--- title: "Ashwagandha and Liver Safety: What You Need to Know" entity: "blog" canonical_url: "https://www.drsmithnd.com/blog/ashwagandha-and-liver-safety-what-you-need-to-know" markdown_url: "https://www.drsmithnd.com/llms/blog/ashwagandha-and-liver-safety-what-you-need-to-know" lastmod: "2026-09-21T15:54:24.000Z" --- Photo credit: [Grigoriy Konsevich](https://www.pexels.com/@grigoriy-konsevich-3808567/) Dear Reader, If you take ashwagandha or I have prescribed it for you, it’s time I update you on some emerging safety information. Before you storm over to your supplement stash and fling it in the garbage, take a breath. This is not an emergency, but it is something I think you should know about. I have been prescribing botanical medicine for almost two decades. I like, super love herbs. I trained extensively in them (truly the worst exams in ND med school…), I am continually upleveling my knowledge, I use them foundationally in practice, and ashwagandha ( Withania somnifera ) is one I have prescribed and taken many, many times. Oh withania my old sleepy friend, you’re in the headlights now my dear. It has come to my attention that some reports of liver injury following ashwagandha use have accumulated internationally, so health regulators have appropriately started looking more closely at them. Health Canada's 2026 review concluded that there was not sufficient evidence to establish a definite link between oral ashwagandha products and liver injury. But—and this is an important but—it also concluded that a possible association could not be ruled out and will continue monitoring the issue. Australia's Therapeutic Goods Administration has taken a somewhat more precautionary position. It describes liver injury following ashwagandha as very rare but potentially serious and recommends that people with current or previous liver problems avoid it. ### What Do We Actually Know? Published case series from Iceland, the United States and India have documented liver injury following ashwagandha use after other potential causes were investigated. The most commonly reported pattern has been cholestatic or mixed liver injury, often involving jaundice and significant itching. In the Iceland/U.S. series, none of the five patients developed liver failure, and the four followed through recovery had liver enzymes return to normal after stopping ashwagandha. The Indian series was more concerning. Five of the eight patients had underlying chronic liver disease, and three developed acute-on-chronic liver failure and died. Context matters enormously here. These case series cannot tell us how likely this is to happen to someone taking ashwagandha. We don't have the denominator we'd need to calculate that risk. Australia currently describes the reported risk as very rare, while Health Canada has stopped short of establishing a definite causal relationship. Case reports and series sit low on the evidence totem pole and cannot tell us how frequently this occurs or establish causation with the certainty of controlled studies. But when we're looking for rare adverse effects, they do matter. A consistent pattern of serious events can provide a safety signal before a random controlled trial would ever be large enough to detect it. ### Is This Just About Shitty Supplements? If only it were that simple. Product quality matters enormously to me, and it is one of the reasons I am so particular about what I prescribe. But we cannot currently say that these liver injuries were simply the result of contaminated, adulterated or poor-quality products. The products in the published investigations were chemically analyzed, and investigators did not identify contamination or adulteration that adequately explained the injuries. The mechanism itself remains uncertain. ### So What Should You Do? If I have prescribed ashwagandha to you and you feel fine, don't panic or abruptly change your treatment. If you're concerned, we can review whether it still makes sense for you based on your status now and if we want, find a substitute. I do not use it in anyone with current or previous liver disease, or with emerging risk of liver disease as a precaution. If you are taking it and develop yellowing of the skin or eyes, dark urine, significant unexplained itching, nausea or vomiting, unusual fatigue, loss of appetite or abdominal pain, stop taking it and seek medical assessment. I don't tell you this because I expect it to happen, I absolutely don’t. But it is part of my responsibility to update my community. Many of us are now taking far more “stuff” than we used to—powders, gummies, greens, sleep blends, coffee / electrolyte/ smoothie drink blends, usually with multiple active ingredients. There’s a reason I ask my patients to tell me everything they are taking is because it isn’t at all uncommon for me to flag problems. ### And Finally In Sum, About Me Accosting People in Healthfood Stores… I use herbs because they do things. Yea no shit lady. Stay with me here. It just so happens that I have been present a few times (so bizarre!) in a health food store when a staff member has been helping a patron considering St John’s Wort. I apparently could not be cool and mind my own business and awkwardly blurted out: ARE YOU ON THE PILL? ARE YOU ON ANY MENTAL HEALTH MEDICATIONS? There are more questions, but you get the gist. Once my son was there and he was MORTIFIED, in a word. I am unphased. So folks, if something is powerful enough to meaningfully affect our physiology in a beneficial way, we cannot believe that it can’t have contraindications, interactions or adverse effects simply because it came out of the ground. Herbs have plenty of drug interactions and contraindications; they are, of course, the original medicine. Act accordingly. I reserve the right to change my mind. If new, quality evidence emerges showing that I should alter how I prescribe something, then I do. Fullstop. This is the standard I want for me and my family, and it is certainly the standard I want for you and yours. Off to pour myself a cuppa from my cauldron. Happy autumn to all, Dr. Kirsten, ND, MSCP #### References Health Canada. Health Product InfoWatch: August 2026 — Ashwagandha for oral use. Marketed Health Products Directorate, 2026. Therapeutic Goods Administration (Australia). Withania somnifera (Ashwagandha) and very rare risk of liver injury. Medicines Safety Update. July 7, 2026. Björnsson HK, Björnsson ES, Avula B, et al. Ashwagandha-induced liver injury: A case series from Iceland and the US Drug-Induced Liver Injury Network. Liver International. 2020;40(4):825–829. doi:10.1111/liv.14393. Philips CA, Valsan A, Theruvath AH, et al. Ashwagandha-induced liver injury—A case series from India and literature review. Hepatology Communications . 2023;7(10):e0270. doi:10.1097/HC9.0000000000000270.