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Milk thistle is said to treat cirrhosis and to protect the liver from viral hepatitis, the damaging effects of alcohol, and hepatotoxic drugs (1). Milk thistle may also improve glycemic control in type 2 diabetes (2), and individual case reports claim fatality reduction in mushroom poisoning (3).

A 2007 Cochrane review of 13 randomized clinical trials assessed milk thistle in 915 patients with alcoholic and/or hepatitis B or C virus liver diseases (4). Data from this analysis determined that intervention had no significant effect on all-cause mortality, complications of liver disease, or liver histology. When all trials were included in the analysis, liver-related mortality was significantly reduced; however, in an analysis limited to high-quality studies, this reduction was not significant. Milk thistle was not associated with a significant increase in adverse effects. The design of these clinical trials did come into question, and the authors questioned the benefits of milk thistle and suggested the need for more well-designed placebo-controlled studies.

A meta-analysis of randomized controlled studies of milk thistle for hepatitis C reported that, although well tolerated, it does not provide overall benefit (5). In vitro, silymarin increases levels of intrahepatic glutathione, an antioxidant important for detoxification (6).

A 2018 systematic review and meta-analysis of 7 studies (370 subjects) found that milk thistle significantly decreased fasting glucose by 37.9 mg/dL (2.1 mmol/L) and hemoglobin A1C by 1.4% (2). A 2020 meta-analysis of 16 studies (1358 subjects) reported that milk thistle reduced fasting glucose, hemoglobin A1C, total cholesterol, and low-density lipoprotein cholesterol (7).

In case reports, 2 cases of Amanita mushroom ingestion poisoning (3) showed favorable results after treatment with silybin.

No serious adverse effects have been reported.

Women who have hormone-sensitive conditions (eg, breast, uterine, and ovarian cancer; endometriosis; uterine fibroids) should avoid the above-ground parts of milk thistle.

Milk thistle may intensify the effects of antihyperglycemic drugs (8) and may interfere with protease inhibitors (eg, indinavir, saquinavir) (9). Milk thistle may increase international normalized ratio (INR) in patients taking warfarin.

Milk thistle may also decrease sirolimus clearance in renal transplant patients with hepatic impairment.

(See also table Some Possible Dietary Supplement–Drug Interactions.)

1. 1. Abenavoli L, Izzo AA, Milic N, et al: Milk thistle (Silybum marianum): a concise overview on its chemistry, pharmacological, and nutraceutical uses in liver diseases. Phytother Res 32(11):2202-2213, 2018. doi: 10.1002/ptr.6171

2. 2. Hadi A, Pourmasoumi M, Mohammadi H, et al: The effects of silymarin supplementation on metabolic status and oxidative stress in patients with type 2 diabetes mellitus: a systematic review and meta-analysis of clinical trials. Complement Ther Med 41:311-319, 2018. doi: 10.1016/j.ctim.2018.08.010

3. 3. Ward J, Kapadia K, Brush E, et al: Amatoxin poisoning: case reports and review of current therapies. J Emerg Med 44(1):116-121, 2013.  doi: 10.1016/j.jemermed.2012.02.020

4. 4. Rambaldi A, Jacobs BP, Gluud C: Milk thistle for alcoholic and/or hepatitis B or C virus liver diseases. Cochrane Database Syst Rev (4)CD003620, 2007. doi: 10.1002/14651858.CD003620.pub3

5. 5. Yang Z, Zhuang L, Lu Y, et al: Effects and tolerance of silymarin (milk thistle) in chronic hepatitis C virus infection patients: a meta-analysis of randomized controlled trials. Biomed Res Int 941085, 2014. doi: 10.1155/2014/941085

6. 6. Valenzuela A, Aspillaga M, Vial S, et al: Selectivity of silymarin on the increase of the glutathione content in different tissues of the rat. Planta Med 55(5):420-422, 1989. doi: 10.1055/s-2006-962056

7. 7. Xiao F, Gao F, Zhou S, et al: The therapeutic effects of silymarin for patients with glucose/lipid metabolic dysfunction: a meta-analysis. Medicine (Baltimore) 99(40):e22249, 2020. doi:10.1097/MD.0000000000022249

8. 8. Wu JW, Lin LC, Tsai TH: Drug-drug interactions of silymarin on the perspective of pharmacokinetics. J Ethnopharmacol 121(2):185-193, 2009. doi: 10.1016/j.jep.2008.10.036

9. 9. Jalloh MA, Gregory PJ, Hein D, et al: Dietary supplement interactions with antiretrovirals: a systematic review. Int J STD AIDS 28(1):4-15, 2017. doi: 10.1177/0956462416671087

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

1. National Institutes of Health (NIH), National Center for Complementary and Integrative Health: General information on the use of milk thistle as a dietary supplement