Comprehensive review of hepatotoxicity associated with traditional Indian Ayurvedic herbs

Core Tip

Core Tip: Ayurvedic herbal medications (AHM) can cause liver injury ranging from an asymptomatic elevation of liver enzymes to cirrhosis and portal hypertension. Patients who develop AHM-related liver injury have a history of consumption of complex polyherbal formulations. In most cases, identification of the offending hepatotoxic agent is difficult due to the number and complexity of herbs involved. However, multiple observational studies, quality case series, and well-performed case studies have demonstrated the hepatotoxic potential associated with certain herbs used in Ayurvedic practice. The commonly utilized and over-the-counter available Indian herbs or their extracts, such as Ashwagandha, Aloe vera, Guggul, Puncture vine, Turmeric, Gotu-kola, Bakuchi, Senna, Noni, Malabar tamarind, and Gurmar have been associated with various types of liver injury ranging from acute self-limiting hepatitis, chronic hepatitis, prolonged cholestasis, hepatic sinusoidal obstruction syndrome, cirrhosis, and portal hypertension and can present clinically as acute severe liver injury, acute liver failure, acute decompensation of cirrhosis or acute on chronic liver failure. Physician knowledge regarding regional and local complementary and alternative practices among the general and patient population is essential in identifying those who develop complications of liver disease secondary to herbal hepatotoxicity, to make optimal treatment decisions, and for early prognostication.