Ashwagandha and fatty liver is a topic of growing concern as this popular herbal supplement, traditionally used for stress management, has been linked to cases of liver injury. Fatty liver disease affects up to 30% of the UK population, and whilst some seek natural remedies, there is no clinical evidence that ashwagandha treats or improves this condition. Documented cases of drug-induced liver injury associated with ashwagandha raise important safety questions, particularly for individuals with existing liver conditions. This article examines the evidence, safety considerations, and proven approaches to managing fatty liver disease.

What Is Ashwagandha and How Does It Work?

Ashwagandha (Withania somnifera) is a traditional herbal remedy originating from Ayurvedic medicine, commonly used as an adaptogen to help the body manage stress. The root and leaf extracts contain bioactive compounds called withanolides, which are thought to be responsible for many of its purported effects. In the UK, most ashwagandha products are available as food supplements in various forms including capsules, powders, and tinctures. Some herbal products may be registered under the Medicines and Healthcare products Regulatory Agency (MHRA) Traditional Herbal Registration (THR) scheme, though these are limited to traditional use claims and do not require evidence of efficacy.

The proposed mechanisms of action include modulation of the hypothalamic-pituitary-adrenal (HPA) axis, which regulates the body's stress response, and potential anti-inflammatory and antioxidant properties. Some research suggests ashwagandha may influence cortisol levels, though the clinical significance of these effects remains under investigation. It has been studied for various conditions including anxiety, sleep disturbances, and cognitive function, though robust clinical evidence supporting these uses is still emerging.

Key points about ashwagandha:

• Most products are classified as food supplements rather than licensed medicines in the UK

• Contains withanolides as primary active constituents

• Traditionally used for stress management and general wellbeing

• Not subject to the same regulatory standards as pharmaceutical products

As with any supplement, the quality, purity, and concentration of active ingredients can vary considerably between manufacturers. Consumers should choose reputable products and be aware that food supplements are not evaluated by regulatory authorities for efficacy or safety in the same rigorous manner as prescription medications, and product labelling may not always accurately reflect contents.

General safety considerations:

• Avoid in pregnancy and breastfeeding due to insufficient safety data

• Use with caution if you have thyroid disease or take thyroid medication

• Discuss with your GP or pharmacist before use, especially if taking other medicines or have existing health conditions

• Report any suspected side effects via the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk or through the Yellow Card app

Understanding Fatty Liver Disease: Causes and Symptoms

Fatty liver disease, medically termed hepatic steatosis, occurs when excess fat accumulates in liver cells. There are two main categories: alcohol-related fatty liver disease (ARLD) and non-alcoholic fatty liver disease (NAFLD). NAFLD is increasingly common in the UK, affecting an estimated 20–30% of the general population, and is closely associated with obesity, type 2 diabetes, and metabolic syndrome. (Note: the term metabolic dysfunction-associated steatotic liver disease (MASLD) is emerging in clinical literature, though NICE guidance currently uses NAFLD.)

The pathophysiology involves an imbalance between fat acquisition (from diet and de novo lipogenesis) and fat disposal (through oxidation and export). When the liver's capacity to process fat is overwhelmed, triglycerides accumulate within hepatocytes. Risk factors include:

• Obesity (particularly central adiposity)

• Insulin resistance and type 2 diabetes

• Dyslipidaemia (elevated triglycerides, low HDL cholesterol)

• Metabolic syndrome

• Certain medications (corticosteroids, tamoxifen, methotrexate)

Most individuals with simple fatty liver (steatosis) experience no symptoms. The condition is often detected incidentally through blood tests showing mildly elevated liver enzymes (ALT, AST, GGT) or imaging performed for other reasons. When fatty liver progresses to non-alcoholic steatohepatitis (NASH), inflammation and liver cell damage occur, potentially leading to fibrosis, cirrhosis, and hepatocellular carcinoma over time.

Symptoms that may develop with advanced disease include:

• Persistent fatigue and malaise

• Discomfort in the right upper abdomen

• Unexplained weight loss

• Jaundice (yellowing of skin and eyes)

According to NICE guidance (NG49), diagnosis typically involves liver function tests and ultrasound imaging to detect steatosis. To assess the risk of advanced fibrosis (scarring), clinicians use non-invasive scoring systems such as the Fibrosis-4 (FIB-4) score or NAFLD Fibrosis Score (NFS), with age-specific cut-offs (for example, FIB-4 <1.3 suggests low risk, whilst >2.67 suggests high risk; in those over 65, a lower threshold of 2.0 may be used). If scores are indeterminate or high risk, the Enhanced Liver Fibrosis (ELF) blood test is recommended to further assess fibrosis. FibroScan (transient elastography) is also commonly used locally as a non-invasive tool to measure liver stiffness.

Seek urgent medical attention (contact your GP urgently, attend A&E, or call NHS 111 for advice) if you experience:

• Jaundice with fever, severe abdominal pain, or confusion

• Vomiting blood or passing black, tarry stools

• New swelling of the abdomen (ascites)

Referral to specialist hepatology services is recommended if there is evidence of advanced fibrosis (for example, ELF score ≥10.51 or persistently high-risk FIB-4/NFS results), diagnostic uncertainty, or persistently abnormal liver function despite lifestyle modification.

Safety Considerations: Ashwagandha and Liver Health

Whilst ashwagandha has been used traditionally for centuries, there have been documented cases of drug-induced liver injury (DILI) associated with its use. Published case reports and reports to the MHRA Yellow Card scheme describe hepatotoxicity linked to ashwagandha-containing products, ranging from mild transaminase elevations to acute liver injury requiring hospitalisation. The exact mechanism of liver injury remains unclear, though it may involve idiosyncratic reactions, contamination, adulteration, or interactions with other substances.

Published case reports describe patients developing jaundice, significantly elevated liver enzymes (ALT and AST levels exceeding 10 times the upper limit of normal), and cholestatic patterns after taking ashwagandha supplements for periods ranging from weeks to months. In most documented cases, liver function improved following discontinuation of the supplement, though some patients required medical intervention. It is important to note that the incidence of such reactions appears to be rare, but the true frequency is difficult to establish due to underreporting and variable product quality.

Particular caution is advised for:

• Individuals with pre-existing liver disease (including fatty liver)

• Those taking medicines that can affect the liver (for example, certain antibiotics, antifungals, or high-dose paracetamol, particularly with heavy alcohol use)

• People consuming alcohol regularly

• Patients with autoimmune conditions affecting the liver

There is no clinical evidence that ashwagandha treats or improves fatty liver disease. Conversely, given the potential for hepatotoxicity, individuals with existing liver conditions should exercise particular caution. Patients should consult their GP or pharmacist before starting ashwagandha, especially if they have abnormal liver function tests or diagnosed liver disease.

Important safety advice:

• If you are taking prescribed medicines (including statins for cholesterol), do not stop them without consulting your doctor. Statins are generally safe in people with fatty liver disease and are important for reducing cardiovascular risk.

• If taking ashwagandha and experiencing symptoms such as jaundice (yellowing of skin or eyes), dark urine, pale stools, persistent nausea, or abdominal pain, stop the supplement immediately and seek medical attention.

• Healthcare professionals may wish to consider baseline liver function tests before starting ashwagandha and periodic monitoring during use, particularly in patients with risk factors for liver disease.

• Report any suspected side effects from ashwagandha or other supplements via the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk or through the Yellow Card app.

Evidence-Based Approaches to Managing Fatty Liver

The management of fatty liver disease, particularly NAFLD, centres on addressing underlying metabolic risk factors through lifestyle modification. According to NICE guidance (NG49), there are currently no licensed pharmacological treatments specifically for NAFLD, making lifestyle intervention the primary therapeutic approach. The evidence base consistently demonstrates that weight loss and increased physical activity can reduce hepatic fat content and improve liver enzyme profiles.

Weight management is fundamental. Studies show that losing 7–10% of body weight can significantly reduce liver fat, inflammation, and even fibrosis in patients with NASH. This should be achieved gradually through sustainable dietary changes rather than crash dieting. A Mediterranean-style diet, rich in vegetables, fruits, whole grains, legumes, nuts, and olive oil whilst limiting processed foods, refined carbohydrates, and saturated fats, has demonstrated benefits for liver health. Reducing sugar intake, particularly fructose from sweetened beverages, is especially important as excess fructose promotes hepatic lipogenesis.

Physical activity recommendations include at least 150 minutes of moderate-intensity aerobic exercise weekly, combined with resistance training. Exercise improves insulin sensitivity and promotes fat oxidation, even in the absence of significant weight loss. Both structured exercise programmes and increased daily activity (walking, cycling, gardening) confer benefits.

Additional evidence-based measures include:

• Alcohol reduction or abstinence: UK Chief Medical Officers advise that to keep health risks from alcohol low, it is safest not to drink more than 14 units per week on a regular basis, spread over 3 or more days. If you have fatty liver disease, particularly if it is progressing, abstinence is preferable.

• Optimising management of comorbidities: Good control of diabetes, appropriate lipid management (statins are generally safe and indicated in NAFLD for cardiovascular risk reduction), and treatment of hypertension.

• Avoiding hepatotoxic substances: This includes certain supplements and unnecessary medications. Do not exceed recommended doses of paracetamol, and be particularly cautious if you drink alcohol regularly.

• Regular monitoring: According to NICE and UK specialist guidance (BSG/BASL), risk stratification uses non-invasive scores (FIB-4 or NAFLD Fibrosis Score with age-specific cut-offs). If scores are indeterminate or high risk, the Enhanced Liver Fibrosis (ELF) blood test is used to assess for advanced fibrosis. Referral to hepatology is recommended if ELF is ≥10.51, if there are persistently high-risk scores, or if there is diagnostic uncertainty.

Patients with NAFLD should be referred to specialist hepatology services if there is evidence of advanced fibrosis, persistently abnormal liver function despite lifestyle modification, or diagnostic uncertainty. Emerging therapies are under investigation, but lifestyle modification remains the evidence-based foundation of care. Patients should not rely on supplements as alternatives to proven lifestyle interventions, and any supplement use should be discussed with healthcare professionals, particularly given potential risks to liver health. If you have concerns about your liver health or need support with lifestyle changes, speak to your GP or practice nurse.

Frequently Asked Questions