Does ashwagandha affect liver enzymes?

Ashwagandha and Liver Enzyme Effects

Ashwagandha can cause significant liver enzyme elevations and potentially serious liver injury in some individuals, particularly with prolonged use or in those with pre-existing liver conditions.

Evidence of Hepatotoxicity

Recent evidence demonstrates that ashwagandha (Withania somnifera) supplements have been associated with liver injury characterized by:

• Elevated liver enzymes (ALT, AST, ALP, GGT) 1, 2, 3
• Cholestatic or mixed pattern of liver injury 2
• Hepatocellular damage with R-values ranging from 1.4 to 11.1 1, 4
• Onset of symptoms typically within 2-12 weeks of starting supplementation 2

Clinical Presentation

When ashwagandha causes liver injury, patients typically present with:

• Jaundice (yellowing of skin and eyes)
• Pruritus (itching)
• Fatigue and lethargy
• Nausea
• Dark-colored urine
• Abdominal discomfort 1, 2, 4

Risk Factors and Severity

The severity of ashwagandha-induced liver injury varies:

• Most cases are self-limiting with normalization of liver tests within 1-5 months after discontinuation 2
• More severe in patients with pre-existing liver disease
• Can progress to acute-on-chronic liver failure in those with underlying chronic liver disease, with reported mortality 3
• One case required liver transplantation 1

Causality Assessment

The Roussel Uclaf Causality Assessment Method (RUCAM) has been used to establish the relationship between ashwagandha and liver injury:

• Multiple case reports show "probable" causality with RUCAM scores of 7 1, 4
• Chemical analysis of supplements confirmed the presence of ashwagandha without adulteration or contamination 3

Histopathological Findings

Liver biopsies in affected patients have shown:

• Acute cholestatic hepatitis 2
• Hepatocellular necrosis
• Lymphocyte/eosinophil predominant portal-based inflammation 3

Monitoring Recommendations

For individuals taking ashwagandha:

• Baseline liver function tests before starting supplementation
• Regular monitoring of liver enzymes, particularly in the first 2-3 months
• Immediate discontinuation if symptoms of liver injury develop
• Follow-up liver function tests within 1-2 weeks if abnormalities are detected 5

Special Populations at Risk

Extra caution is warranted in:

• Patients with pre-existing liver disease (highest risk group) 3
• Those taking other hepatotoxic medications
• Individuals who consume alcohol regularly
• Patients taking medications metabolized by the liver due to potential interactions 5

Management of Suspected Ashwagandha-Induced Liver Injury

1. Immediate discontinuation of ashwagandha
2. Monitor liver function tests until normalization
3. Supportive care for symptom management
4. Consider ursodeoxycholic acid for cholestatic symptoms 4
5. In severe cases, referral to hepatology and consideration of intensive interventions may be necessary 6

Ashwagandha should be used with caution, and patients should be educated about the potential risk of liver injury. Healthcare providers should include ashwagandha in their differential diagnosis when evaluating patients with unexplained liver enzyme elevations or acute liver injury.