Ashwagandha & Liver Injury: What Clinicians Need to Know with Dr Eric Viegas

In this Root Cause Medicine podcast episode, Dr. Kate Kresge is joined by Dr. Eric Viegas, quality and safety lead at Fullscript, to explore emerging concerns around ashwagandha-associated drug-induced liver injury (DILI). While ashwagandha remains one of the most widely used adaptogens in integrative medicine, recent international case reports have highlighted rare but clinically meaningful hepatic adverse events. This episode equips clinicians with a mechanistic understanding of potential risk factors, withanolide content that may increase vulnerability, and practical strategies for patient screening, education, and monitoring—without dismissing the therapeutic value of this foundational herb.

Dr. Eric Viegas is a quality expert at Fullscript, where he oversees supplement quality programs, supply chain integrity, and clinical-grade standards. With expertise in pharmacology, toxicology, and nutraceutical regulation, Dr. Viegas supports practitioners in making evidence-informed decisions around supplement sourcing, formulation, and patient safety. Learn more: https://fullscript.com

Liver Function and Safety Monitoring Labs

Nutritional Considerations for Hepatic Resilience

Lifestyle and Integrative Support Strategies

All strategies are intended for educational support and clinical consideration and should be applied within the context of individualized care.

This episode is sponsored by Fullscript, a comprehensive care delivery platform designed to support whole-person, integrative healthcare. Fullscript allows clinicians to streamline supplement dispensing, lab ordering, and patient education in one free, centralized system—helping reduce administrative burden while supporting clinical decision-making. For practitioners, Fullscript offers access to professional-grade supplements, evidence-informed protocols, and lab integrations that can support more efficient treatment planning and follow-up. For patients, it provides a clear, organized way to receive recommendations, manage refills, and stay engaged in their care. The goal is not to replace clinical judgment, but to make it easier for clinicians to focus on what matters most: thoughtful, individualized patient care.

Yes, but it appears to be rare. Published case series and reports describe ashwagandha-associated drug-induced liver injury (DILI) with symptom onset most often within weeks (commonly ~2–12 weeks) after starting, and improvement typically occurring after stopping the product. Clinicians should treat this as an uncommon, but plausible, idiosyncratic adverse event rather than a predictable toxicity for all users (Björnsson et al., 2020).

Reported presentations resemble other forms of DILI and may include fatigue, pruritus, dark urine, and jaundice; some patients may have nonspecific malaise before overt cholestatic or hepatocellular patterns are recognized on labs. Educate patients to discontinue the product and seek evaluation promptly if these symptoms occur (Björnsson et al., 2020).

In published cases, liver injury has typically appeared within 2 to 12 weeks after initiation (though individual variability exists, as with other DILI phenotypes). This timing supports a practical monitoring window for higher-risk patients, especially early in therapy (Björnsson et al., 2020).

Risk appears to be influenced by host vulnerability and context, including pre-existing liver disease or prior liver injury, significant polypharmacy, and higher oxidative stress burden. Because DILI is often idiosyncratic, risk stratification is imperfect; however, these factors justify a more conservative approach and closer follow-up (Siddiqui et al., 2021; Björnsson et al., 2020).

A clinically cautious approach is to: