TABLE 1.

Demography and clinical details of patients with ashwagandha-induced liver injury

	Patient 1	Patient 2	Patient 3	Patient 4	Patient 5	Patient 6	Patient 7	Patient 8
Sex	Male	Female	Male	Male	Female	Male	Male	Male
Age (y)	75	31	34	58	50	39	68	47
Diabetes	Yes	No	No	Yes	No	No	Yes	No
Hypertension	No	No	No	No	No	No	Yes	No
Overweight or obese	No	No	No	No	Yes	No	No	No
Chronic liver disease	Yes	No	Yes	No	No	Yes	Yes	Diagnosed during event
Etiology of chronic liver disease	NAFLD	—	NASH	—	—	Alcohol (abstinent)	NAFLD	Cryptogenic
Other comorbidities	None	None	None	NHL in long remission	Bipolar disorder	None	None	None
Co-medications	Insulin, oral hypoglycemic agents	None	None	None	Amisulpride and lithium for over 3 y	None	Insulin, oral hypoglycemic agents	None
Indication for ashwagandha use	Insomnia	Postpregnancy “stress”	Appetite stimulant	“Anticancer” preventive	Stress detox and sleep aid	Fever	General wellness and energy booster	General wellness and energy booster
Duration of herb intake (d)	30	14	60	94	540	30	60	17
Dose	Approximately 20 g/d	10–15 g/d	10–15 g/d	500 mg daily	~100 mL daily	Manufacturer instruction	Manufacturer instruction	Manufacturer instruction
Time to symptom onset (d)	24	14	52	96	540	30	62	15
Onset of lab abnormalities (d)	35	14	62	100	546	30	65	16
Predominant symptoms	Lethargy and jaundice	Pruritus	Pruritus and jaundice	Jaundice and pruritus	Pruritus and jaundice	Jaundice and abdominal distension	Lethargy and jaundice	Jaundice and pruritus
Clinical presentation	ACLF	Acute hepatitis	Acute hepatitis	Acute hepatitis	Acute hepatitis	ACLF	Acute hepatitis	ACLF
Steroid use for treatment	No	No	Yes, 40 mg/d for 15 d	Yes, 40 mg/d for 30 d	No	No	Yes, 40 mg/d for 30 d	No
Resolution of HILI	No	Yes	Yes	Yes	Yes	No	Yes	No
Time to resolution (d)		45	30	60	95	—	56	—
Outcome	Dead	Alive	Alive	Alive	Alive	Dead	Alive	Dead
Time from diagnosis to final follow-up (d)	288	375	430	486	235	30	302	242
Ashwagandha product consumed	Homemade powder	Lehyam (herbal jam)	Branded powder	Nonbranded tablets	Detox tea	Branded powder	Branded powder and tablets	Branded powder and syrup
Person who prescribed the herb	Self, OTC	Ayurveda practitioner	Self, OTC	Ayurveda practitioner	Self, OTC	Ayurveda practitioner	Ayurveda practitioner	Ayurveda practitioner

Abbreviations: ACLF, acute-on-chronic liver failure; HILI, herb-induced liver injury; NHL, non-Hodgkin lymphoma; OTC, over-the-counter.