Comparative Efficacy of Herbal Products on Metabolic Parameters in Metabolic-Dysfunction Associated Liver Disease: A...

Metabolic dysfunction-associated steatotic liver disease (MASLD) is closely linked to dyslipidemia, insulin resistance, and impaired glucose metabolism. Herbal products are widely used in MASLD, but their comparative metabolic effects and certainty of evidence remain unclear. We conducted a systematic review and network meta-analysis to evaluate herbal products on metabolic outcomes in MASLD.

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and International Prospective Register of Systematic Reviews registration (CRD420251236813), we searched PubMed, Web of Science, EMBASE, and Cochrane through September 2025 for randomized trials of herbal products in adults with MASLD. Primary outcomes were triglycerides (TG), fasting blood glucose (FBG), and Homeostatic Model Assessment of Insulin Resistance (HOMA-IR); secondary outcomes included cholesterol fractions, hemoglobin A1c, and body mass index. Random-effects network meta-analysis estimated mean differences (MDs) (95% confidence interval); certainty was assessed using CINeMA (Confidence in Network Meta-Analysis).

A total of 123 trials were included (n = 8595). For TG, significant reductions vs placebo occurred with Korean red ginseng (MD: -99.00), naringenin (MD: -92.50), and artichoke leaf (MD: -52.60; all P < .01); surface under the cumulative ranking curve (SUCRA) favored naringenin and Korean red ginseng (both 0.96). For FBG, green tea (MD: -16.98; P = .03), hesperidin + flaxseed (MD: -14.44), and garlic (MD: -13.51) were top-ranked (SUCRA: 0.90, 0.89, 0.87). For HOMA-IR, sumac (MD: -2.32; P < .01), green tea (MD: -1.81), and berberine + tocotrienols + green coffee (MD: -1.80) showed greatest improvements (SUCRA: 0.94 for sumac). Artichoke leaf, curcumin, and green tea improved total cholesterol, low density lipoprotein-cholesterol, and body mass index; no intervention reduced hemoglobin A1c. CINeMA showed high confidence only for artichoke leaf on total cholesterol; moderate for select TG, high density lipoprotein-cholesterol, and HOMA-IR outcomes; remaining were low or very low.

Selected herbal products, particularly artichoke leaf, curcumin, green tea, flaxseed, and garlic may offer modest, domain-specific metabolic improvements in MASLD, though confidence was low for most outcomes. These therapies may serve as adjuncts, not substitutes for approved treatments. Larger randomized controlled trials with standardized formulations, long-term safety data, and liver-specific outcomes are needed.