Evidence Level
Milk thistle is the most extensively researched herbal hepatoprotectant. The landmark Ferenci et al. (1989) RCT demonstrated that 420mg/day silymarin significantly improved survival in patients with alcoholic cirrhosis over a 2-year period. Saller et al. (2001) conducted a systematic review confirming silymarin's hepatoprotective effects across multiple liver conditions. More recently, Zhong et al. (2017) published a meta-analysis specifically evaluating silymarin in NAFLD, finding significant reductions in liver enzymes. The HALT-C trial (2012, n=1049) tested silymarin at higher doses (420mg and 700mg three times daily) in hepatitis C patients, finding dose-dependent reductions in ALT. While silymarin's poor oral bioavailability has been a limitation, phytosome formulations (silymarin-phosphatidylcholine complex) have demonstrated 4-10x improved absorption in pharmacokinetic studies.