Ashwagandha Can Cause Liver Injury and Should Be Avoided or Used with Extreme Caution
Yes, ashwagandha (Withania somnifera) use can cause clinically significant liver disease, presenting primarily as cholestatic or mixed hepatocellular-cholestatic injury with jaundice, pruritus, and elevated liver enzymes. Multiple case series from Iceland, the United States, and India have documented this hepatotoxic potential, with some cases progressing to acute-on-chronic liver failure and death in patients with pre-existing liver disease 1, 2.
Clinical Presentation and Pattern of Injury
Ashwagandha-induced liver injury typically manifests as cholestatic or mixed hepatitis after 2-12 weeks of use 1. The characteristic features include:
- Severe jaundice and pruritus that can persist for 5-20 weeks, even after discontinuation 1
- Elevated liver enzymes with R-values ranging from 1.4-5.4, indicating cholestatic to mixed patterns 1, 3, 4
- Symptoms including nausea, lethargy, abdominal discomfort, and dark urine 1, 5
- Liver biopsy findings showing acute cholestatic hepatitis with hepatocellular necrosis and portal inflammation with lymphocytes/eosinophils 1, 2
High-Risk Populations
Patients with pre-existing chronic liver disease face particularly severe outcomes, including acute-on-chronic liver failure with high mortality 2. In the largest case series from India, all three patients with underlying chronic liver disease who developed ashwagandha-induced liver injury died 2. This represents a critical safety concern that distinguishes ashwagandha from many other herbal supplements.
Recovery and Prognosis
In patients without pre-existing liver disease, ashwagandha-induced liver injury is typically self-limited, with normalization of liver tests occurring within 1-5 months after discontinuation 1. However, the injury can be prolonged and severe, with one case requiring liver transplantation 3. One patient in the Indian series progressed to chronic herb-induced liver injury 2.
Causality Assessment
Chemical analysis of implicated supplements confirmed the presence of ashwagandha without contamination or adulteration, establishing the herb itself as the causative agent 1, 2. Causality assessment using the Roussel Uclaf Causality Assessment Method (RUCAM) consistently yielded scores of 7, indicating "probable" causation 3, 4.
Clinical Recommendations
Given the documented hepatotoxic potential, the following approach is warranted:
- Avoid ashwagandha entirely in patients with any pre-existing liver disease, as the risk of acute-on-chronic liver failure with fatal outcomes is unacceptably high 2
- Screen for ashwagandha use in any patient presenting with unexplained cholestatic liver injury, as this is an emerging and increasingly recognized cause of herb-induced liver injury 6
- Educate patients that ashwagandha supplements, despite being "natural," carry real hepatotoxic risk and should be discontinued immediately if symptoms of liver injury develop 2
- Monitor liver function tests if a patient insists on using ashwagandha, though avoidance is the safest strategy 6
Context Within Drug-Induced Liver Injury Guidelines
Herbal and dietary supplements, including ashwagandha, are recognized causes of drug-induced liver injury that must be ruled out when evaluating elevated liver tests 6. The consensus guidelines emphasize that all pharmaceuticals, over-the-counter products, and herbal supplements should be considered and excluded as potential causes of acute liver injury 6.
Important Caveats
- The latency period of 2-12 weeks means patients may not connect their symptoms to ashwagandha use, making careful medication history essential 1
- Young, healthy individuals are not protected from ashwagandha hepatotoxicity, as documented cases include patients in their 20s and 30s without risk factors 3, 4
- The widespread marketing of ashwagandha as a safe Ayurvedic supplement creates a false sense of security that must be countered with patient education about documented hepatotoxic risks 2