The popularity of botanical supplements, supplements derived from plants and herbs, has experienced a significant surge in recent years. This trend is fueled in part by online advertisements and social media content that touts these supplements as effective treatments for various health concerns, including gastrointestinal problems, menopausal symptoms and high cholesterol. Examples of these botanicals include Ashwagandha, Turmeric, Shilajit, Kratom and Sea Moss among others.

Do we really know what we're taking?

However, recent research published in JAMA Network Open reveals that approximately 15.6 million adults in the United States have used at least one potentially liver-damaging botanical in the past month.

Dr Alisa Likhitsup, a clinical assistant professor of medicine at the University of Michigan's Division of Gastroenterology & Hepatology is the lead researcher of a study investigating this phenomenon. She has expressed concern about the potential for these supplements to cause liver damage. She shared her insights with Gastroenterology & Endoscopy News, emphasizing the importance of healthcare providers discussing supplement use with their patients to mitigate potential risks.

“For the past five years, we have seen a rise in cases of patients getting liver injury, some even requiring liver transplant," she said, “that brought our attention to the issue.

“Generally, there are other reasons for the transplant, but it’s often a compounding factor that they were taking supplements as well,” she continued. Likhitsup added that some patients were healthy and supplement ingestion appeared to be the only cause of liver injury.

Hepatotoxicity refers to liver damage caused by exposure to harmful substances, such as drugs, chemicals or toxins. It occurs when these substances cause injury to liver cells, leading to inflammation, impaired liver function, or even liver failure in severe cases.

The liver plays a crucial role in detoxification, metabolism, and numerous other bodily functions. When its cells are injured, the liver's ability to perform these functions is impaired. This can result in a buildup of toxins in the body, further exacerbating the damage.

It is important to note that not all cases of hepatotoxicity present with symptoms, especially in the early stages. This is why it is important to be aware of the potential risks of hepatotoxicity and to take steps to protect your liver.

Between July 1, 2023, and February 1, 2024, researchers analyzed data from 9,685 adults (average age 47) who were part of the National Health and Nutrition Examination Survey (NHANES) to analyze prescription drug and herbal and dietary supplement use over 30-day periods.

The six hepatotoxic botanicals evaluated in the study were used by 5% of participants. Participants tended to be older, white, more educated and living with a chronic condition, notably arthritis, diabetes or a thyroid disorder. The most frequently used botanical was Turmeric, followed by Green Tea, Ashwagandha, Garcinia Cambogia, Red Yeast Rice and Black Cohosh.

The researchers pointed out that the number of individuals who reported using a potentially liver-damaging botanical in the past 30 days is similar to the number of patients prescribed potentially hepatotoxic medications, such as simvastatin and nonsteroidal anti-inflammatory drugs.

Dr Elena Ivanina, an integrative gastroenterologist and founder of The Center for Integrative Gut Health and Gut Love in New York, stated patients frequently don't disclose their supplement usage to physicians. This occurs due to multiple factors, including fear of dismissal and providers not inquiring about supplement use.

Ivanina acknowledged that certain herbal supplements have shown promising health benefits in research. For example, curcumin, the active compound in Turmeric, has proven to be an effective treatment for inflammatory bowel disease (IBD).

A 2020 clinical trial found that patients who took a highly bioavailable form of curcumin for 12 weeks saw a reduction in IBD activity, with no reported side effects. Furthermore, a 2022 meta-analysis on curcumin's impact on IBD noted that multiple studies have identified various cellular targets through which curcumin may help slow the disease's progression, though the exact mechanisms are still not fully understood.

“Vitamins, herbs and supplements can be used safely with the supervision of a physician,” Dr Ivanina said.

“Being [actively involved in] your patient’s supplementation protocol to help guide them to make safe decisions is key.”

Risks with being unregulated

The absence of FDA oversight to guarantee supplement content is a major issue.

A 2019 study investigated the potential for mislabeling and adulteration in herbal and dietary supplements linked to liver damage. Researchers examined 272 products and discovered that a alarmingly high proportion, over 50%, contained chemical ingredients that were not accurately reflected on the product labels. This discrepancy between labeled and actual ingredients raises serious concerns about consumer safety and the potential for unintended adverse effects, particularly liver injury, in individuals using these supplements. The findings underscore the importance of regulatory oversight and the need for consumers to exercise caution and consult with healthcare professionals before using herbal or dietary supplements.

“Herbs have historically been used as medicine, but now we have technology that is creating formulations that are more potent and mixed with other ingredients—and none of this is overseen by a regulatory body,” Ivanina said.

"The botanicals’ liver toxicity likely has to do with the way the compounds are metabolized," Likhitsup said. However, “we don’t have the data to say that these are all [metabolized via] the same pathway. It could also be drug-to-drug interactions.

“For right now, we still believe the toxicity can be low in the majority of patients. But we don’t have enough data yet to tell in who or when they become toxic to the liver.”

There are certain individuals who should always avoid unnecessary medications or supplements, particularly those with pre-existing health conditions, compromised liver function, or those taking multiple medications that may interact. For these individuals, even seemingly harmless supplements can pose risks, making it crucial to consult with healthcare providers before starting any new treatment.

Likhitsup recommended that physicians counsel patients with existing liver disease or elevated liver enzymes about which supplements are hepatotoxic and should be avoided.

She said: “We need to be taking more caution, asking patients if they are taking these supplements, and if there is liver injury, I would advise patients to stop taking them.”

In conclusion, hepatotoxicity presents an important reason for healthcare providers to routinely ask patients about their use of supplements. With numerous herbal and dietary supplements associated with liver damage, it is crucial for physicians to remain alert to potential risks, particularly in patients with existing liver conditions.

By being aware of the dangers linked to specific supplements, clinicians can offer better guidance, helping patients make safer choices and avoid harm to liver health. Ongoing monitoring and open conversations about supplement use are essential in protecting overall well-being.