Ashwagandha and Fatty Liver: What the Evidence Shows

Ashwagandha and fatty liver disease is a topic attracting growing interest, particularly as more people in the UK seek complementary approaches alongside conventional care. Ashwagandha (Withania somnifera) is an adaptogenic herb used in Ayurvedic medicine, and some early research has explored its potential effects on liver health, inflammation and metabolic function. However, the evidence base remains limited, and there are important safety considerations for people with liver conditions. This article examines what the current research shows, what the NHS recommends for fatty liver management, and why speaking to your GP before taking any supplement is essential.

What is fatty liver disease and how is it managed in the UK?

Fatty liver disease in the UK is managed primarily through lifestyle modification, including weight loss, diet and exercise, as no licensed pharmacological treatment for MASLD currently exists. NICE NG49 guides risk stratification using tools such as the FIB-4 score and ELF test.

Fatty liver disease is a condition in which excess fat accumulates within liver cells, and in the UK it is broadly divided into two main types: metabolic dysfunction-associated steatotic liver disease (MASLD, previously called non-alcoholic fatty liver disease or NAFLD) and alcohol-related liver disease (ALD). MASLD is closely linked to obesity, type 2 diabetes, high cholesterol and insulin resistance, and is increasingly common in the UK population.^[1][4] ALD results from prolonged excessive alcohol consumption.

In its early stages, fatty liver disease often causes no symptoms and is frequently identified incidentally during blood tests or abdominal ultrasound scans. If left unmanaged, it can progress through stages of inflammation (steatohepatitis) and fibrosis, potentially leading to cirrhosis or liver failure in a minority of people.

Management in the UK is primarily guided by NICE and NHS recommendations. As of the time of writing, there is no licensed pharmacological treatment specifically indicated for MASLD in the UK; clinical management centres on lifestyle modification, including sustained weight loss, a balanced diet, increased physical activity and, where relevant, reduction or cessation of alcohol intake.^[1][5] Conditions such as type 2 diabetes, hypertension and dyslipidaemia are managed alongside liver disease, as controlling these can slow progression.

In primary care, risk stratification is an important step. NICE guidance (NG49) recommends using non-invasive scoring tools such as the FIB-4 score or the NAFLD Fibrosis Score to identify people at higher risk of advanced fibrosis.^[1][2] Where these scores suggest intermediate or high risk, the enhanced liver fibrosis (ELF) test, recommended by NICE (DG34), can help guide decisions about specialist referral.^[1][2] People with persistently abnormal liver function tests, a high FIB-4 or ELF score, or clinical features suggesting advanced disease should be referred to a hepatologist or specialist liver service.

Red flags that warrant prompt assessment include jaundice (yellowing of the skin or eyes), ascites (abdominal swelling due to fluid), gastrointestinal bleeding, or signs of hepatic encephalopathy such as confusion or drowsiness. Anyone experiencing these symptoms should seek urgent medical attention.

Regular monitoring through liver function tests and stepwise non-invasive assessment is recommended for those with confirmed or suspected fatty liver disease, in line with NICE NG49.

Is ashwagandha good for fatty liver, what does the evidence say?

Current clinical evidence is insufficient to confirm ashwagandha is beneficial for fatty liver disease, and no UK body such as NICE or the MHRA has endorsed its use for this purpose. Most data comes from small or preclinical studies with significant methodological limitations.

The current clinical evidence is insufficient to confirm that ashwagandha is beneficial for fatty liver disease in humans, and no UK regulatory body such as NICE or the MHRA has endorsed its use for this purpose. Ashwagandha (Withania somnifera) is an adaptogenic herb used in Ayurvedic medicine, and while it has attracted research interest for a range of conditions including stress, thyroid function and metabolic health, its specific effects on liver fat accumulation remain poorly studied in robust human trials.

Most of the available data comes from preclinical studies conducted in animal models or small, short-duration human studies with methodological limitations. Some laboratory and animal research has suggested that withanolides, the active compounds in ashwagandha, may have anti-inflammatory and antioxidant properties that could theoretically benefit liver tissue. However, findings from animal studies do not reliably translate to human outcomes, and the doses used in laboratory settings often differ substantially from those found in commercially available supplements.

A small number of human studies have examined ashwagandha's effects on liver enzymes such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST), with some reporting modest reductions. However, these studies were not specifically designed to assess fatty liver disease, their sample sizes were too small to draw firm conclusions, and their findings have not been replicated in large, well-designed randomised controlled trials.

It is also important to note that ashwagandha products sold in the UK are typically classified as food supplements rather than licensed medicines, and are not subject to the same pre-market safety and efficacy evaluation as licensed pharmacological treatments. NICE NG49 does not recommend ashwagandha or any other herbal supplement as part of MASLD management.

In summary, while early research is exploratory and not without interest, there is no official endorsement of ashwagandha supplementation for clinically meaningful improvement in fatty liver disease. Patients should not use ashwagandha as a substitute for evidence-based management.

How might ashwagandha affect liver health?

Ashwagandha may theoretically support liver health via antioxidant and anti-inflammatory mechanisms, but it has also been linked to drug-induced liver injury in case reports. People with existing liver conditions face a potential risk of harm rather than guaranteed benefit.

Ashwagandha may influence liver health through several proposed biological mechanisms, though it is important to note that these remain largely theoretical or based on preclinical data rather than confirmed human evidence. The primary active constituents, withanolides, are thought to exert antioxidant effects by reducing oxidative stress within liver cells, which is one of the drivers of inflammation and fibrosis in fatty liver disease. Some research also suggests anti-inflammatory activity, potentially modulating pathways involved in hepatic inflammation.

Additionally, ashwagandha has been studied for its potential to improve insulin sensitivity and reduce blood glucose levels, both of which are relevant to MASLD given its close association with metabolic syndrome. If these metabolic effects are confirmed in larger trials, they could indirectly support liver health. Some animal studies have also suggested a possible role in reducing lipid accumulation in liver tissue, though again, human evidence is lacking.

However, there is an important safety consideration that must not be overlooked: ashwagandha has been associated with cases of drug-induced liver injury (DILI) in published case reports. These cases have included cholestatic hepatitis and, in rare instances, more severe liver injury. The mechanism is not fully understood, and it is unclear whether the risk relates to specific preparations, doses or individual susceptibility. The MHRA has received reports of suspected adverse reactions associated with ashwagandha supplements, including liver-related effects, through the Yellow Card scheme.^[6]

Ashwagandha should not be taken during pregnancy, when trying to conceive, or whilst breastfeeding.^[10] There is insufficient evidence of safety in these groups, and some traditional use data raise concerns about potential effects on pregnancy.

This means that for people who already have compromised liver function, including those with fatty liver disease, taking ashwagandha supplements carries a potential risk of harm rather than guaranteed benefit. Caution is therefore strongly advised, and medical guidance should be sought before use.

What does the NHS recommend for managing fatty liver disease?

The NHS recommends gradual sustained weight loss, a Mediterranean-style diet, regular physical activity and alcohol reduction as the cornerstones of MASLD management. No herbal or dietary supplement, including ashwagandha, is endorsed as part of standard NHS care.

The NHS recommends a structured lifestyle approach as the cornerstone of managing fatty liver disease, particularly MASLD, with no specific herbal or dietary supplement currently endorsed as part of standard care.

The most effective intervention supported by evidence is gradual, sustained weight loss. NICE NG49 states that losing between 7% and 10% of body weight can reduce liver fat, improve liver enzyme levels and, in some cases, reverse early-stage fibrosis.^[1][2] Weight loss should be achieved gradually and maintained over time.

Dietary guidance from the NHS and NICE encourages a Mediterranean-style diet, which is rich in vegetables, legumes, wholegrains, oily fish and olive oil, and low in saturated fat, refined sugars and ultra-processed foods. Reducing or eliminating alcohol is also strongly recommended, even in people whose fatty liver is not primarily alcohol-related, as alcohol can accelerate liver damage.

Regular physical activity is independently beneficial for liver health, with both aerobic exercise and resistance training shown to reduce hepatic fat content.^[1][4] NHS guidance recommends at least 150 minutes of moderate-intensity activity per week for adults, consistent with general physical activity guidelines for adults in England.^[7][8]

For people with associated conditions such as type 2 diabetes or high cholesterol, optimising management of these conditions through medication and lifestyle changes is an integral part of fatty liver management. Some medicines used for type 2 diabetes, including GLP-1 receptor agonists, are being investigated for their potential hepatic benefits.^[9] However, their use specifically for fatty liver disease, outside of their licensed indications, is not a standard commissioned pathway, and access and commissioning decisions vary between Integrated Care Boards (ICBs) in England and may change over time. Individuals should discuss their options with their GP or specialist.

Regular follow-up with a GP or specialist is important to monitor disease progression, repeat non-invasive risk stratification as appropriate, and adjust management as needed, in line with NICE NG49.

Should you talk to your GP before taking ashwagandha supplements?

Yes, anyone with fatty liver disease should speak to their GP before taking ashwagandha, given its association with liver injury and potential interactions with prescribed medicines. Stop taking it and seek prompt medical advice if jaundice, dark urine or abdominal pain develop.

Yes, anyone with fatty liver disease or any other liver condition should speak to their GP before starting ashwagandha supplements, given the documented association between ashwagandha and liver injury in some individuals. This is particularly important because supplements are not subject to the same pre-market safety and efficacy evaluation as licensed medicines in the UK, and the quality, purity and dose of ashwagandha can vary considerably between products.

Your GP can review your current liver function tests, assess whether supplementation poses a specific risk given your medical history, and advise on whether any potential benefit is plausible in your individual case. If you are already taking prescribed medicines, including those for diabetes, thyroid conditions or cholesterol, it is essential to discuss potential interactions. Ashwagandha may affect thyroid hormone levels and could interact with immunosuppressants or sedative medications; your GP or pharmacist can advise on your specific circumstances.

Ashwagandha should not be used during pregnancy, when trying to conceive, or whilst breastfeeding.^[10] If you are pregnant or planning a pregnancy, speak to your GP or midwife before taking any herbal supplement.

If you develop any of the following symptoms after starting ashwagandha, you should stop taking it and contact your GP promptly:

• Yellowing of the skin or whites of the eyes (jaundice)

• Dark urine or pale stools

• Persistent nausea, vomiting or abdominal pain

• Unusual fatigue or loss of appetite

If symptoms are severe or rapidly worsening, seek urgent assessment via NHS 111 or attend your nearest A&E department.

Patients, carers and healthcare professionals who suspect that a supplement has caused an adverse reaction are encouraged to report it via the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk. Reporting helps the MHRA monitor the safety of supplements and medicines available in the UK.

In conclusion, while ashwagandha is widely available and generally considered safe in healthy adults at recommended doses, the evidence does not currently support its use as a treatment for fatty liver disease, and the potential for liver harm in susceptible individuals means that medical guidance should always be sought first.

Scientific References

1. Metabolic dysfunction-associated steatotic liver disease (MASLD): assessment and management (NG49).
2. Metabolic dysfunction-associated steatotic liver disease (MASLD): assessment and management (NG49) – full PDF.
3. MRI-based technologies for assessing non-alcoholic fatty liver disease – The diagnostic tests (HTG655).
4. Non-alcoholic fatty liver disease (NAFLD).
5. Resmetirom (Rezdiffra) authorised to treat metabolic dysfunction-associated steatohepatitis (MASH) in adults.
6. Herbal medicines: report suspected adverse reactions to the Yellow Card scheme.
7. Physical activity guidelines for adults aged 19 to 64.
8. New UK CMO activity guidelines show every movement counts.
9. GLP-1 Receptor Agonists and Cirrhosis in Metabolic Dysfunction-Associated Steatotic Liver Disease.
10. Use of medicines in pregnancy and breastfeeding.

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