or fatty liver disease.

Who should not take TUDCA without a consultation: people with gallstone disease, especially with large stones or bouts of colic; with inflammation of the gallbladder; with obstruction of the bile ducts; pregnant and breastfeeding women. Caution is also needed in chronic bowel diseases, since bile acids can worsen diarrhoea.

In supplements TUDCA is most often offered in capsules of several hundred milligrams. In the Kars et al. study 1750 mg a day was used over four weeks, but this was a research dose for a specific metabolic question, not a universal recommendation.

When essential phospholipids are considered

EPL are most often offered for fatty liver disease and alcoholic injury. However, the largest and longest study in alcoholic disease (Lieber et al., 2003) did not show a slowing of fibrosis. So for a person who continues to consume alcohol, phospholipids will not help avoid the consequences.

In fatty liver disease the foundation remains weight loss: according to the EASL-EASD-EASO guidelines, a 7-10% reduction in weight is associated with improvement in liver fat content and histological indicators. EPL may be considered an auxiliary agent at the doctor's decision, but they do not replace a calorie deficit and physical activity.

Who EPL are not suitable for: people allergic to soy or peanuts (a cross-reaction is possible), and also those who expect a quick result. The effect in studies, if it was observed at all, developed over months of intake. If there is any doubt about tolerability, it is worth starting with a consultation.

Athletes and «liver protection on a cycle»

The most common reason people at the gym buy TUDCA is a wish to «cover the liver» while taking oral anabolic steroids. The editorial team is compelled to repeat: there are no randomised studies that would show that TUDCA or EPL prevent steroid cholestasis, hepatic peliosis or adenomas.

The review by Pope and co-authors (Endocrine Society, 2014) and the LiverTox database describe liver injury with the use of 17-alpha-alkylated steroids as dose-dependent and potentially severe. The logic of «I'll take more protection and then I can take more of the drug» is mistaken and dangerous.

A different situation is an athlete without any drugs in whom elevated ALT has been found. First it is worth ruling out the muscular origin of the enzymes: have tests done after 5-7 days without hard training, add GGT and creatine kinase. Often after this the «liver problem» disappears without any agents.

How to assess a product and not overpay

If the decision to take one has been made, the next question is quality. The market for TUDCA as a supplement is heterogeneous, and the price does not always reflect the content of active substance. For EPL it is important to distinguish standardised phosphatidylcholine preparations from ordinary lecithin, which contains far less phosphatidylcholine.

The editorial team advises paying attention to the following signs of quality:

• the exact name of the substance and the amount per capsule (TUDCA, not «bile acids» in general; for EPL - the phosphatidylcholine content as a percentage or in milligrams);
• the presence of a certificate of analysis from an independent laboratory;
• for EPL - information on the origin of the raw material and the absence of allergens;
• the absence of «proprietary blends» without disclosing the doses of individual components;
• registration as a medicinal product, if it exists in your country.

Taking TUDCA and EPL at the same time is theoretically possible, since the mechanisms differ, but there are no studies that would show an additional benefit of the combination. If you want to «hedge» with both agents, it is worth first honestly assessing whether the problem you are hedging against exists.

Finally, the cheapest and most effective «hepatoprotector» is what a person does not do: does not abuse alcohol, does not take hepatotoxic drugs without indications and does not gain excess weight. No agent from this article compensates for these factors.

Editorial conclusions

TUDCA is more logical to consider where the problem concerns bile, and essential phospholipids - as an auxiliary agent in metabolic liver injury. Neither has convincing evidence that would make it mandatory, and neither protects against hepatotoxic drugs.

For most people who train, the right order of action is to interpret tests taking into account the load, find out the cause of the abnormalities and only then discuss a specific agent with a doctor.

The difference in mechanisms of action we covered in detail in the article «TUDCA vs Essential phospholipids: what is the difference». We also recommend the editorial pieces «UDCA vs Silymarin: what to choose and for whom», on NAC and silymarin and on liver tests in athletes.

References

1. Kars M, Yang L, Gregor MF, et al. Tauroursodeoxycholic acid may improve liver and muscle but not adipose tissue insulin sensitivity in obese men and women. Diabetes. 2010;59(8):1899–1905.
2. Lieber CS, Weiss DG, Groszmann R, et al. II. Veterans Affairs Cooperative Study of polyenylphosphatidylcholine in alcoholic liver disease. Alcohol Clin Exp Res. 2003;27(11):1765–1772.
3. Gundermann KJ, Kuenker A, Kuntz E, Droździk M. Activity of essential phospholipids (EPL) from soybean in liver diseases. Pharmacol Rep. 2011;63(3):643–659.
4. European Association for the Study of the Liver (EASL), European Association for the Study of Diabetes (EASD), European Association for the Study of Obesity (EASO). EASL–EASD–EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. J Hepatol. 2016;64(6):1388–1402.
5. Pettersson J, Hindorf U, Persson P, et al. Muscular exercise can cause highly pathological liver function tests in healthy men. Br J Clin Pharmacol. 2008;65(2):253–259.
6. Pope HG Jr, Wood RI, Rogol A, et al. Adverse health consequences of performance-enhancing drugs: an Endocrine Society scientific statement. Endocr Rev. 2014;35(3):341–375.
7. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury. Androgenic steroids. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012–.