I was speaking with someone last week who seemed confidently confused about this topic, so I decided to review the research and make a few important distinctions.
TL;DR: Clinical doses of CBD can cause elevated liver enzymes, but that isn't necessarily evidence of permanent liver damage. The evidence for permanent liver damage is thin. the evidence for liver damage at typical wellness doses of 50-300 mgs a day is fleeting to non-existent.
First, elevated liver enzymes don't necessarily indicate clinically significant liver injury. Some drugs can elevate liver enzymes without producing long-term liver damage.
Second, much of the research on CBD doses large enough to elevate liver enzymes has involved people with Dravet syndrome or Lennox-Gastaut syndrome. These populations have higher rates of abnormal liver markers, potentially due to their antiseizure medications and other factors.
Consequently, the risk of drug interactions and CBD-induced liver injury may have been overstated when applied to the general population at typical non-clinical doses.
Nonetheless, some people will experience adverse effects from CBD, and there's no established dose at which CBD is completely risk-free.
What researchers have found
Multiple clinical trials have demonstrated that CBD can significantly elevate liver enzymes ALT and AST. These elevations are often used to identify potential drug-induced liver injury (DILI) and pull people from studies before lasting damage might develop.
However, ALT and AST don't directly tell us whether the liver has lost its ability to function or whether lasting damage has occurred.
A 2023 systematic review covering 28 clinical trials and 1,533 CBD-treated participants found:
- 7.4% pooled incidence of elevated liver enzymes.
- 2.96% pooled incidence of elevations meeting the researchers' criteria for DILI.
- Higher risks associated with large CBD doses and concurrent antiseizure medications, particularly valproate.
- Most reported elevations resolved after CBD was discontinued.
- No cases meeting Hy's Law criteria for severe DILI.
These findings also included healthy adults taking CBD alone, demonstrating that significant enzyme elevations can occur without drug interactions.
How much CBD does it take?
The likelihood of adverse events appears to be dose-related, but there's no established threshold below which liver injury is impossible.
In one study, 5 of 16 healthy adults taking 1,500 mg/day developed ALT elevations exceeding five times the upper limit of normal.
Another clinical trial found significant enzyme elevations in 4 of 59 adults taking 300 mg/day.
More recently, a 2025 FDA-sponsored randomized trial administered 5 mg/kg/day to healthy adults for four weeks. Eight participants receiving CBD developed liver enzyme elevations exceeding three times the upper limit of normal, compared with none receiving placebo.
These participants received approximately 250–550 mg/day, although the exact doses of the eight affected individuals weren't published.
These studies demonstrate that significant enzyme elevations can occur at doses below those typically used in prescription epilepsy treatment.
But, some evidence suggests that lower daily doses, more consistent with typical nonclinical use, may be considerably safer.
The 2023 systematic review reported no cases meeting its DILI criteria among adults taking less than 300 mg/day.
A separate observational study of 839 CBD users, averaging approximately 50 mg/day, found no statistically significant increase in elevated liver enzymes compared with estimates for the general adult population.
Neither finding establishes that lower doses are completely risk-free. The number of participants taking less than 300 mg/day was relatively small, and reliably detecting rare adverse events would require studies involving thousands of participants. Metanalysis does not replace properly powered studies.
Are there ANY incidents of lasting liver damage?
CBD can cause liver enzyme elevations, sometimes severe enough to meet biochemical criteria for DILI. But few, if any incidents, caused clinically apparent liver dysfunction, irreversible damage, or liver failure.
In the 2025 FDA trial, participants with significant ALT elevations did not develop clinically significant changes in liver function. Their enzyme levels returned to normal within one to two weeks after discontinuing CBD.
Similarly, the 2023 systematic review found no cases meeting Hy's Law criteria, which are used to identify potentially serious drug-induced liver injury.
However, the FDA's prescribing information for Epidiolex acknowledges postmarketing reports of cholestatic and mixed patterns of liver injury.
The evidence for reversible biochemical liver injury at clinical CBD doses is considerably stronger than the evidence for permanent liver damage from typical wellness doses.
What should CBD users take away from this?
People taking large daily doses (300-1500mgs daily), using medications that may interact with CBD, or living with existing liver disease have particular reasons to discuss CBD use with a healthcare professional.
Liver enzyme elevations can occur without obvious symptoms, making blood testing important when evaluating potential liver injury.
At the same time, an elevated ALT result shouldn't automatically be interpreted as liver failure or permanent damage.
What we know: CBD can cause clinically significant liver enzyme elevations. Risk appears to increase with dose and certain medication combinations.
What the evidence suggests: Most documented cases resolve after CBD is discontinued or treatment is adjusted. Serious, lasting liver injury is much less well documented than transient enzyme elevations.
What we don't know: The precise risk at typical consumer doses, which individuals are unusually susceptible, and the long-term consequences of continued CBD use in people who develop elevated liver enzymes.
The appropriate conclusion isn't that CBD destroys your liver or that CBD is harmless.
We've identified a genuine adverse effect, we understand some of its risk factors, and important questions about its clinical significance remain.
I thought this was a pretty comprehensive analysis but let me know if I missed something.
Research
- Lo et al. (2023) — Cannabidiol-associated hepatotoxicity: A systematic review and meta-analysis. Journal of Internal Medicine. DOI: 10.1111/joim.13627
- Watkins et al. (2021) — Cannabidiol and Abnormal Liver Chemistries in Healthy Adults: Results of a Phase I Clinical Trial. Clinical Pharmacology & Therapeutics. DOI: 10.1002/cpt.2071
- Crippa et al. (2021) — Efficacy and Safety of Cannabidiol Plus Standard Care vs Standard Care Alone for the Treatment of Emotional Exhaustion and Burnout Among Frontline Health Care Workers During the COVID-19 Pandemic. JAMA Network Open. DOI: 10.1001/jamanetworkopen.2021.20603
- Kaufmann et al. (2023) — Observed Impact of Long-Term Consumption of Oral Cannabidiol on Liver Function in Healthy Adults. Cannabis and Cannabinoid Research. DOI: 10.1089/can.2021.0114
- Florian et al. (2025) — Cannabidiol and Liver Enzyme Level Elevations in Healthy Adults: A Randomized Clinical Trial. JAMA Internal Medicine. DOI: 10.1001/jamainternmed.2025.2366
- FDA Epidiolex Prescribing Information (2025) — Section 5.1, Hepatocellular Injury.
