Introduction: Herbs and herbal products are worldwide used in large amounts for treating minor ailments and for disease prevention. However, certain adverse reactions, such as liver injury have been associated with the consumption of some herbs and herbal products. Herb-induced liver injury (HILI) is caused by an herb or herbal extract that contains many chemicals, at least one of which is responsible for the hepatotoxic impact. In contrast, drug-induced liver damage (DILI) is a type of hepatic injury for which the causative chemical agent is mostly known1. Therefore, HILI represents a clinical challenge. Herbs are classified in 5 categories namely A, B, C, D and E by LiverTox Database2.
Purpose: This study aims to evaluate the most common herbs and herbal products found in Akhtars in Turkey for their hepatotoxic effects together with edible plants carrying hepatotoxic metabolites.
Materials and Methods: List of common herbs and herbal products found in Akhtars in Turkey has been prepared through publication survey and, hepatotoxic categories of these herbs are designated in accordance with LiverTox Database within National Library of Medicine (nlm.gov.).
Findings: Examples to hepatotoxic categories of herbs and herbal products commonly found in akhtars, determined according to the LiverTox Database, are as follows:
Category A (Drug is well described, more than 50 cases): Green tea extract, Germander, Black cohosh
Category B (Drug is reported, 12-50 cases): Aloe vera, Pennyroyal oil, Skullcap, Turmeric
Category C (Less than 12 cases): Ashwaganda, Comfreyz
Category D (Less than 3 cases): Echinacea, Horse chestnut
Category E (No evidence): Quercetin
Conclusion: It is clear that misuse of herbs and herbal products has serious side effects. As seen in green tea extract, there are many herbs that cause liver damage depending on the duration and dose of use, including products that are considered safe by the public. Among these, especially slimming preparations can be risky as they contain many herbs in single or mixed form. Awareness should be raised in society for the correct use of herbal products; such products should not be easily accessible, and their entry into the country should be strictly controlled. There is a need for physicians to report the cases they encounter with herbal products in order to access more reliable information on this issue.

References:
1 Teschke, R.; Wolff, A.; Frenzel, C.; Schwarzenboeck, A.; Schulze, J.; Eickhoff, A. Drug and herb induced liver injury: Council for International Organizations of Medical Sciences scale for causality assessment. World J. Hepatol. 2014, 6, 17–32.

2 Patel-Rodrigues, P.A.; Cundra, L.; Alhaqqan, D.; Gildea, D.T.; Woo, S.M.; Lewis, J.H. Herbal- and Dietary-Supplement-Induced Liver Injury: A Review of the Recent Literature. Livers 2024, 4, 94-118.