Drug-Induced Liver Injury: 5 Things to Know

Nancy S. Reau, MD


March 07, 2019

5. All-natural does not mean risk-free.

The DILIN found that 15%-20% of DILI cases could be attributed to herbal and dietary supplements.[13] This number is likely to be substantially underestimated, as patients rarely reveal their use of herbal and dietary supplements, and few adverse reactions to herbal and dietary supplements are reported.[14]

According to the DILIN, most liver injury that is induced by herbal and dietary supplements is attributed to bodybuilding agents (eg, anabolic steroids), green tea extract, and multi-ingredient nutritional supplements, many of which also list green tea as a component. Others implicated include those for weight loss, depression, sexual performance, gastrointestinal upset, immune support, and joint support, as well as Chinese herbs.[15]

Perspective is important. Although herbal and dietary supplements may be commonly implicated in DILI, most people will not experience liver injury; it is uncommon despite their widespread use. A population-based survey in Iceland attributed 16% of DILI cases to herbal and dietary supplements, but this translated to an incidence of herbal and dietary supplement–related acute liver injury of just 3 per 100,000 persons.[16]

Clinicians must ask patients about their use of herbal and dietary supplements, recognizing that many patients are hesitant to discuss nontraditional alternatives.

One more thing...

The LiverTox website, a collaboration of the National Institute of Diabetes and Digestive and Kidney Diseases, the National Library of Medicine, and the DILIN, provides up-to-date information on DILI, including herbal and dietary supplements. This freely available resource is searchable, with abundant educational information and an option to submit case reports.

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