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. 2020 Apr;40(4):825-829.
doi: 10.1111/liv.14393. Epub 2020 Feb 11.

Ashwagandha-induced liver injury: A case series from Iceland and the US Drug-Induced Liver Injury Network

Helgi K Björnsson  1 , Einar S Björnsson  1 , Bharathi Avula  2 , Ikhlas A Khan  2 , Jon G Jonasson  1 , Marwan Ghabril  3 , Paul H Hayashi  4 , Victor Navarro  5
Affiliations

Ashwagandha-induced liver injury: A case series from Iceland and the US Drug-Induced Liver Injury Network

Helgi K Björnsson et al. Liver Int. 2020 Apr.

Abstract

Background & aims: Ashwagandha (Withania somnifera) is widely used in Indian Ayurvedic medicine. Several dietary supplements containing ashwagandha are marketed in the US and Europe, but only one case of drug-induced liver injury (DILI) due to ashwagandha has been published. The aim of this case series was to describe the clinical phenotype of suspected ashwagandha-induced liver injury.

Methods: Five cases of liver injury attributed to ashwagandha-containing supplements were identified; three were collected in Iceland during 2017-2018 and two from the Drug-Induced Liver Injury Network (DILIN) in 2016. Other causes for liver injury were excluded. Causality was assessed using the DILIN structured expert opinion causality approach.

Results: Among the five patients, three were males; mean age was 43 years (range 21-62). All patients developed jaundice and symptoms such as nausea, lethargy, pruritus and abdominal discomfort after a latency of 2-12 weeks. Liver injury was cholestatic or mixed (R ratios 1.4-3.3). Pruritus and hyperbilirubinaemia were prolonged (5-20 weeks). No patient developed hepatic failure. Liver tests normalized within 1-5 months in four patients. One patient was lost to follow-up. One biopsy was performed, showing acute cholestatic hepatitis. Chemical analysis confirmed ashwagandha in available supplements; no other toxic compounds were identified. No patient was taking potentially hepatotoxic prescription medications, although four were consuming additional supplements, and in one case, rhodiola was a possible causative agent along with ashwagandha.

Conclusions: These cases illustrate the hepatotoxic potential of ashwagandha. Liver injury is typically cholestatic or mixed with severe jaundice and pruritus, but self-limited with liver tests normalizing in 1-5 months.

Keywords: dietary supplements; drug-induced liver injury; liver.

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Conflict of interest statement

Conflicts of interest: The authors have no conflicts of interest to declare.

Figures

Figure 1:
Figure 1:
Liver biopsy from case 1 showing liver tissue with mild mononuclear cell inflammatory infiltrate and prominent canalicular cholestasis.
See this image and copyright information in PMC

Comment in

  • An Eye into the Allegations about Ashwagandha.
    Mohan A, Menon A, Chacko J, Mohan P, Robin DT. Mohan A, et al. Liver Int. 2020 Aug;40(8):2034-2035. doi: 10.1111/liv.14459. Epub 2020 Apr 21. Liver Int. 2020. PMID: 32267603 No abstract available.
  • Ashwagandha as a cause for liver injury.
    Björnsson HK, Björnsson ES, Avula B, Khan IA, Jonasson JG, Ghabril M, Hayashi PH, Navarro V. Björnsson HK, et al. Liver Int. 2020 Aug;40(8):2035-2036. doi: 10.1111/liv.14551. Epub 2020 Jun 11. Liver Int. 2020. PMID: 32475004 No abstract available.

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