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Supplements' Share of Drug-Induced Liver Injury Rose Over 20 Years in U.S. Registry

A larger share of serious liver injury cases came from supplements and cancer drugs over two decades, while the antibiotic share fell.

By Dr. Josh Axe · November 2, 2026 · 1 source · Watch

Photo: Pexels

At a glance

What they found: Oncology patients and those over 65 had significantly higher overall and liver-related mortality.
Who was studied: 1,983 high-causality drug-induced liver injury cases, median age 52, 59% female, with and without prior chronic liver disease.

A 20-year U.S. registry of serious drug-induced liver injury, published October 23, 2026 in Hepatology, found the share of cases linked to herbal and dietary supplements rose significantly even as the share linked to antibiotics fell.

1,983cases tracked

41%from antibiotics

30%oncology deaths

A 20-year U.S. registry study tracked 1,983 confirmed cases of idiosyncratic drug-induced liver injury, meaning liver damage from an unpredictable reaction to a medication, supplement or herbal product rather than dose-related poisoning. Patients were followed for 6 months at multiple U.S. sites from 2004 to 2024. Median age was 52, 59% were female and 54% had a liver-cell pattern of injury. Antibiotics remained the leading drug class at 41% of cases, but their share, along with isoniazid, nitrofurantoin and central nervous system drug cases, decreased significantly over the two decades. Over the same period, the share from herbal and dietary supplement products and cancer drugs, including checkpoint inhibitors, increased significantly. Severity markers, including peak bilirubin and the clotting measure INR, decreased significantly over time.

Patients with pre-existing chronic liver disease had higher mortality than those without it. Oncology patients and those over 65 had significantly higher overall and liver-related mortality. Children presented more often with liver-cell injury but had lower death rates than adults. Cancer patients with liver injury had a 30% death rate at 6 months, with most deaths from causes other than liver failure.

Severe allergic-type liver reactions happen when the immune system mistakenly attacks liver cells after exposure to a drug, herbal compound or supplement ingredient, often in people with a genetic susceptibility. Herbal and dietary products aren't standardized or tested for liver safety the way prescription drugs are, so contamination, mislabeled ingredients or unexpectedly high doses of active compounds can play a role.

Leading Drug Class in Severe Liver Injury Cases

Hepatology, 2026, Fontana

This registry draws from referred, high-causality cases at specialized centers, not a population-wide survey, so it cannot show how common liver injury is relative to how many people use each product. This shows a link, not proof that any one product causes liver injury in a given person.

Dr. Axe’s Take

Antibiotics still caused 41% of these liver injuries, and they don't address why infections keep coming back; an unneeded course can cost you liver injury on top of gut disruption. The rising share from herbal and dietary supplements tells me quality and dose matter as much as the ingredient: a concentrated extract is not turmeric or ginger in food. What I'd watch for is new fatigue, dark urine or yellowing skin after starting any medication or supplement, so tell your doctor everything you take. And listen, never stop or change a medication on your own. Make that change with your practitioner.

— Dr. Axe

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Study summary

Who: 1,983 high-causality drug-induced liver injury cases, median age 52, 59% female, with and without prior chronic liver disease.
Design: Observational registry, consecutive cases followed for 6 months across multiple U.S. sites, 2004 to 2024.
Dose: Not applicable; observational registry of real-world drug and supplement exposures.
Primary result: Antibiotics caused 41% of cases; antibiotic and CNS-drug shares decreased significantly over 20 years while herbal/supplement and cancer-drug shares increased significantly.
Secondary: Peak bilirubin, INR and severity scores decreased significantly over time; oncology patients had a 30% death rate at 6 months, mostly from non-liver causes.
Funding / conflicts: Funding and conflicts not reported in the abstract.
Date: Oct 23, 2026