Can CBD or cannabis cause liver damage?

Hepatotoxicity is a real concern with high-dose CBD, established through clinical trial data. In Epidiolex trials, liver enzyme elevations (ALT/AST >3x upper limit of normal) occurred in 5–20% of patients on high doses (20mg/kg/day), with 3 cases of serious hepatotoxicity. Risk factors: concomitant valproate use (dramatically increases risk), high CBD doses, and pre-existing liver disease. Mechanism: likely CYP450 enzyme inhibition causing drug-drug interactions, plus possible direct hepatotoxic effects. At lower doses (typical supplement doses of 10–100mg/day), liver enzyme elevations are rare in clinical studies. THC: less evidence for direct hepatotoxicity, but cannabis use is associated with accelerated fibrosis progression in patients with pre-existing hepatitis C. Practical guidance: patients on hepatotoxic medications (valproate, methotrexate, statins) should have liver function monitored if using high-dose CBD. Commercial CBD supplements at typical doses appear low-risk for liver injury in healthy individuals.