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

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.

• Authors: Helgi K Björnsson, Einar S Björnsson, Bharathi Avula, Ikhlas A Khan, Jon G Jonasson, Marwan Ghabril, Paul H Hayashi, Victor Navarro
• Journal: Liver international : official journal of the International Association for the Study of the Liver (Liver Int) Vol. 40 Issue 4 Pg. 825-829 (04 2020) ISSN: 1478-3231 [Electronic] United States
• PMID: 31991029 (Publication Type: Journal Article, Research Support, N.I.H., Extramural, Research Support, N.I.H., Intramural)
• Copyright: © 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Chemical References

• Plant Extracts
• Ashwagandha

Topics

• Adult
• Chemical and Drug Induced Liver Injury (etiology)
• Chemical and Drug Induced Liver Injury, Chronic
• Europe
• Female
• Humans
• Iceland
• Male
• Middle Aged
• Plant Extracts
• Withania
• Young Adult