Herbal Hepatotoxicity — RACP Adult Medicine MCQ

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ModerateClinical PharmacologyHerbal HepatotoxicityRACP Adult Medicine

A 55-year-old man presents with fatigue, anorexia, and dark urine. His ALT is 1,200 U/L, AST 980 U/L, bilirubin 120 µmol/L, and INR 2.5. He has been taking a traditional herbal supplement containing kava for 3 months. What is the most likely diagnosis?

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Correct answer: D — Drug/herbal-induced liver injury

Kava (Piper methysticum) is a well-recognised hepatotoxin that has caused acute liver failure requiring transplantation. The TGA has issued safety warnings about kava-containing products. Other common herbal hepatotoxins include black cohosh, green tea extract (catechins), and comfrey (pyrrolizidine alkaloids). Drug-induced liver injury (DILI) from herbal and dietary supplements is an increasingly recognised cause of acute liver failure in Australia. R-factor (ALT/ULN ÷ ALP/ULN) helps classify the pattern (hepatocellular, cholestatic, or mixed). Causality assessment uses the RUCAM/CIOMS scale.

Reference: eTG – 2025 – Gastrointestinal; TGA – 2024 – Kava Safety Information