Herbal Supplements and Liver Damage: A Growing Concern

5 min read ·
Bottom Line

Liver injury from herbal and dietary supplements is a real and growing problem: in the U.S. DILIN registry, supplements’ share of liver-injury cases roughly tripled from about 7% to about 20% between 2004 and 2013, putting them alongside antibiotics as a leading cause of severe drug-induced liver injury. A handful of products account for much of the harm — concentrated green tea extract (EGCG at 800 mg/day or more), kava, black cohosh, and bodybuilding products spiked with anabolic steroids or SARMs. The practical danger is that "natural" reads as safe, and U.S. labels rarely warn of liver risk, so the burden falls on the user to recognize trouble. Stop any new supplement and seek care if you notice fatigue, nausea, dark urine, right-upper-abdomen pain, or yellowing of the skin or eyes, because injury can worsen even after you quit.

The trend documented by the DILIN network (Navarro et al. 2017, Hepatology) is not an abstraction: some of these cases end in acute liver failure and transplant referral. What makes the pattern hard to catch is that the injury rarely announces itself as "supplement damage" — patients and even clinicians often look elsewhere first, because a product sold for wellness is not the obvious suspect. The sections below cover which products carry the most risk and the warning signs that should prompt you to stop and get tested.

The Most Implicated Supplements

Green tea extract (EGCG): One of the most-reported single botanical causes of DILI in Western countries, with cases linked to high EGCG doses (often 700+ mg/day from concentrated extracts in weight-loss products). The European Food Safety Authority concluded in 2018 that EGCG doses of 800 mg/day or more from supplements are associated with hepatotoxicity, and Health Canada has required liver-warning labels on green tea extract supplements since 2017.

Kava (Piper methysticum): Associated with severe hepatotoxicity, including fulminant liver failure requiring transplant. The FDA issued a Consumer Advisory in 2002, and Germany, the United Kingdom, France and other jurisdictions have placed restrictions on kava supplements at various points.

Black cohosh: Used for menopausal symptoms; associated with dozens of hepatotoxicity reports worldwide, including some transplant cases. EMA assessments and Australia's Therapeutic Goods Administration require liver-warning labels on black cohosh products.

Bodybuilding supplements: Anabolic-androgenic steroid analogs, SARMs, and undeclared compounds are a leading cause of DILI in young men in DILIN; cholestatic injury is the typical pattern.

Warning Signs

Early hepatotoxicity symptoms include fatigue, nausea, dark urine, right-upper-quadrant discomfort, and jaundice (yellowing of the skin or whites of the eyes). Stop any new supplement immediately if these appear and seek medical evaluation. Liver injury can progress even after the supplement is stopped — early recognition is critical.

Sources

  1. Navarro VJ, Khan I, Björnsson E, Seeff LB, Serrano J, Hoofnagle JH. "Liver injury from herbal and dietary supplements." Hepatology, 2017;65(1):363–373. PMID: 27677775. DOI: 10.1002/hep.28813.
  2. Navarro VJ, Barnhart H, Bonkovsky HL, Davern T, Fontana RJ, Grant L, Reddy KR, Seeff LB, Serrano J, Sherker AH, Stolz A, Talwalkar J, Vega M, Vuppalanchi R. "Liver injury from herbals and dietary supplements in the U.S. Drug-Induced Liver Injury Network." Hepatology, 2014;60(4):1399–1408. PMID: 25043597. DOI: 10.1002/hep.27317.
  3. European Food Safety Authority Panel on Food Additives and Nutrient Sources added to Food. "Scientific opinion on the safety of green tea catechins." EFSA Journal, 2018;16(4):5239. DOI: 10.2903/j.efsa.2018.5239.
  4. Hoofnagle JH, Bonkovsky HL, Phillips EJ, Li YJ, Ahmad J, Barnhart H, Durazo F, Fontana RJ, Gu J, Khan I, Kleiner DE, Koh C, Rockey DC, Seeff LB, Serrano J, Stolz A, Tillmann HL, Vuppalanchi R, Navarro VJ; Drug-Induced Liver Injury Network. "HLA-B*35:01 and Green Tea-Induced Liver Injury." Hepatology, 2021;73(6):2484–2493. PMID: 32892374. DOI: 10.1002/hep.31538.
  5. U.S. Food and Drug Administration. "Consumer Advisory: Kava-Containing Dietary Supplements May Be Associated With Severe Liver Injury." 2002. fda.gov.
  6. Teschke R, Schwarzenboeck A, Hennermann KH. "Kava hepatotoxicity: a clinical survey and critical analysis of 26 suspected cases." European Journal of Gastroenterology & Hepatology, 2008;20(12):1182–1193. PMID: 19279474. DOI: 10.1097/MEG.0b013e3283036768.
  7. European Medicines Agency, Committee on Herbal Medicinal Products. "Assessment report on Cimicifuga racemosa (L.) Nutt., rhizoma." EMA/HMPC/600717/2017. ema.europa.eu.
  8. Health Canada. "Green tea extract-containing natural health products and the risk of liver injury." 2017 risk-communication update. recalls-rappels.canada.ca.
  9. Robles-Diaz M, Gonzalez-Jimenez A, Medina-Caliz I, Stephens C, García-Cortes M, García-Muñoz B, Ortega-Alonso A, Blanco-Reina E, Gonzalez-Grande R, Jimenez-Perez M, Rendón P, Navarro JM, Gines P, Prieto M, Garcia-Eliz M, Bessone F, Brahm JR, Paraná R, Lucena MI, Andrade RJ; Spanish DILI Registry. "Distinct phenotype of hepatotoxicity associated with illicit use of anabolic androgenic steroids." Alimentary Pharmacology & Therapeutics, 2015;41(1):116–125. PMID: 25394890. DOI: 10.1111/apt.13023.

Reviewed against 9 peer-reviewed and regulatory sources (safety category).

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