Ashwagandha and Liver Injury: What the Case Reports Say
Key takeaways
- The published literature on ashwagandha liver injury is small. A 2026 scoping review found 13 publications covering 25 patients. An earlier systematic review of herb-induced liver injury counted 9 ashwagandha cases among 936 cases attributed to herbal products.
- Symptoms appeared after weeks of use, not days. The best-known case series reported a latency of 2 to 12 weeks from starting the supplement to jaundice.
- The injury pattern is usually cholestatic or mixed rather than hepatocellular, with jaundice and itching as the presenting complaints. In that series the R ratios ran 1.4 to 3.3.
- Most patients recovered. In the five-case series, four had liver tests return to normal within 1 to 5 months of stopping, though itching and high bilirubin lasted 5 to 20 weeks.
- Case reports have no denominator. They can't tell you how often this happens, and no published report supports a rate.
How many reports exist
The count is in the dozens, and that's the honest scale.
The first published case linking ashwagandha to liver injury appeared in 2017. Björnsson and colleagues published a five-case series in Liver International in 2020, taking three cases from Iceland and two from the US Drug-Induced Liver Injury Network. A systematic review of herb-induced liver injury published in 2021 identified 936 cases across 79 herbal products, and ashwagandha accounted for 9 of them, roughly 1%.
A scoping review published in 2026 searched the literature through December 2025 and found 13 publications describing 25 patients. That's the current ceiling.
Two large pharmacovigilance registries, one in Spain covering 856 hepatotoxicity cases from 1994 to 2016 and one across Latin America covering 367 cases from 2011 to 2019, recorded herbal injuries without a single ashwagandha case.
How long before symptoms appeared
Weeks, in every report that gives a number.
In the Liver International series, all five patients developed jaundice plus nausea, lethargy, itching, or abdominal discomfort after a latency of 2 to 12 weeks. Their mean age was 43, with a range of 21 to 62.
Other reports sit inside that window. One 2021 case report described a 39-year-old woman with nausea and vomiting six weeks after starting ashwagandha. Another described a 40-year-old man with jaundice and itching 20 days after switching brands.
The latency matters clinically. It's long enough that people don't connect the supplement to the symptom.
What the injury looks like
Cholestatic or mixed, most of the time.
In the Liver International series the R ratios, the ratio clinicians use to classify the pattern, ran from 1.4 to 3.3, covering mixed and cholestatic injury. One biopsy showed acute cholestatic hepatitis.
Jaundice and itching dominate the presentation. The 2026 scoping review reached the same conclusion across 25 patients: cholestatic or mixed phenotypes predominated, and purely hepatocellular injury was less frequent.
The lab numbers can be alarming. The 39-year-old woman's bilirubin rose from 9.0 to 19.1 mg/dL with ALT at 1,514 U/L. The 40-year-old man's bilirubin went from about 8.5 to 25.2 mg/dL with only modest ALT and AST elevation, which fits a cholestatic picture.
Causality was assessed formally in the series, and most reports in the scoping review classified ashwagandha as a probable or likely cause. Two caveats travel with that. Four of the five patients were taking other supplements, and one case flagged rhodiola as a possible co-cause. Chemical analysis did confirm ashwagandha in the available products.
How the cases ended
Recovery, in most of them.
No patient in the Liver International series developed hepatic failure. Liver tests normalized within 1 to 5 months in four of the five, and the fifth was lost to follow-up. Itching and high bilirubin ran longer than the enzymes, persisting 5 to 20 weeks.
The scoping review described the same shape: most patients recovered after stopping, usually over weeks to months. "Most" is doing real work in that sentence.
The severe end
The severe reports cluster around people who already had liver disease.
The 2026 scoping review recorded one case of acute liver failure requiring transplantation and three deaths among patients with pre-existing cirrhosis who decompensated.
A US surveillance analysis estimated roughly 23,000 emergency department visits a year attributed to dietary supplement adverse events. Herb-induced liver injury is a diagnosis of exclusion, so attribution depends on someone asking about supplements, and it's often missed when nobody asks.
Why none of this gives you a rate
This is the limit that matters most.
A case report has no denominator. Twenty-five patients in the literature tells you the injury happens. It doesn't tell you whether that's 25 out of a hundred thousand users or 25 out of ten million, because nobody knows how many people took ashwagandha and stayed well.
Under-reporting pushes both ways. Mild injury resolves on its own and never reaches a journal. Serious injury reaches a transplant center and gets written up.
The registries point the same way. A Spanish registry logging 32 herbal liver injuries over 22 years with no ashwagandha is a statement about who got referred. There's no cohort study of ashwagandha users with protocol liver monitoring, and until there is, no incidence figure is defensible.
When to stop and get seen
Stop the supplement and contact a clinician the same day if you develop yellowing of the skin or eyes, dark urine, pale stools, itching, nausea with vomiting, or pain in the upper right abdomen.
Go to an emergency department rather than waiting for an appointment if the jaundice is obvious, if you're vomiting and can't keep fluids down, or if you're unusually drowsy.
Bring the bottle. Product identity matters for attribution, and multi-ingredient formulas make it harder. If you already have liver disease, raise ashwagandha with your hepatologist first.
Frequently asked questions
How common is ashwagandha liver injury?
Unknown, and that's not a hedge. Roughly 25 patients have been described in the peer-reviewed literature, with no cohort study to divide that by. Any percentage you see quoted is not supported by these reports.
How long does it take to show up?
Two to twelve weeks in the main case series, with other reports at three and six weeks. It's a delayed reaction, not a same-day one.
Does it resolve after stopping?
In the published series, yes for most people. Liver tests returned to normal within 1 to 5 months, and itching and jaundice lingered 5 to 20 weeks.
Is it the ashwagandha or something else in the product?
Often hard to say. Four of the five patients in the series were taking other supplements, and one case flagged rhodiola as a possible co-cause. Multi-ingredient products make attribution genuinely difficult.
Are people with liver disease at higher risk?
The severe outcomes reported, including three deaths, occurred in patients who already had cirrhosis. That's the clearest risk signal in the literature.
Should I get liver tests if I've been taking it?
If you've taken it for weeks and feel well, there's no published protocol that says test. If you have symptoms, that's a same-day conversation with a clinician.
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This article is for general information only and does not constitute medical advice. Statements about dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease. Talk with your health care provider before using ashwagandha, especially if you have a liver condition or take prescription medication.
Sources
- Björnsson HK et al., Liver Injury due to Ashwagandha: A Case Series from Iceland and the US DILI Network, Liver Int 2020
- McIntyre D et al., Ashwagandha (Withania somnifera)-Associated Liver Injury: A Scoping Review, Cureus 2026
- Ballotin VR et al., Herb-induced liver injury: Systematic review and meta-analysis, World J Clin Cases 2021
- LiverTox: Ashwagandha, National Institute of Diabetes and Digestive and Kidney Diseases
- NIH Office of Dietary Supplements, Ashwagandha consumer fact sheet