Ephedra

What You Need to Know

What is Ephedra?

Also known as: Ephedra sinica, ma huang, Chinese ephedra, Sida cordifolia, epitonin, ephedra

Ephedra sinica is an herb with a long history of use in traditional Chinese medicine for asthma, bronchitis, allergies and cold and flu symptoms.

During the 80s, ephedra became popular outside of traditional Chinese medicine for weight loss and to enhance sports performance. Its popularity continued to grow, and it was found in many nutritional supplements marketed for weight loss and performance enhancement until supplements containing ephedra were banned by the U.S. Food and Drug Administration (FDA) in 2006.

The primary active ingredients in ephedra are believed to be the alkaloids ephedrine and pseudoephedrine, which are thought to increase heart rate, constrict blood vessels (which increases blood pressure), dilate bronchial tubes (which makes it easier to breathe) and have thermogenic properties (increases body heat and metabolic rate).

A synthetic form of pseudoephedrine is found in over-the-counter decongestants and cold medicines, and synthetic ephedrine is used to treat asthma (but it has largely been replaced by newer medications). Synthetic ephedrine and pseudoephedrine have also been used to make the illicit street drug methamphetamine, as reported by The New York Times.

Ephedra in the United States

Dietary supplements containing any amount of ephedra alkaloids have been banned in the United States since 2006.

In Canada, ephedra is authorized by Health Canada for use only as a nasal decongestant.

Nutritional supplements with ephedra can't contain stimulants, such as caffeine, that might heighten the effect of the ephedra. Also, they can't exceed 400 mg per dose or 1600 mg per day of ephedra, or 8 mg ephedrine per dose or 32 mg per day of ephedrine. Products with implied or unproven claims for weight loss, appetite suppression, body-building effects or increased energy are not permitted.

Why Do People Use Ephedra?

1) Weight Loss

Ephedra is used in weight loss supplements. Proponents claim that it may help promote weight loss and suppress appetite. 

Prior to the ban on ephedra supplements, many dietary supplements marketed for weight loss also contained caffeine-containing herbs, such as green tea, yerba mate and guarana. The ephedra/caffeine combination, however, is now widely believed to heighten the potential health risks and is not recommended.

2) Sports Performance

Ephedra is similar in structure to amphetamine, so it has been used to increase athletic performance in strength and endurance sports, increase alertness and aggressiveness on the field, and reduce fatigue in sports such as ice hockey, baseball, football, and cycling. There isn't good evidence, however, that it can improve sports performance, and is not recommended for this purpose given the potential side effects.

Ephedra is banned by many sports associations, including the International Olympic Committee, the National Football League (NFL) and the National Collegiate Athletic Association (NCAA).

3) Asthma and Other Respiratory Disorders

Ephedra has a long history of use in traditional Chinese medicine as a folk remedy for asthma, bronchitis, allergies, fever, chills and cold and flu symptoms, such as nasal congestion. 

Caveats

Side effects of ephedra may include:

  • nausea
  • headache; dizziness
  • irritation of the stomach; diarrhea
  • anxiety; psychosis
  • kidney stones
  • tremors
  • dry mouth
  • irregular or rapid heart rhythms; heart damage
  • high blood pressure
  • restlessness; nervousness; sleeping problems
  • decreased appetite
  • flushing; sweating
  • increased urination

Use of ephedra has also been associated with stroke, seizures, psychosis and death.

A study commissioned by the National Institutes of Health reviewed 16,000 adverse event reports and identified two deaths, nine strokes, four heart attacks, one seizure and five psychiatric cases involving the use of ephedra where there were no other possible factors that could have contributed to these results.

The NIH-commissioned study also concluded that ephedra was associated with higher risks of mild to moderate side effects such as heart palpitations, psychiatric and digestive effects, and symptoms of hyperactivity of the autonomic nervous system (tremor, insomnia), especially when combined with caffeine or other stimulants such as kola nut, green tea, guarana or yerba mate.

Many of the side effects of ephedra have been attributed to overdose, abuse and combining it with other stimulants that heighten its effect, such as caffeine. Side effects of ephedra, however, can vary and don't always depend on the dose. Serious adverse effects may also occur in susceptible people at low doses.

The risk of side effects and adverse effects appears to be greater in people with preexisting conditions, such as heart disease, high blood pressure; heart rate disorders; thyroid disease; hypoglycemia; glaucoma; anxiety; glaucoma; pheochromocytoma; diabetes; kidney disease or kidney stones; mental illness or a history of mental illness; enlarged prostate; cerebral insufficiency and a history of seizures, stroke, or transient ischemic attacks. People with these health conditions should avoid ephedra. People with allergies to ephedra, ephedrine, or pseudoephedrine should also avoid ephedra.

Ephedra is believed to increase the risk of heat stroke because it increases metabolism and impairs the body's ability to lose heat.

Ephedra shouldn't be taken two weeks before or after surgery. It shouldn't be used by pregnant or nursing women or children. People with anorexia nervosa or bulimia should avoid ephedra because it affects appetite.

Supplements haven't been tested for safety and due to the fact that dietary supplements are largely unregulated, the content of some products may differ from what is specified on the product label. Also keep in mind that the safety of supplements in pregnant women, nursing mothers, children, and those with medical conditions or who are taking medications has not been established. 

Remember, products containing ephedra were banned by the FDA in 2006.

Potential Interactions

Based on known interactions between the active ingredients of ephedra, ephedrine, and pseudoephedrine, the following medications could theoretically interact with ephedra:

  • Aerolate, T-Phyl, and Uniphyl (theophylline) -- a medication used for asthma, emphysema, and chronic bronchitis
  • Amphetamines, such as those used for narcolepsy or attention deficit hyperactivity, such as Adderall (dextroamphetamine)
  • Antidepressants, particularly monoamine oxidase inhibitors (MAOIs), such as Marplan (isocarboxazid), Nardil (phenelzine) and Parnate (tranylcypromine), due to an increased risk of high blood pressure and stroke; tricyclic antidepressants, such as Elavil (amitriptyline) and Pamelor (nortriptyline)
  • Aspirin (acetylsalicylic acid
  • Blood pressure medicatio;
  • Diabetes medications, such as insulin, Glucophage (metformin), Diabeta, Glynase, Micronase (glyburide
  • Narcotics, such as codeine
  • Pitosin (Oxytocin) or Secale Alkaloid Derivatives
  • St. John's Wort
  • Stimulants -- Ephedra should not be combined with other substances with a stimulant effect, such as caffeine and Sudafed (pseudoephedrine hydrochloride), as it may have an additive effect. Herbs known to contain caffeine include green tea, kola nut, guarana and yerba mate, while bitter orange is a stimulant.

Sources:

Blumenthal M, Goldberg A, Brinckmann J. Herbal Medicine: Expanded Commission E Monographs . Boston: Integrative Medicine Communications; 2000:111-117.

Food and Drug Administration. FDA announces rule prohibiting sale of dietary supplements containing ephedrine alkaloids effective April 12. April 12, 2004. Accessed January 18, 2008 <http://www.fda.gov/bbs/topics/news/2004/NEW01050.html>.

Food and Drug Administration. The Tenth Circuit Court of Appeals Upholds FDA's Decision Banning Dietary Supplements Containing Ephedrine Alkaloids. August 23, 2006. Accessed January 18, 2008 <http://www.cfsan.fda.gov/~dms/cfsup145.html>.

Health Canada. Ephedra/ephedrine - Frequently Asked Questions. January 2002. Accessed January 18, 2008. <http://www.hc-sc.gc.ca/ahc-asc/media/advisories-avis/_2002/2002_01bk2_e.html>.

National Institutes of Health Office of Dietary Supplements. Ephedra and Ephedrine Alkaloids for Weight Loss and Athletic Performance. July 1, 2004. Accessed January 18, 2008. <http://dietary-supplements.info.nih.gov/factsheets/ephedraandephedrine.asp>.

Shekelle P, Morton SC, Maglione M, Hardy M, Suttorp M, Roth E, Jungvig L, Mojica W, Gagné J, Rhodes S, McKinnon E, and Newberry S. Ephedra and Ephedrine for Weight Loss and Athletic Performance Enhancement: Clinical Efficacy and Side Effects. Prepared for the Agency for Healthcare Research and Quality, 2003. Accessed January 18, 2008. <www.ahrq.gov/clinic/ephedinv.htm>.

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