Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Sep 27, 2021; 13(9): 1019-1041
Published online Sep 27, 2021. doi: 10.4254/wjh.v13.i9.1019
Herbal and dietary supplement induced liver injury: Highlights from the recent literature
Stephanie M Woo, William D Davis, Soorya Aggarwal, Joseph W Clinton, Sara Kiparizoska, James H Lewis
Stephanie M Woo, William D Davis, Joseph W Clinton, Sara Kiparizoska, Department of Internal Medicine, MedStar Georgetown University Hospital, Washington, DC 20007, United States
Soorya Aggarwal, James H Lewis, Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, DC 20007, United States
Author contributions: Woo SM, Davis WD, Aggarwal S, Clinton JW, Kiparizoska S and Lewis JH contributed equally to this work; all authors have read and approve the final manuscript.
Conflict-of-interest statement: There are no conflicts of interest to be declared.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Stephanie M Woo, MD, Staff Physician, Department of Internal Medicine, MedStar Georgetown University Hospital, 3800 Reservoir Road, Washington, DC 20007, United States.
Received: May 4, 2021
Peer-review started: May 4, 2021
First decision: June 4, 2021
Revised: June 8, 2021
Accepted: August 9, 2021
Article in press: August 9, 2021
Published online: September 27, 2021

Herbal-induced liver injury (HILI) is an important and increasingly concerning cause of liver toxicity, and this study presents recent updates to the literature. An extensive literature review was conducted encompassing September 2019 through March 2021. Studies with clinically significant findings were analyzed and included in this review. We emphasized those studies that provided a causality assessment methodology, such as Roussel Uclaf Causality Assessment Method scores. Our review includes reports of individual herbals, including Garcinia cambogia, green tea extract, kratom as well as classes such as performance enhancing supplements, Traditional Chinese medicine, Ayurvedic medicine and herbal contamination. Newly described herbals include ashwagandha, boldo, skyfruit, and ‘Thermo gun’. Several studies discussing data from national registries, including the United States Drug-Induced Liver Injury (DILI) Network, Spanish DILI Registry, and Latin American DILI Network were incorporated. There has also been a continued interest in hepatoprotection, with promising use of herbals to counter hepatotoxicity from anti-tubercular medications. We also elucidated the current legal conversation surrounding use of herbals by presenting updates from the Federal Drug Administration. The highlights of the literature over the past year indicate interest in HILI that will continue as the supplement industry in the United States grows.

Keywords: Herbal-induced liver injury, Dietary supplement-induced liver injury, Drug-induced liver injury, Roussel Uclaf Causality Assessment Method, Hepatotoxicity, Liver toxicity

Core Tip: Herbal-induced liver injury is a growing concern worldwide with increasing rates of reported cases. Here we provide an encompassing review of reported new cases of well-established herbals along with newly described herbals causing liver injury over the past year. Causality assessment was emphasized. New studies addressing the hepatocytoprotective effects in human studies are also emphasized.