Germany is considering forbidding the sale of products containing more than tiny amounts of the herbal medicine kava kava after 24 cases of liver damage linked to the medicine have been reported in Germany. Knut Janssen, a spokesman for the German Federal Institute for Drugs and Medical Devices (BfArM) in Bonn, said that of the 24 cases, one person died and three had to have liver transplants. Diagnoses included liver failure, hepatitis and cirrhosis. Kava kava, an extract from the root of the shrub Piper methysticum, can be sold without a prescription. It has been used for over 3,000 years for its medicinal effects as a sedative, muscle relaxant and diuretic. It has become increasingly common in recent years in Europe and the US. The shrub is a member of the pepper family, and is native to the South Pacific. Janssen said that the BfArM had sent letters to producers and dealers informing them of the potential action. They have until around December 10 to respond. However, he said evidence is strong that kava kava can cause liver damage, and chances are high that the BfArM will forbid its sale in Germany, except in preparations with only minute amounts.