# Which supplements are linked to liver injury?

Source: https://www.healthnews24.co.za/answers/supplements-and-liver-injury-risk/
Publisher: Healthnews24 (South Africa's supplement answer desk)
Updated: 2026-10-27

> The supplements most often linked to liver injury are ashwagandha, concentrated green tea extract (EGCG) and multi-ingredient fat burners, plus any product secretly contaminated with anabolic steroids. Cases are rare and mostly reported as case series, but they are real. In South Africa, stop the product and see a doctor if you develop yellow eyes or skin, dark urine, itching or upper abdominal pain.

Key facts:
- Björnsson et al. (2020): five ashwagandha liver-injury cases, onset 2-12 weeks after starting, recovery in 1-5 months, no liver failure.
- EFSA (2018): EGCG intakes of 800 mg/day or more from supplements were associated with raised liver enzymes.
- Duiven et al. (2021): 38% of 66 Dutch web-shop supplements marketed for fat loss, muscle or energy contained undeclared doping substances.
- Denmark banned ashwagandha in food supplements in 2023; the Netherlands' RIVM advised against it in 2024.

## Which supplements have been linked to liver injury?

Four groups come up repeatedly in the medical literature. The evidence is mostly case reports and case series, so it shows that harm can happen, not how often.

| Group | What is reported | Evidence level |
|---|---|---|
| Ashwagandha (root extracts) | Cholestatic or mixed liver injury, usually 2-12 weeks after starting | Emerging safety signal (case series) |
| Green tea extract (EGCG) | Raised liver enzymes at 800 mg/day or more of EGCG from supplements | Regulatory assessments (EFSA, UK COT) |
| Fat burners and thermogenic blends | Stimulant overload, green tea extract, undeclared drugs | Multi-ingredient, hard to attribute |
| Steroid-contaminated "muscle" products | Cholestatic injury from undeclared anabolic steroids | Contamination studies |

## How strong is the evidence for ashwagandha?

A case series by Björnsson and colleagues (Iceland and the US DILIN network, 2020) described five people with ashwagandha-induced liver injury. Onset was 2-12 weeks after starting, the pattern was cholestatic or mixed, and everyone recovered within 1-5 months with no liver failure. An Indian case series reported similar findings.

Regulators have reacted: Denmark banned ashwagandha in food supplements in 2023, the Netherlands' RIVM advised against use in 2024, and an EU-level review was under consideration in 2026. In South Africa, ashwagandha capsules are sold by retailers such as Faithful to Nature; no ban applies here, but the same cautions do. Read our full answer on [whether ashwagandha is safe in South Africa](/answers/is-ashwagandha-safe-south-africa/).

## What about green tea extract and fat burners?

EFSA's 2018 assessment linked supplemental EGCG intakes of 800 mg/day or more to raised transaminases (a marker of liver stress), and the UK Committee on Toxicity published a statement on green tea catechin hepatotoxicity in 2024. Fat burners are harder to judge because they combine caffeine, green tea extract and other actives. In South Africa they are sold as Category D complementary medicines, and Dis-Chem Living Fit pages for brands such as USN, NPL and Biogen state the products have not been evaluated by SAHPRA. See [are fat burners safe in South Africa](/answers/are-fat-burners-safe-south-africa/) and [does green tea extract help fat loss](/answers/does-green-tea-extract-help-fat-loss/).

## Why do contaminated products matter?

Geyer and colleagues (2004) found undeclared anabolic steroids in 14.8% of 634 non-hormonal supplements from 13 countries. Duiven and colleagues (2021) found undeclared doping substances in 38% of 66 Dutch web-shop products marketed for fat loss, muscle, energy or hormones. Anabolic steroids can cause cholestatic liver injury, so a "natural" muscle or testosterone product is not automatically safe.

## Who should be most careful?

- Anyone with existing liver disease or who drinks heavily
- People on prescription medicines that stress the liver (ask your pharmacist)
- Anyone stacking several herbal or stimulant products at once
- Pregnant or breastfeeding women, and under-18s

L-glutamine also carries a caution in liver disease, particularly where hepatic encephalopathy is a risk.

## What are the warning signs?

Stop the product and contact a doctor promptly if you notice yellow skin or eyes, dark urine, pale stools, persistent itching, upper right abdominal pain, nausea or unusual fatigue. Take the tub or box, with the batch number, to the appointment. Then [report the side effect](/answers/how-to-report-a-supplement-side-effect-south-africa/).

## How can you lower the risk?

- Start one new supplement at a time, so a reaction can be traced.
- Prefer single-ingredient products with clear doses over multi-ingredient "stacks".
- Keep total EGCG well below 800 mg/day.
- If you are drug-tested, choose batch-tested products and read [what third-party tested means](/answers/what-does-third-party-tested-mean/).

This is general information, not medical advice.

## Sources

- [Björnsson et al. (2020) Ashwagandha-induced liver injury: case series from Iceland and the US DILIN. Liver International 40:825](https://iris.landsbokasafn.is/en/publications/ashwagandha-induced-liver-injury-a-case-series-from-iceland-and-t-2/)
- [Ashwagandha-induced liver injury: a case series from India and literature review (PubMed)](https://pubmed.ncbi.nlm.nih.gov/37756041/)
- [NutraIngredients (Apr 2018): EFSA safety assessment on green tea catechins (EGCG) and liver effects](https://www.nutraingredients.com/Article/2018/04/19/EGCG-warning-EFSA-safety-assessment-suggests-green-tea-supplements-should-come-with-warning)
- [UK Committee on Toxicity (2024): Statement on the hepatotoxicity of green tea catechins, lay summary](https://cot.food.gov.uk/sites/default/files/2024-11/COT%2008.2024%20-%20Statement%20on%20the%20hepatotoxicity%20of%20green%20tea%20catechins_Lay%20summary.pdf)
- [Duiven et al. (2021) Undeclared doping substances are highly prevalent in commercial sports nutrition supplements. J Sports Sci Med 20:328](https://jssm.org/jssm-20-328.xml-abst)