Liver Injury Due to Herbals, Botanicals, and Other Dietary Supplements

There is an increasing awareness of liver injury resulting from herbals, botanicals, and other dietary supplements. The literature is rife with case reports of hepatotoxicity attributed to various single or multi-ingredient products. The U.S. Drug Induced Liver Injury Network (DILIN) was funded by the National Institutes of Health starting in 2003 to better understand the causes of liver injury from drugs and dietary supplements. The DILIN's early findings indicated that dietary supplements are the second most common types of agents to cause liver injury, after antimicrobials. Products used for the purposes of bodybuilding and muscle enhancement are the most common types of supplements implicated in liver injury. The injury resulting from those products is characteristic, with prolonged jaundice and pruritus being typical. On the other hand, injury resulting from non-bodybuilding products, such as those used for weight loss among other reasons, tends to be of a different pattern and more commonly associated with the need for liver transplantation than even injury resulting from prescription medications.

Clinical investigators face several challenges in achieving a better understanding of liver injury due to herbals, botanicals, and other dietary supplements. Among them, the most vexing is the chemical complexity of supplements. This complexity prevents a firm attribution of liver injury to the precise ingredient, or combination of ingredients. An additional problem includes the lack of a standard nomenclature for marketed products which, in turn, confounds clinicians' ability to group products of similar composition or use. A standard nomenclature would allow clinicians to group products and recognize common patterns of injury. This, in turn, could give insight into the mechanism and precise causes of injury.

Chalasani N, Fontana RJ, Bonkovsky HL, et al. Causes, clinical features, and outcomes from a prospective study of drug induced liver injury in the United States. Gastroenterology 2008;135:1924 – 34. Navarro, VJ, Barnhart H, Bonkovsky HL, Davern T, Fontana RJ, Grant L, Reddy KR, Seeff LB, Serrano J, Sherker AH, Stolz, Talwalker J, Vega M, Vuppalanchi R. Liver injury from herbals and dietary supplements in the U.S. Drug-Induced Liver Injury Network. Hepatology 2014;60;1399 – 1408.