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Several dietary supplements containing ashwagandha are marketed in the US and Europe, but only one case of drug\u2010induced liver injury (DILI) due to ashwagandha\u00a0has been published. The aim of this case series was to describe the clinical phenotype of suspected ashwagandha\u2010induced liver injury.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Five cases of liver injury attributed to ashwagandha\u2010containing supplements were identified; three were collected in Iceland during 2017\u20102018 and two from the Drug\u2010Induced Liver Injury Network (DILIN) in 2016. Other causes for liver injury were excluded. Causality was assessed using the DILIN structured expert opinion causality approach.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Among the five patients, three were males; mean age was 43\u00a0years (range 21\u201062). All patients developed jaundice and symptoms such as nausea, lethargy, pruritus and abdominal discomfort after a latency of 2\u201012\u00a0weeks. Liver injury was cholestatic or mixed (<jats:italic>R<\/jats:italic> ratios 1.4\u20103.3). Pruritus and hyperbilirubinaemia were prolonged (5\u201020\u00a0weeks). No patient developed hepatic failure. Liver tests normalized within 1\u20105\u00a0months in four patients. One patient was lost to follow\u2010up. One biopsy was performed, showing acute cholestatic hepatitis. Chemical analysis confirmed ashwagandha in available supplements; no other toxic compounds were identified. No patient was taking potentially hepatotoxic prescription medications, although four were consuming additional supplements, and in one case, rhodiola was a possible causative agent along with ashwagandha.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>These cases illustrate the hepatotoxic potential of ashwagandha. Liver injury is typically cholestatic or mixed with severe jaundice and pruritus, but self\u2010limited with liver tests normalizing in 1\u20105\u00a0months.<\/jats:p><\/jats:sec>","DOI":"10.1111\/liv.14393","type":"journal-article","created":{"date-parts":[[2020,1,28]],"date-time":"2020-01-28T22:29:17Z","timestamp":1580250557000},"page":"825-829","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":114,"title":["Ashwagandha\u2010induced liver injury: A case series from Iceland and the US Drug\u2010Induced Liver Injury Network"],"prefix":"10.1111","volume":"40","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3150-5653","authenticated-orcid":false,"given":"Helgi K.","family":"Bj\u00f6rnsson","sequence":"first","affiliation":[{"name":"Landspitali University Hospital Reykjavik Iceland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8392-0632","authenticated-orcid":false,"given":"Einar S.","family":"Bj\u00f6rnsson","sequence":"additional","affiliation":[{"name":"Landspitali University Hospital Reykjavik Iceland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bharathi","family":"Avula","sequence":"additional","affiliation":[{"name":"National Center for Natural Products Research School of Pharmacy University of Mississippi University MS USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ikhlas A.","family":"Khan","sequence":"additional","affiliation":[{"name":"National Center for Natural Products Research School of Pharmacy University of Mississippi University MS USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jon G.","family":"Jonasson","sequence":"additional","affiliation":[{"name":"Landspitali University Hospital Reykjavik Iceland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marwan","family":"Ghabril","sequence":"additional","affiliation":[{"name":"Indiana University School of Medicine Indianapolis IN USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5371-1020","authenticated-orcid":false,"given":"Paul H.","family":"Hayashi","sequence":"additional","affiliation":[{"name":"University of North Carolina Chapel Hill NC USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Victor","family":"Navarro","sequence":"additional","affiliation":[{"name":"Einstein Healthcare Network Sidney Kimmel Medical College Philadelphia PA USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2020,2,11]]},"reference":[{"key":"e_1_2_9_2_1","doi-asserted-by":"publisher","DOI":"10.1038\/ajg.2016.114"},{"key":"e_1_2_9_3_1","doi-asserted-by":"publisher","DOI":"10.1002\/hep.28813"},{"key":"e_1_2_9_4_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2013.02.006"},{"key":"e_1_2_9_5_1","doi-asserted-by":"publisher","DOI":"10.1002\/hep.27317"},{"key":"e_1_2_9_6_1","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2019.02.002"},{"key":"e_1_2_9_7_1","doi-asserted-by":"publisher","DOI":"10.1038\/ajg.2012.138"},{"key":"e_1_2_9_8_1","doi-asserted-by":"publisher","DOI":"10.5152\/tjg.2014.4486"},{"key":"e_1_2_9_9_1","doi-asserted-by":"publisher","DOI":"10.3390\/ijms17030313"},{"key":"e_1_2_9_10_1","doi-asserted-by":"publisher","DOI":"10.1097\/MEG.0b013e32835f6889"},{"key":"e_1_2_9_11_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.cgh.2017.12.051"},{"key":"e_1_2_9_12_1","doi-asserted-by":"publisher","DOI":"10.3945\/jn.110.133025"},{"key":"e_1_2_9_13_1","doi-asserted-by":"publisher","DOI":"10.3390\/molecules14072373"},{"key":"e_1_2_9_14_1","first-page":"1","article-title":"Trends 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