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

• Published in: Liver International
• Main Authors: Björnsson, Helgi K, Björnsson, Einar S, Avula, Bharathi, Khan, Ikhlas A, Jonasson, Jon G, Ghabril, Marwan, Hayashi, Paul H, Navarro, Victor
• Other Authors: 1Landspitali University Hospital, Reykjavik, Iceland. 2National Center for Natural Products Research, School of Pharmacy, University of Mississippi, University, MS, USA. 3Indiana University School of Medicine, Indianapolis, IN, USA. 4University of North Carolina, Chapel Hill, NC, USA. 5Einstein Healthcare Network, Sidney Kimmel Medical College, Philadelphia, PA, USA.
• Format: Article in Journal/Newspaper
• Language: English
• Published: Wiley 2020
• Subjects: dietary supplements; drug-induced liver injury; liver; Aukaverkanir lyfja; Fæðubótarefni; Chemical and Drug Induced Liver Injury; Indian; Iceland
• Online Access: http://hdl.handle.net/2336/621333; https://doi.org/10.1111/liv.14393

To access publisher's full text version of this article click on the hyperlink below 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. United States Department of Health & Human Services National Institutes of Health (NIH) - USA NIH National Institute of Diabetes & ...