Ashwagandha (Withania somnifera)-Associated Liver Injury: A Scoping Review of Clinical Characteristics and Safety Considerations

Background: Ashwagandha (Withania somnifera) is a widely used herbal supplement marketed for stress relief and wellness. Although generally perceived as safe, accumulating reports of ashwagandha-associated liver injury have raised concern for hepatotoxic potential. Materials and methods: We conducted a global scoping review of the peer-reviewed clinical literature to systematically map and synthesize reports of ashwagandha-attributed liver injury. PubMed, Ovid MEDLINE(R) ALL, and MEDLINE Ultimate were searched through December 2025, with supplementary reference list screening. Eligible studies included peer-reviewed case reports and case series describing liver injury associated with single-ingredient ashwagandha products or multi-ingredient formulations containing ashwagandha. Non-peer-reviewed sources and non-English publications were excluded. Results: Thirteen publications met the inclusion criteria, encompassing 25 patients across multiple global regions. Liver injury typically develops after weeks of use. Cholestatic or mixed biochemical phenotypes predominated, commonly presenting with jaundice and pruritus; purely hepatocellular injury was less frequent. When applied, causality assessments generally classified ashwagandha as a probable or likely cause. Most patients recovered following discontinuation and supportive care, usually over weeks to months. Severe outcomes included one case of acute liver failure requiring transplantation and three deaths among patients with pre-existing cirrhosis who developed decompensation. Conclusions: The published literature supports the existence of a reproducible clinical syndrome of idiosyncratic, frequently cholestatic, ashwagandha-associated liver injury. Routine assessment of herbal supplement exposure is warranted in unexplained hepatitis or cholestasis, and patients with advanced chronic liver disease should be counseled to avoid ashwagandha. These findings suggest improved supplement traceability and strengthened pharmacovigilance to mitigate herbal-induced liver injury.