Ashwagandha and Fatty Liver: Is It Safe?

If you have fatty liver disease and are wondering whether ashwagandha is safe to take, the answer is not straightforward. Ashwagandha (Withania somnifera) is a popular herbal adaptogen widely sold in the UK for stress, fatigue, and sleep, but it has been linked to cases of drug-induced liver injury in published case reports. For people already living with non-alcoholic fatty liver disease (NAFLD) or metabolic dysfunction-associated steatotic liver disease (MASLD), the risk-benefit balance is particularly uncertain. This article outlines what the evidence shows, which warning signs to watch for, and what to discuss with your GP before trying this supplement.

What is ashwagandha and why do people take it?

Ashwagandha is an Ayurvedic herbal adaptogen sold in the UK as a food supplement for stress, fatigue, and sleep. Most products are not MHRA-licensed, so quality and withanolide concentration vary widely between brands.

Ashwagandha (Withania somnifera) is a herbal adaptogen used in Ayurvedic medicine, most commonly taken to help manage stress, fatigue, and sleep difficulties. In the UK, most ashwagandha products are sold as food supplements and are regulated primarily under general food law, overseen by the Food Standards Agency (FSA) and enforced by Trading Standards. This means there is no MHRA pre-market authorisation process for these products, though producers have a legal duty to ensure their products are safe and correctly labelled before placing them on sale. A small number of herbal products may instead hold an MHRA Traditional Herbal Registration (THR), which requires evidence of quality and traditional use, but most ashwagandha products on sale in the UK do not hold a THR.^[2][3]

People take ashwagandha in several forms, including:

• Capsules or tablets containing root or leaf extract

• Powders added to drinks or food

• Liquid tinctures

Because ashwagandha supplements sit outside the medicines licensing framework, the quality, concentration, and purity of products can vary considerably between brands. Standardised extracts (often labelled by their withanolide content) tend to be used in clinical research, but many over-the-counter products do not specify their withanolide concentration, making it difficult to compare them with study findings.

The supplement is widely marketed for stress relief and general wellbeing, and interest in it has grown substantially in the UK in recent years. However, widespread availability does not mean universal safety, particularly for people who already have an underlying health condition such as non-alcoholic fatty liver disease (NAFLD) or metabolic dysfunction-associated steatotic liver disease (MASLD). Anyone with a pre-existing liver condition should approach any new supplement with caution, use products from reputable UK suppliers, and seek professional advice before starting. Where possible, avoid multi-ingredient products, as these make it harder to identify the cause if an adverse effect occurs.

What does the evidence say about ashwagandha and liver health?

Ashwagandha has been linked to drug-induced liver injury in published case reports, and neither NICE nor NHS guidance recommends it for fatty liver disease. The evidence base is insufficient to support its routine use as a liver-protective supplement.

The evidence on ashwagandha and liver health is mixed, and people with fatty liver disease should be aware that the supplement has been linked to cases of drug-induced liver injury (DILI). Several published case reports, including cases reported in peer-reviewed journals such as BMJ Case Reports, have described cholestatic or hepatocellular liver injury in individuals taking ashwagandha supplements, in some cases requiring hospitalisation.^[4][5] Pharmacovigilance signals, including reports submitted to the MHRA Yellow Card scheme, have also been recorded. Liver injury has generally resolved after stopping the supplement, but this is not guaranteed, and in some reported cases the course was prolonged.

At the same time, some small-scale studies have suggested that ashwagandha may have anti-inflammatory or antioxidant properties that could theoretically benefit liver tissue.^[12] However, these studies are generally short in duration, involve small numbers of participants, and have not been conducted specifically in people with NAFLD or MASLD. Neither NICE (NG49: Non-alcoholic fatty liver disease: assessment and management) nor NHS guidance identifies ashwagandha as a recommended or evidence-based therapy for NAFLD or MASLD.^[6][7] The evidence base is therefore insufficient to support routine use of ashwagandha as a liver-protective supplement.

For people who already have fatty liver disease, the liver's capacity to metabolise compounds may be altered, which could affect how ashwagandha and its active constituents are processed. This does not mean ashwagandha is definitively harmful in this group, but it does mean the risk-benefit balance is less clear than in people with healthy liver function.

Key points to bear in mind:

• There is no evidence-based recommendation for ashwagandha as a treatment or supplement in fatty liver disease

• Published DILI cases have occurred at doses within the range commonly sold in UK supplements^[4][5]

• If you develop symptoms that may suggest liver injury (see the section below), stop ashwagandha immediately and seek medical advice

• Liver injury has generally resolved after stopping the supplement, but recovery is not guaranteed

Given this uncertainty, a conversation with a GP or hepatologist before starting ashwagandha is strongly advisable for anyone with a known liver condition.

Which signs of liver stress should you watch for when taking supplements?

Stop ashwagandha immediately and contact your GP if you develop jaundice, dark urine, pale stools, persistent nausea, upper right abdominal pain, unusual fatigue, or unexplained itching. Jaundice with confusion requires urgent contact with NHS 111.

Anyone taking ashwagandha, particularly those with pre-existing fatty liver disease, should be alert to symptoms that may indicate liver stress or injury. It is worth noting that in NAFLD and MASLD, liver function tests (LFTs) can sometimes be within the normal range even when liver disease is present.^[6][8] However, suspected drug-induced liver injury (DILI) typically does produce biochemical changes on LFTs, so monitoring remains important.

Symptoms that warrant stopping ashwagandha immediately and contacting your GP include:

• Jaundice: yellowing of the skin or whites of the eyes

• Dark urine: tea or cola-coloured urine, which can indicate bilirubin excretion

• Pale or clay-coloured stools

• Persistent nausea or loss of appetite that is new or worsening

• Upper right abdominal discomfort or tenderness

• Unusual fatigue that is disproportionate to activity levels

• Itching (pruritus) without an obvious skin cause

If any of these symptoms develop, stop the supplement straight away and contact your GP promptly. If you develop jaundice alongside confusion or you feel acutely unwell, contact NHS 111 for urgent advice, as these may indicate more serious liver decompensation.

It is good practice to have baseline LFTs checked by your GP before starting any new supplement if you have a known liver condition. This gives a reference point against which any future changes can be compared. If you are already having regular monitoring for fatty liver disease, inform your GP that you are taking ashwagandha so that any changes in your results can be interpreted in context.

If you suspect a supplement has caused a side effect, this can be reported to the MHRA via the Yellow Card scheme at yellowcard.mhra.gov.uk, which helps build the national evidence base on supplement safety.

What should you tell your GP or liver specialist before trying ashwagandha?

Tell your GP your liver diagnosis and fibrosis stage, all current medications and supplements, and the specific ashwagandha product and dose you are considering. Your GP may recommend baseline liver function tests and could advise against use if your liver disease is advanced.

Before starting ashwagandha, people with fatty liver disease should have an open conversation with their GP or hepatologist, providing as much relevant information as possible to allow a properly informed assessment. This is particularly important because supplements are not routinely captured on NHS medication records unless the patient mentions them.

Information to share with your clinician includes:

• Your current liver diagnosis, including any recent ultrasound or fibroscan results and the stage of fibrosis if known

• All current medications, including prescribed drugs, over-the-counter medicines, and any other supplements, as some combinations may increase the risk of liver stress

• The specific ashwagandha product you are considering, including the dose, extract type, and withanolide concentration if stated on the label

• Any other health conditions, such as thyroid disorders or autoimmune conditions: some evidence suggests ashwagandha may influence thyroid hormone levels and could interact with immunosuppressant therapy, so specialist input is advisable in these situations^[10]

• Whether you are pregnant or breastfeeding: ashwagandha should be avoided in pregnancy, and is also best avoided during breastfeeding due to insufficient safety data; do not take it in either situation unless specifically advised by a specialist^[11]

Your GP may recommend checking LFTs before you start and again after a period of use if you proceed; the timing and frequency of monitoring is best determined by your clinician based on your individual circumstances. They may also advise against use if your liver disease is at an advanced stage or if you are taking hepatically metabolised medicines. Asking for all supplements to be documented in your medical record is also worthwhile.

If you are managing your weight as part of your fatty liver treatment, your GP or a specialist weight-management service can advise on evidence-based approaches. Bolt Pharmacy is a GPhC-registered UK online pharmacy offering online weight-management consultations, with prescriber review and pharmacist support, which may be relevant if lifestyle and medical weight management form part of your care plan.

Ultimately, the decision to take ashwagandha with fatty liver disease should be made with clinical input rather than based on general supplement marketing, given the current uncertainty in the evidence.

Scientific References

1. Summary of responses to call for evidence on Ashwagandha.
2. Apply for a traditional herbal registration (THR).
3. Guidance on new provisions for traditional herbal medicinal products and homoeopathic medicinal products.
4. Herb Induced Liver Injury.
5. Ashwagandha-Induced Hepatic Injury: A Case Report.
6. Metabolic dysfunction-associated steatotic liver disease (MASLD): assessment and management (NG49).
7. Metabolic dysfunction-associated steatotic liver disease (MASLD): assessment and management (NG49) — full guideline PDF.
8. Non-alcoholic fatty liver disease (NAFLD).
9. Non-invasive tests for diagnosing NAFLD in adults — research recommendation.
10. Efficacy and Safety of Ashwagandha Root Extract in Subclinical Hypothyroid Patients.
11. Reproductive and developmental safety assessment of Ashwagandha (Withania somnifera).
12. Anti-inflammatory and anti-angiogenic effects of Withania somnifera.

Frequently Asked Questions