Ashwagandha, Turmeric, and More: Popular Herbal Supplements Linked to Liver Damage

Herbal and dietary supplements (HDSs) include a wide range of products consumed by millions of people to improve overall health and treat minor ailments. Around 5% to 12% of HDS products are plant-derived and contain complex multi-ingredient botanicals. Chemical analyses of herbal dietary products have linked them to confirmed liver toxicity and revealed frequent disparities between product labels and actual ingredients.

A study by JAMA Network Open examined six botanical ingredients associated with hepatotoxicity:

1. Turmeric (curcumin)

2. Green tea

3. Garcinia cambogia

4. Black cohosh

5. Red yeast rice

6. Ashwagandha

The Drug-Induced Liver Injury Network (DILIN), a multicenter U.S. observational program, collected and analyzed data from patients with hepatotoxic effects linked to various drugs and HDS products. The study found that the proportion of drug-induced liver injury (DILI) cases attributed to HDSs nearly tripled, rising from 7% in 2004-2005 to 20% in 2013-2014. ^[1]

The most commonly implicated botanical products in DILI cases include kratom, turmeric, green tea extract, and Garcinia cambogia, with potentially severe and even fatal liver injury.

The Dietary Supplement Health and Education Act (DSHEA) of 1994 classified herbal and dietary supplements as products containing nutritional ingredients such as vitamins, minerals, botanicals or herbs, amino acids, and other dietary substances intended to supplement the diet.

Since then, the use of herbal and dietary supplements has increased dramatically in the United States. According to the National Health and Nutrition Examination Survey (NHANES), usage rose from 32.9% in the 1971-1974 cohort to 52% in the 2011-2012 cohort and approximately 57.6% in the 2017-2018 cohort. The economic impact of the HDS industry in the U.S. is significant, with sales exceeding $150 billion in 2023, making it a competitor to the prescription drug market. ^[1]

Do Herbal and Dietary Supplements Affect the Liver?

Though herbal and dietary supplements are generally considered safe, studies suggest a potential link to hepatotoxicity.

Whatever medications or supplements one consumes pass through the liver, which plays a key role in their breakdown. While FDA-approved medications undergo rigorous testing, supplements do not go through the same regulatory process before reaching the market. However, this does not mean that every individual who consumes these products will experience liver damage.

Dr. Kingston, President of Regulatory and Scientific Affairs at Safety Call International, shared his views in a Global News Wire article, stating that the JAMA study exaggerates liver injury risks from the six botanical products.

Dr. Kingston expressed disappointment that the authors reported drug-induced liver injury cases in percentage terms for botanical products rather than comparing them with other medications. _[2]

Given the results, the JAMA study suggested that clinicians should be aware of the potential adverse effects of these largely unregulated products.

Six Herbal Dietary Products and Their Link to Hepatotoxicity

1. Turmeric
Turmeric, derived from the Curcuma longa root, is widely used for its health benefits, including reducing inflammation, improving antioxidant activity, lowering cancer risk, and promoting heart health. However, excessive turmeric consumption has been linked to an increased risk of kidney stone formation and liver injury. Studies have shown that consuming large quantities can contribute to acute liver injury, liver failure, and liver damage. However, using turmeric in small amounts in cooking is considered safe and beneficial.

2. Ashwagandha 

Ashwagandha (Withania somnifera) is an herb native to India and Southeast Asia, also known as Indian ginseng. It offers various health benefits, including enhancing brain function, reducing inflammation, and alleviating stress, pain, sleep disorders, skin diseases, diabetes, arthritis, and epilepsy. Additionally, it helps combat fatigue and counteracts aging effects.

However, studies have linked ashwagandha to liver injury, potentially due to excessive consumption, contamination with impurities, or high concentrations of its extracts.

3. Green tea

Green tea is rich in antioxidants, which help reduce inflammation and protect against cancer, heart disease, obesity, and diabetes. However, excessive consumption of green tea extract, commonly found in herbal and dietary supplements, has been associated with liver damage.

The U.S. National Institute of Diabetes and Digestive and Kidney Diseases has warned that green tea extract is linked to liver injury.

The acute hepatotoxicity caused by turmeric appears to be idiosyncratic and possibly immunologically mediated. The HLA-B*35:01 allele has been associated with liver injury from turmeric, green tea, Garcinia cambogia, and Polygonum multiflorum. These four herbs contain bioactive polyphenols, which may contribute to hepatotoxicity.

4. Garcinia Cambogia

Garcinia cambogia, derived from the Malabar tamarind tree native to Southeast Asia, has been traditionally used to treat gastrointestinal issues and rheumatism. It is also marketed as an appetite suppressant and weight-loss aid with anti-inflammatory properties.

5. Black Cohosh

Black cohosh (Actaea racemosa) is commonly used as a supplement to manage menopausal symptoms. However, the U.S. Pharmacopeia advises against excessive consumption, as prolonged use (approximately 42 weeks) has been linked to liver injury.

Studies also indicate that mislabeled black cohosh products may contribute to hepatotoxicity. Additionally, excessive intake can cause gastrointestinal irritation, headaches, dizziness, and vomiting.

6. Red Yeast Rice

Red yeast rice is a dietary supplement used to lower cholesterol. It contains several monacolins, particularly monacolin K, which is chemically identical to lovastatin—an HMG-CoA reductase inhibitor used to manage hyperlipidemia.

Liver injury from red yeast rice (in capsule or tablet form as OTC medication) is linked to the presence of lovastatin in doses ranging from 1 to 10 mg per tablet. Lovastatin is metabolized in the liver via CYP3A4, and its hepatotoxic effects may be due to a toxic or immunogenic metabolite. ^[3]

MedBound Times reached out to Dr. Beatrice Synnah, Assistant Professor (BAMS, MS Shalya Tantra) at Sumandeep Ayurved Medical College and Hospital, Pipariya Vadodara, Gujarat, for her insights on herbal supplements and liver health.

_{Disclaimer: The information on this website is for informational purposes only and is not intended to substitute medical advice, diagnosis or treatment. Always contact your healthcare practitioner regarding any questions you may have about medical conditions, procedures or treatment.}

References

1. Likhitsup, Alisa, Vincent L. Chen, and Robert J. Fontana. 2024. "Estimated Exposure to 6 Potentially Hepatotoxic Botanicals in US Adults." JAMA Network Open 7 (8): e2425822. https://doi.org/10.1001/jamanetworkopen.2024.25822.

2. American Botanical Council. 2024. "JAMA Paper Exaggerates Liver Injury Risk of Several Herbal Dietary Supplements." GlobeNewswire News Room, August 10. https://www.globenewswire.com/news-release/2024/08/10/2927990/0/en/JAMA-Paper-Exaggerates-Liver-Injury-Risk-of-Several-Herbal-Dietary-Supplements.html.

3. National Institute of Diabetes and Digestive and Kidney Diseases. 2012–. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury. Updated June 1, 2024. Bethesda, MD. https://www.ncbi.nlm.nih.gov/books/.

By Dr. Lakshmisahithi Tanneru

_MSM