On The Shelf
Mickie Cathers
Over half of all Americans take a daily multi-vitamin or dietary supplement with recent polls showing that number may be rising. Meanwhile, the incidence of documented cases of supplement-induced liver damage has also been rising. As herbal and supplement usage continues to grow, with the market expected to expand at an annual growth rate of over 20% over the next decade, it’s all the more important for pharmacists to educate patients about safe and effective use.
Background
According to the 2017–2018 National Health and Nutrition Examination Survey conducted by CDC, 58% of U.S. adults aged 20 and older reported taking dietary supplements in the past 30 days. A 2024 poll by the Council for Responsible Nutrition suggested that this number has risen to 75% for adults 18 and older. Nearly all respondents to the poll (91%) considered supplements essential to their health.
Research published in 2014 in Hepatology suggested that around 20% of liver toxicity cases in the United States are linked to herbal and dietary supplements, with bodybuilding products leading the charge. The authors noted that non-bodybuilding herbal dietary supplements can cause liver injury that is more severe than conventional medications, sometimes leading to transplantation. This liver injury pattern was hepatocellular, similar to acute viral hepatitis, and most often occurred in women. Products and supplements such as Herbalife, kava, green tea, and Hydroxycut were frequently implicated in liver injuries.
A February 2022 study published in Liver Transplantation revealed a significant rise in acute liver failure cases tied to herbal and dietary supplements over the past 25 years. Ghabril and colleagues showed an eightfold increase in acute liver failure linked to herbal and dietary supplements. The severity of these cases sometimes led to liver transplants. Clinical presentations within the study varied widely, with cases ranging from asymptomatic liver test abnormalities to acute liver failure.
Heavy hitters
Liver injury from herbal supplements is often idiosyncratic, meaning it can vary greatly among individuals and take time to manifest. Effects can occur days, months, or even years after the initiation of a new herbal supplement. This variability makes it challenging to gauge safety.
Some popular botanicals, including turmeric and ashwagandha, are linked to liver damage despite their widespread use for various health benefits. These supplements, taken for issues ranging from allergies to weight loss, can pose serious health risks. Concentrated forms of milk thistle, green tea, giloy, and Phyllanthus niruri also contribute to liver damage.
A 2022 analysis published in Arquivos de Gastroenterologia highlighted the risks of dietary supplement–induced liver injury, citing specific products and outcomes. Dall’Alba and colleagues reviewed 428 clinical cases of drug-induced liver injury, reporting that 84.6% of cases required hospitalization, while 8.9% led to liver transplantation. Results indicated that the most frequent agents of liver injury were Herbalife, OxyElite Pro, and Hydroxycut products; polygonum multiflorum herbs; and green and kava teas.
What to tell your patients
The increasing frequency of these cases underscores the need for awareness and open dialogue. Ask your patients about their supplement use and reassure them about their health-seeking behaviors while emphasizing caution. Highlight that “herbal” doesn’t always mean “safer.” Patients often assume natural products are safe and may be taking daily supplements for memory enhancement and wellness without realizing the potential risks associated with some highly concentrated ingredients such as ashwagandha and turmeric.
Encourage patients to read labels and note quantities of potential hepatoxic herbs present within the products. ■