Liver therapy. Herbal agent
ATC code: A05BA03 (Silymarin)
Brand names
Legalon, Milk Thistle
A complex of flavonolignans from milk thistle fruit (Silybum marianum): silibinin (main component), silydianin, silychristin. The manufacturer claims antioxidant, membrane-stabilising, antifibrotic effects in hepatocytes and enhanced liver regeneration. In international hepatology, silymarin is one of the most studied herbal agents, but with a disappointing verdict: large RCTs have not shown clinically meaningful effects for any of the conditions it is marketed for.
Not recommended
The Cochrane review 'Milk thistle for alcoholic and/or hepatitis B or C virus liver diseases' (2007) concluded there was no clinically meaningful effect on survival, fibrosis, or biochemical markers. 2018 does not recommend silymarin for alcoholic liver disease. The foundation is complete alcohol cessation and, in severe hepatitis, prednisolone.
Not recommended
For NAFLD/MAFLD, the foundation is 7-10% weight reduction, management of comorbidities (diabetes, dyslipidaemia), and alcohol cessation. 2023 and 2021 do not recommend silymarin. Pharmacotherapy is discussed in patients with confirmed MASH and significant fibrosis: resmetirom (in the US), pioglitazone, and GLP-1 agonists.
Not recommended
— Liver 'detox' and cleansing: Milk thistle/Karsil is one of the top-selling 'hepatoprotectors for liver cleansing' in Russian pharmacies. 'Cleansing' is not a clinical concept. The 2007 Cochrane review of silymarin showed no clinically meaningful effect on survival or fibrosis in chronic liver disease.
Not recommended
Treatment of chronic hepatitis C since 2014 is based on direct-acting antivirals (DAAs). They cure the infection in over 95% of patients in 8-12 weeks. 2020 and 2023 guidelines do not mention silymarin as hepatitis C therapy. Attempts to treat hepatitis C with silymarin mean declining effective therapy in favour of ineffective therapy.
Not recommended
Taking milk thistle 'after drinking' or 'before drinking for liver protection' is a marketing device. There are no clinical data on reduced liver damage with single or episodic alcohol intake. Only systemic cessation of alcohol abuse works.
Pregnancy safety data are limited. Not used without clear indication.
Not recommended during breastfeeding.
silymarin is evaluated for the following indications with varying evidence strength: Alcoholic liver disease (evidence tier D), Non-alcoholic fatty liver disease (evidence tier D), Chronic hepatitis C (evidence tier F). See the full indication matrix with dosing and citations above on this page.
Common side effects of silymarin (≥ 1 in 100): Dyspepsia, diarrhoea, Allergic reactions. See the Safety section for uncommon and serious reactions.
Pregnancy safety data are limited. Not used without clear indication.
Not recommended during breastfeeding.
silymarin is contraindicated in: Hypersensitivity to milk thistle, silymarin, or other Asteraceae plants; Lactase deficiency, lactose intolerance (for some formulations). Full list in the Safety section.
the liver is a regenerating organ that recovers on its own once the damaging factor is removed. You can help the liver only by eliminating the cause of damage: alcohol cessation, weight loss, stopping a hepatotoxic drug. Silymarin adds nothing to this process.