Khat is a stimulant derived from the fresh leaves of the evergreen shrub Catha edulis, which is native to parts of East Africa and the Arabian Peninsula. Chewing khat leaves is a well established social habit in areas where the shrub is endemic and causes a mild euphoria. Khat chewing has been implicated in causing rare but serious, clinically apparent acute and chronic liver injury.


Khat (pronounced "kaat") is a product of the leaves of the evergreen shrub Catha edulis that is native to Ethiopia, Kenya, North Yemen and Madagascar. Chewing the leaves releases a stimulant that is absorbed through the oral mucosa and results in mild stimulation, heightened sense of awareness and euphoria. Khat chewing is a common practice and social habit, particularly among men in areas of East Africa and the Arabian Peninsula where the shrub is endemic. Recently, immigrants from those countries have introduced the practice to other areas of the world, including North America, Europe, and Australia. The active ingredient of khat is believed to be phenylalkylamine alkaloids (cathinone, cathine and nor pseudoephedrine), which have sympathomimetic effects that resemble those of the amphetamines. Khat has no current medicinal use and is considered a drug of abuse with potentially serious psychological and neurological adverse effects. Khat is banned in the United States, but is legal and available in Africa, the Middle East, and some countries in Europe including the UK. Common side effects of chewing khat include excitation, confusion, decreased appetite, hyperactivity, hypertonia and hyperthermia. Chronic use has been linked to disruption of personal and family relations, depression, psychiatric problems, hypertension, myocardial infarction and stroke.


There is little information of whether acute or chronic khat use is associated with serum enzyme elevations or alterations in liver function. However, in recent years several individual case reports and small case series of serious acute and chronic liver injury attributed to khat have been published, largely from the UK and Europe and in immigrants from areas of the world where khat use is frequent. The onset of injury usually occurs after years of khat use and can present acutely with nausea, fatigue, pruritus and jaundice or chronically, with signs and complications of portal hypertension. The pattern of liver enzyme elevations is typically hepatocellular and, in acute cases, the aminotransferase levels can be markedly elevated. Autoantibodies occur in a proportion of cases and the disease often resembles autoimmune hepatitis with chronic inflammation and fibrosis. However, responses to corticosteroid therapy are usually only partial, at least if khat use continued. Immunoallergic features (rash, fever, eosinophilia) are not common. Some patients suffer from multiple bouts of acute injury which leads to fibrosis and cirrhosis, portal hypertension and hepatic failure. Resolution occurs if khat chewing is stopped, but relapses are common, even in some patients who deny relapse in khat use. While most cases have been described from Europe and North America, chronic liver disease and cirrhosis of unknown cause are frequent in areas of the world where khat is commonly used.

Likelihood score: B (highly likely cause of clinically apparent liver injury).

Mechanism of Liver Injury

Khat leaves have multiple components, some of which may be hepatotoxic. In animals, liver injury and fibrosis have been reproduced by chronic khat exposure. Interestingly, liver injury specifically related to khat has not been reported from areas of the world where it is commonly used, despite some studies specially focusing on the frequency of liver injury among chronic khat users. In these countries where Catha edulis is endemic and common, only freshly cut khat leaves are used and they are typically sold the day that they are harvested. Thus, the liver injury associated with khat use that has been reported from North America, Europe and Australia may be related to the storage and shipping of the leaves, either from a contaminant or a breakdown product during storage. There is a superficial resemblance of the liver injury from khat to that of amphetamines, particularly methylenedioxymethamphetamine (MDMA, ecstasy). Contamination with ecstasy might be done to enhance the euphoric effects of khat, especially in long stored leaves that typically have less cathinone due to its metabolism.

Outcome and Management

The liver injury attributed to khat use can be severe and progressive, but resolution has been reported in patients who have stopped use of khat. Because khat use can result in psychological and physical dependence, stopping its regular use may be difficult. Corticosteroids are often used in patients who present with autoimmune features, but they appear to have little effect in khat related liver injury and should not be considered routine therapy. Liver transplantation has been successful in some patients, with end stage liver disease attributed to khat chewing.

Drug Class: Agents of Abuse; Herbal and Dietary Supplements


Case 1. Recurrent acute hepatitis attributed to Khat.(1)

A 24 year old man presented with a one week history of jaundice and fatigue and was found to have abnormal liver tests. He was otherwise healthy, denied a history of alcohol or drug use, was taking no medications, and had no risk factors for viral hepatitis. Laboratory tests showed a total bilirubin of 11.2 mg/dL, ALT 2449 U/L, and AST 1388 U/L. Alkaline phosphatase levels were not provided. Importantly, the INR was elevated at 1.6 qualifying the case as being severe. Abdominal ultrasound was normal. A percutaneous liver biopsy showed a cholestatic hepatitis with eosinophils and plasma cells but little interface hepatitis. Tests for viral hepatitis, and other potential viral causes were negative. Over 8 days of hospitalization he improved clinically, and serum enzymes decreased (Table). After discharge he did not return for follow up but presented two months later with a similar acute history and similar laboratory abnormalities. At this point he admitted to use of khat. He was born in Somalia, lived for several years in India, and had immigrated to Canada three years previously. He admitted to chewing khat (a common practice among Somali immigrants) 4 or 5 times monthly in recent years in Canada. His prior use in Somalia was not provided. Again, his symptoms and laboratory abnormalities improved during an 8 day hospitalization but were still abnormal at discharge, the INR being 1.6. Note that the second episode was more severe, with an INR of 1.9 and a higher AST to ALT ratio. He was strongly advised to avoid further use of khat. He again did not return for follow up.

Key Points

Laboratory Values


The history and presentation of this case were typical of khat hepatotoxicity as seen in Europe and North America. The onset can be sudden despite long term use and no previous symptoms or signs of liver injury. The liver biopsy showed acute hepatitis with scant fibrosis, but the injury was clearly severe and multiple such bouts would likely result in cirrhosis. The lack of mentioning khat use during the first admission and the lack of follow up are also typical of khat hepatotoxicity. It is illegal and addictive. The patient likely lacked medical insurance or resources to obtain regular medical care. The major psychotropic agent in khat is cathinone, an amphetamine-like central nervous system stimulant. Interestingly, the clinical presentation, course, and potential for causing cirrhosis with continued use resemble the liver injury from ecstasy (methylenedioxymethamphetamine: MDMA).



Khat – Abyssinian Tea, Chat, Gat, Kat, Miraa, Oat, Qat, Somali Tea


Agents of Abuse; Herbal and Dietary Supplements


Fact Sheet at Drug Enforcement Administration

Information at Drug & Chemical Evaluation Section, Drug Enforcement Administration



Waters M, Oxner A, Krajden S, Sultanian R. Acute liver injury associated with khat use in a 24-year-old male. Case Reports Hepatol. 2018;2018:2816907. [PMC free article: PMC6280303] [PubMed: 30584482]


References updated: 29 January 2024

Abbreviations: HDS, herbal and dietary supplements.

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    (24 year old Somalian male Canadian immigrant presented with acute hepatitis of unknown cause [bilirubin 11.1 mg/dL, ALT 2449 U/L, Alk P not given, INR 1.6], which improved during hospitalization without further follow up until 2 months later when he presented with similar injury at which point he was found to have been chewing khat weekly for the previous 3 years: Case 1).
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    (32 year old Yemeni male who had immigrated to the US one year previously developed abdominal pain and abnormal liver tests [bilirubin 0.7/2.0 mg/dL, ALT 328 U/L, Alk P 78 U/L], admitting to khat use 5-6 times monthly but much less than previously in Yemen, with improvement after stopping and normal liver tests 3 weeks later).
  • Shaikhain G, Gaballah M, Alhazmi A, Khardali I, Hakami A, Oraiby M, Alharbi S, et al. Fatalities involving khat in Jazan, Saudi Arabia, 2018 to 2021. Toxics. 2023;11:506. [PMC free article: PMC10303278] [PubMed: 37368606]
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