01/04/2026
Buyer beware and get regular screening for liver function if you take supplements.
In liver transplant centers across the U.S., there’s a story that has become more common in recent years.
The people showing up with liver damage are different ages with different motivations, but share the same story.
Someone shows up with fatigue that feels “off.” Nausea that hangs around. Maybe some abdominal pain. Maybe a faint yellow tint in the eyes that they didn’t notice until somebody else pointed it out. Their labs come back to indicate severe liver injury.
So, the team runs the usual list.
Viral hepatitis: ruled out.
Heavy alcohol use: ruled out.
An overdose: ruled out.
A prescription medication with a known liver-tox profile: ruled out.
Increasingly, there is one more critical question on that list: Are you taking any herbal or dietary supplements?
And that’s where the story gets unsettling.
In the last quarter century, supplement-related liver failure has surged.
One UNOS database analysis (1995–2020) found an eight-fold increase in herbal supplement and dietary supplement-related liver failure leading to transplant waitlisting - among non-acetaminophen drug-induced acute liver failure cases, the share attributed to supplements rose from 2.9% to 24.1% over the study period.
Those cases are specifically leading to transplant waitlisting, not “all liver failure nationally,” but it’s still an alarming trend.
**Why does this feel so surprising?**
Supplements live in a psychological category closer to self-care than medicine.
You can buy them a few aisles over from regulated drugs, in similarly professional packaging, with language that reads like gentle support: inflammation, metabolism, stress, immunity, “detox.” Many are sold as multi-ingredient blends with concentrated herbal extracts, which makes it hard to identify what ingredient did the damage when something goes wrong.
And crucially, the U.S. regulatory setup almost guarantees this mismatch between vibes and risk.
Today, dietary supplements can be marketed without FDA “approval” for safety and effectiveness the way drugs are, and FDA generally does not pre-approve supplement labeling claims before sale.
So, we have built a world where:
* supplement products can feel pharmaceutical,
* be purchased like groceries,
* and be trusted like medicine,
* without being evaluated for safety or efficacy like medicine.
That gap is where “surprising” liver failure is emerging from.
The scope: it’s bigger than most people realize
Two numbers that made me update my mental model:
In the Drug-Induced Liver Injury Network (DILIN, a prospective network of U.S. referral centers), liver injury attributed to herbal/dietary supplements rose from 7% to 20% over the study period they analyzed.
In that same DILIN report, the non-bodybuilding supplement cases (often multi-ingredient products) were more likely to lead to death or transplant compared to injury from conventional medications (13% vs 3%). Yikes.
That second point is important because it betrays a common assumption (even for me): “in the rare cases when supplements cause issues, they’re probably mild.”
Sometimes they are mild. But, other times, they are a one-way ticket to a transplant evaluation. My point is not that taking an herbal supplement is likely to cause liver damage, but rather that it can.
And supplement use is common enough that even rare severe outcomes add up. A CDC NHANES data brief found 57.6% of U.S. adults had used a dietary supplement in the past 30 days (2017–2018).
So even if the individual risk is low, the population-level math gets worrisome pretty quickly.
**Which supplements show up in these cases?**
When people talk about supplement-related liver injury, they don’t mean “a standard multivitamin at recommended doses.”
The heavy hitters tend to fall into a few buckets:
1) Multi-ingredient blends
These are the hardest to evaluate and the easiest to market. A proprietary blend of various herbal components is basically a fog machine in capsule form.
2) Weight loss and “metabolism” products
A common culprit in the literature, often involving concentrated botanical extracts (or mixtures of those extracts).
3) Bodybuilding products
These frequently involve anabolic steroid-type ingredients and can cause a distinctive cholestatic pattern with prolonged jaundice. These are less likely to be fatal / require transplant, but can still cause serious problems
Specific ingredients recur across case series and clinical resources. One widely cited review highlights anabolic steroids, green tea extract, and multi-ingredient nutritional supplements as major implicated agents.
And NIH’s LiverTox has a dedicated entry on green tea, including supplement-associated liver injury reports. Most people tolerate brewed green tea well; the risk signal shows up far more with concentrated green tea extracts. However, LiverTox notes rare cases even with very large intakes of regular brewed green tea.
**The “patent medicine” psychology is alive and well**
Here’s the trap: early symptoms of supplement-mediated injury are weirdly easy to explain away.
Fatigue. Nausea. Appetite changes. You are more likely to think “My stomach feels off” than “my green tea supplement is harming my liver”
In fact, maybe the nausea means it’s “working.” Maybe you’re “detoxing.”
In the 19th-century patent-medicine era, some snake oil remedies were intentionally formulated to burn, sting, or tingle because sensation could be sold as proof. An analysis of Clark Stanley’s Snake Oil Liniment found capsicum (hot pepper extract that causes a burning sensation) plus traces of camphor and turpentine (strong-smelling plant-derived compounds that irritate the skin and create warmth or stinging sensation).
You could tell that they were doing “something!”
**The part clinicians wish every patient would do**
If you take one thing from this, make it this:
Treat supplements like medications when you talk to your pharmacist and doctor.
Bring the list. Give them the details. Don’t hesitate to ask your pharmacist about potential interactions or risks.
There are some circumstances where taking specific supplements may be the right choice for your health picture. Your doctor can help you think through those decisions. I certainly would not paint myself as broadly anti-supplement.
But, the industry is very poorly regulated, and it can be hard to know which products you can trust to contain what they claim, at the claimed dosages, and without unexpected contaminants.
If you want a practical filter before you buy something:
**A quick checklist**
* Be wary of proprietary blends (unclear doses, unclear efficacy, unclear risk).
* Be extra cautious with “fat burner,” “detox,” “cleanse,” and “metabolism” claim positioning (these categories show up repeatedly in liver toxicity discussions).
* Prefer products with credible third-party testing (USP/NSF type programs can reduce some of the uncertainty related to quality, even though they don’t magically guarantee safety or effectiveness).
Assume that dangerous supplement interactions are possible if you take prescriptions, drink alcohol regularly, or have underlying liver disease. Ask your healthcare provider.
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