Al-Hijamah (Prophetic Wet Cupping Therapy) is a Novel Adjuvant Treatment for Viral Hepatitis That Excretes Viral Particles and Excess Ferritin Percutaneously, Synergizes Pharmacotherapy, Enhances Antiviral Immunity and Helps Better HCC Prevention and Treatment: A Novel Evidence-Based Combination with Prophetic Medicine Remedies

Figures & data

Figure 1 HCC cells exhibit the Warburg effect.

Figure 2 There is a structural similarity between the fenestrated capillaries in the skin dermis (superficial subepidermal capillary plexus) and the renal glomerular capillaries.

Notes: (A) The skin may act as a super-kidney during Al-hijamah for proper excretion of the disease-causing substances. (B) Scientific bases of Taibah theory for explaining how Al-hijamah (wet cupping therapy of prophetic medicine) works in treating different diseases. Data from these studies.^16,17.

Box 1 Importance of Decreasing Serum Ferritin in Patients Having Viral Hepatitis. Serum Ferritin Was Significantly Decreased via Direct Excretion Using Al-Hijamah

Serum ferritin is a strong predictor of treatment response in viral hepatitis.^Citation19 Increased serum ferritin is in chronic hepatitis C patients is associated with a decreased response to interferon therapy.^Citation20 Patients with chronic hepatitis C may be more sensitive to iron hepatotoxicity than patients with hemochromatosis.^Citation21 Increased serum ferritin marks iron-induced oxidative stress that contributes to chronicity of hepatitis C, non-alcoholic and alcoholic liver diseases.^Citation22 Hyperferritinemia and hepatic iron overload are commoner in chronic hepatitis B and more severe in patients co-infected with hepatitis D virus.^Citation23 Increased serum ferritin correlates with severe necro-inflammatory activity in hepatitis patients.^Citation24 High serum ferritin, ALT, γ-glutamyl transpeptidase, liver iron concentration, and increased liver stiffness are markers of HCV viremia.^Citation25 Iron overload plays a role in hepatic fibrogenesis and carcinogenesis. Hyperferritinemia in hepatic patients can be explained by cellular necrosis, synthesis increase, inflammation and iron overload.^Citation26 Increased iron accumulation in the liver is a risk factor for hepatocellular carcinoma in patients with alcoholic cirrhosis ± nonalcoholic hepatosteatosis.^Citation27 Phlebotomy (decreases serum ferritin and iron overload) improves therapeutic response to interferon in patients with chronic hepatitis C.^Citation28 Iron depletion was associated with a biochemical response in 22% of patients who did not respond to interferon monotherapy.^Citation29 Iron depletion in patients with chronic hepatitis C who have elevated serum ferritin values induces a significant reduction in necro-inflammatory activity (notable decrease in average alanine aminotransferase values) and improves their response to subsequent treatment with interferon.^Citation30

Note: Data from El-Shanshory et al.¹⁸

Box 2 Suggested Therapeutic Benefits of Al-Hijamah to Viral Hepatitis Patients

Increasing the antiviral immunity^Citation31 Excreting viral particles percutaneously (Taibah mechanism). Excreting disease-causing substances as ferritin and free radicals.^Citation18 Potentiating the pharmacological effects of current therapeutics. Exerting tissue-protective effects (better to be combined with other prophetic medicine remedies as nigella sativa).^Citation32 Normalizing serum liver enzymes (better to be combined with other prophetic medicine remedies as nigella sativa).^Citation32 Excreting excess lipids, eg, cholesterol and triglycerides (better to be combined with other prophetic medicine remedies as nigella sativa).^Citation32 Excreting abnormal proteins as antigen-antibody complexes (Taibah theory). Treating associated co-morbidities that may augment hepatitis and other viral infections, eg, immune suppression.^Citation33,Citation34 Alleviating some drugs-induced side effects, eg, Ribavirin reduces absolute lymphocytes counts in Hepatitis C virus infection^Citation35 while Al-hijamah induces lymphocytosis.^Citation31

Figure 3 Pathogenesis of hepatitis viral infection.

Notes: Causative pathological substances of viral hepatitis (viral particles, viral antigens, viral antigen-antibody complexes, inflammatory cytokines, free radicals and others) are present in the blood of hepatitis patients and may leak into the interstitial fluids (interstitial fluids are formed through filtration of blood plasma). They cannot be excreted in urine and become retained favoring a chronic viral hepatitis status. Al-hijamah is capable of excreting all the causative pathological substances.

Figure 4 First suction step during Al-hijamah.

Notes: (A) Applying suction pressure (inside sucking cups) causes creation of skin upliftings that gradually increase in size inside the sucking cups. Skin upliftings inside sucking cups contain interstitial fluids, some filtered fluids and causative pathological substances. (B) Skin sterilization. (C) Applying sucking cups to the upper back region. (D) Applying sucking cups to the right hypochondrium (right subcostal region). (E) Formation of the skin upliftings where the skin enters inside the sucking cups causing widened peri-capillary spaces and increased filtration of the fenestrated dermal capillaries (beneath the skin barrier). (F) Cup margins leave a temporary sign immediately after removal of the cups and before scarification step.

Figure 5 Skin scarification step (shartat mihjam).

Notes: (A) Scarifying the skin superficially helps opening the skin barrier and excretion of the collected fluids with causative pathological substances (in agreement with Taibah mechanism). (B) Ideal skin scarifications (reflect the hand skills of the hijamatologist) are superficial, longitudinal, vertical, productive, in parallel rows, to the inside of the cup margin, equally done and distributed and covers the whole cup position. (C) The bloody excretion increases when adding the sucking cups. (D) The bloody excretion is the sum of the excretion coming from all the skin scarifications.

Figure 6 Upon applying the sucking cups again (with opening skin barrier), collected fluids containing causative pathological substances get out completely.

Notes: (A) Negative (suction) pressure is transmitted to around the skin capillaries to increase the capillary filtration at both capillary ends, which results in clearance of the capillary blood from causative pathological substances (in agreement with the evidence-based Taibah theory). (B) The bloody excretion becomes clotted. (C) The bloody excretion is usually small in amount and not profuse, ie, no major blood loss occurs. (D) The site of cups application and scarifications after finishing Al-hijamah.

Figure 7 Restoration of homeostasis (through excretion of the causative pathological substances).

Notes: This decreases the virus load and allows the immune system to overcome hepatitis infection and potentiates the therapeutic effects of pharmacological treatments (in agreement with Taibah theory).

Figure 8 Natural prophetic medicine remedies.

Notes: (A) Medicinal plants. (B) Prophetic medicine drinks. Prophetic medicine foods.

Box 3 Nigella Sativa Benefits to Viral Hepatitis and HCC Patients

Hepatoprotective Ameliorates acute endotoxemia-induced liver dysfunction in rats.^Citation43 Improves diabetic control, weight gain in streptozotocin-induced experimental diabetes.^Citation44 Protects viability and architecture of the hepatocytes and islet cells in streptozotocin-induced experimental diabetes.^Citation44 Exerts hepato-protective activity (protects against ischemia-reperfusion injury).^Citation45 Behaves as an agonist of PPAR-gamma receptors and is suitable as a treatment for diabetes, obesity and metabolic syndrome. Protects against liver damage induced by Schistosoma mansoni (reduces worm number, ova deposition, potentiates praziquantel anti-schistosomiasis effect and protects the liver functions during bilharzizsis).^Citation45 Exerts hepatoprotective effects against hypervitaminosis A and enhances the immunological functions (potent inducer of IgG and IgM).^Citation46 Protected the liver cells against injury in cholestatic jaundice (during bile duct ligation).^Citation47 Exerts therapeutic and anti-oxidant effects against lipopolysaccharides-induced inflammation in diabetic patients.^Citation48 Antifibrotic effect Attenuates hepatic fibrosis.^Citation49 Nutritional supplement Nigella sativa improves malnutrition associated with metabolic diseases, eg, Refsum’s disease.^Citation50 Induces significant hyperfibrinogenemia, significant transient prothrombin time prolongation and thrombin time reduction.^Citation51 Antioxidant Prevents loss of hepatic GSH in toluene-induced oxidative stress.^Citation52 Improves greatly (especially thymoquinone-rich fraction) the plasma antioxidant capacity and expression of antioxidant genes in hypercholesterolemic animals.^Citation53 Thymoquinone induces hepatic quinone reductase and glutathione transferase and plays a possible role in protection against chemical carcinogenesis and toxicity.^Citation54 Protects maternal liver and embryos against free radical-induced damage in diabetic animals.^Citation55 Antimicrobial Exerted protective effects against murine cytomegalovirus infection.^Citation56 Exerts in vivo antifungal effects.^Citation57 Exerts strong biocidal effects against all stages of Schistosoma parasite (miracidia, cercaria and adult worm).^Citation45 Decreases hepatitis viral load, improves response to oxidative stress and improves the clinical condition and glycemic control in hepatitis patients.^Citation42 Anticancer effects Protects against DNA damage, colon carcinogenesis and liver damage induced by azoxymethane.^Citation58 Inhibits benzo(a)pyrene-induced forestomach carcinogenesis in mice.^Citation59 Immunopotentiation Exerts hypoglycemic and immunopotentiation effects in streptozotocin-induced diabetic hamsters.^Citation60 Antitoxic Protects against cisplatin-induced toxicity in rats.^Citation61 Inhibits effects of 20-methylcholanthrene-induced fibrosarcoma tumorigenesis.^Citation62 Protects against aflatoxin-induced hepatotoxicity.^Citation63 Exert antimutagenic activity.^Citation64 Helps in resolution of hepato-renal toxicity induced by bromobenzene.^Citation65 Induces hepatoprotective effects against isoniazide-induced hepatotoxicity in rabbits.^Citation66 Protects against hepatotoxic metals, eg, lead, CCL4 and cadmium.^Citation45 Anticancer Has a chemo-preventive effect against the progression to liver cancer.^Citation67 Attenuates diethyl nitrosamine-induced hepatic carcinogenesis (through antioxidant mechanisms).^Citation54 Protects liver and tissues against chemotherapy (cyclophosphamide)-induced hepatotoxicity.^Citation55 Exerts antineoplastic effects on hepatocellular carcinoma cells.^Citation62 Miscellaneous Enhances memory, attention and cognition while preserving the normal cardiac, liver and kidney functions.^Citation68 Thymoquinone is safe with no harmful effects.^Citation69 Has no or minimal side effects (at high doses) as regards liver functions.^Citation70

Box 4 Natural Honey Benefits to Viral Hepatitis and HCC Patients

Hepato-tonic effects Honey protected the ultrastructure of hepatocytes during experimental obstructive jaundice.^Citation71 Exerts significant antibacterial activity (against staphylococcus aureus).^Citation72 Honey is a prebiotic food that re-engineers the gut microbiome towards a healthy state & decreases significantly gut bacterial colonization.^Citation73 Exerts antimicrobial properties and bifidogenic effects.^Citation74 Improves intestinal microflora.^Citation74 Antitoxic effects Hepatoprotective effects, eg, honey protects against carbon tetrachloride-induced hepatonephrotoxicity Protects against toxicity of mycotoxins (of Aspergillus parasiticus and Aspergillus ochraceus) and ochratoxins.^Citation74 Protects against cadmium-induced hepatotoxicity.^Citation75 Decreases side effects and toxic effects of concomitantly administered therapeutics, eg, toxic effects of pentylenetetrazole.^Citation76 Antioxidant Contains active ingredients, eg, chrysin that possesses potent anti-oxidant and cancer chemopreventive activities.^Citation77 Propolis decreases hepatocytes apoptosis, protects hepatocytes against oxidative stress and improves hepatic histomorphology in experimental obstructive jaundice.^Citation78

Box 5 Costus Benefits to Viral Hepatitis and HCC Patients

Anti-hepatitis Suppress hepatitis B virus surface antigen and envelop antigen gene expression in human hepatoma cells.^Citation79 A related herb (Saussurea grandifolia) is used in Korea for treating hepatitis and hematuria.^Citation80 Hepatoprotective Protects the liver cells against D-galactosamine and lipopolysaccharide-induced hepatitis.^Citation81 Exhibits hepatoprotective, anti-inflammatory, anti-ulcer and anticancer activities.^Citation82 Anticancer Dehydrocostuslactone (an extract of saussurea lappa) induces apoptosis in liver cancer cells (via an endoplasmic reticulum stress mechanism).^Citation83 Cynaropicrin (in Saussurea lappa extract) suppressed the viability of cancer cells with minimal toxicity to hepatocytes.^Citation84 Antioxidant Potent antioxidant effects (scavenges DPPH, nitric oxide, superoxide radicals along with its ability to inhibit lipid peroxidation and glutathione oxidation).^Citation79,Citation82

Box 6 Ajwa Benefits to Viral Hepatitis and HCC Patients

Antitoxic Protects hepatic functions and hepatocyte structure against aflatoxin-induced hepatotoxicity (together with nigella sativa).^Citation89 Protects hepatocytes against lead-induced hepatotoxicity.^Citation90 Proved to treat tissue damage due to toxin exposure through many mechanisms.^Citation88 Ajwa dates reverted HCC cells to normal hepatocytes’ morphology and behavior.^Citation87 Exerts potent antitoxic mechanisms.^Citation88 Exerts potent antioxidant effects Contain large amounts of antioxidants, eg, melatonin and vitamin E. Protects against oxidative damage and hepatotoxicity induced by subchronic exposure to dimethoate.^Citation91 Boosted up the antioxidant enzymes that stabilize biological molecules in the liver tissue. Antiatherogenic nutrient Exerted a significant decrease in serum triacylglycerol and oxidative stress and did not worsen serum glucose and lipid/lipoprotein patterns. Exerted antimutagenic, anti-inflammatory, gastroprotective, hepatoprotective, nephroprotective, anticancer and immunostimulant activities. Nutritional supplement Is a potent safe nutritional supplement (main chemical components include carbohydrates, dietary fiber, enzymes, protein, fat, minerals, vitamins, phenolic acids and carotenoids).^Citation92 Protein content in dates may treat hypoproteinemia of liver diseases.

Table 1 Comparison Between Al-Hijamah (Wet Cupping Therapy) and Phlebotomy (Venesection)

	Phlebotomy (Venesection)	Al-Hijamah (Wet Cupping Therapy of Prophetic Medicine)
Definition	Venesection, a hematological treatment that involves cutting (or puncturing) a vein to cause it to bleed, reduces the quantity of noxious substances in blood or blood-related chemicals inside the vessel wall.	A minor therapeutic percutaneous treatment in which blood is filtered at the fenestrated dermal skin capillaries under the influence of the suction pressure in the sucking cups. The excretory function is carried out by clearing blood and interstitial fluids of pathogenic agents that, depending on the etiology and pathogeneses of the various diseases, cause those diseases.
Worldwide practice	Practiced worldwide	Very minimal. Not receiving enough attention worldwide despite its marvelous therapeutic benefits in all medical specialties.
Therapeutic indications	To reduce the quantity or concentration of an element or component of the blood, such as the red cell mass and hematocrit value in polycythemia and the iron overload in thalassemia and hemochromatosis.	Treats all disease indications that benefit from blood and tissues clearance from causative pathological substances including:  1. Musculoskeletal pain conditions  2. Hematological conditions as hemolysis and iron overload  3. Cardiovascular diseases as hypertension  4. Inborn metabolic errors as galactosemia  5. Dermatological conditions as urticaria.  6. Neuropsychiatric conditions as headache.  7. Malignancy  8. Metabolic conditions as gout  9. Viral conditions as hepatitis and AIDS  10. Respiratory and ENT conditions
How to perform?	Venesection and bloodletting (donation) in a donation bag.	6 Ss:  1. Selecting the appropriate anatomical areas for the application of sucking cups  2. Strict skin sterilization (at the beginning)  3. Skin suction (1st time using sucking cups)  4. Skin scarifications  5. Skin suction (2nd time using sucking cups)  6. Strict skin sterilization (at the end).
Side effects	Rare. Anemia, phlebitis, bleeding.	Rare. Skin blebs (Taibah sign),^Citation93 transient post-cupping marks, transient skin bruises.
Nature of excretion	Whole blood.	A mixture of components forming a bloody fluid that contains some blood cells, hemolyzed blood cells, filtered fluids (at the fenestrated dermal capillaries), interstitial fluids, and a significant proportion of the causative pathological substances.
Quantity of excreted causative pathological substances	A proportionate amount of the causative pathological substances ie, removal of 500 cc whole blood (out of 5 Liters) decreases 10% of substances concentration.	Maximal (a filtrate at the dermal capillaries) and not related to the blood component in the bloody excretion. In a previous report, removal of about 20 cc of the bloody excretion during Al-hijamah clears the circulation from about 25% of the excess ferritin and 69% of malondialdehyde.^Citation18
The need for subsequent blood transfusion	None if phlebotomy was done properly.	No need as the amount of blood loss is minimal.
Can it be done for certain anemias as thalassemia?	No. To avoid exaggerating the anemic condition.	Yes. It is recommended (minimal blood loss) to excrete the excess iron overload, free radicals and other causative pathological substances. It did not increase the anemic condition.
Repeatability	Repeatable according to patient’s condition and indications.	Repeatable according to patient’s condition and indications.
Other names	Venesection, phlebotomy, fasd (in Arabic medicine).	Triple S technique.
A plenty of therapeutic benefits eg, analgesic effect	None.	Present.

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