Ephedra

Ephedrine-containing products are sold as over-the-counter aids to improve athletic performance, enhance weight loss, decrease cigarette craving, promote uterine contractions and promote menstruation. Therapeutic uses include treatment for nocturnal enuresis, diabetic neuropathic edema, dysmenorrheal, narcolepsy and myasthenia gravis. Recently noted in the news, and not uncommon to substance abuse, we thought it was important to provide you with information about ephedra.

Ephedra is an evergreen shrub found throughout the world. Ephedra comes from the Ephedraceae family of plants. It has several scientific names, such as Ephedra major (America), Ephedra trifurca (America) and Ephedra sinica (this is Asian and called Chinese Ma Huang). Evidence indicates that Ephedra was used as a medicine more than 60,000 years ago; its active ingredient, ephedrine, was first isolated in 1887. Ma Huang ephedra has the highest concentration of ephedrine. Ephedrine, a central nervous system stimulant (sympathomimetic) and a decongestant, acts similarly to epinephrine, also known as adrenaline. However, ephedrine can be taken orally; epinephrine must be injected. Ephedrine is metabolized into norephedrine. Also called phenylpropanolamine or PPA, norephedrine has been banned as an over-the-counter substance. Ephedrine, similar in structure to amphetamines, can cause a false positive urine drug screen for amphetamines. In fact, Ephedrine is used sometimes by “clubbers” in place of Ecstacy.

Adverse effects of ephedrine include: death, heart attacks, strokes, seizures, dizziness, headache, nausea, vomiting, irregular heartbeat and palpitations, restlessness, insomnia, psychosis, memory loss and muscle injury. Serious thermogenic effects, such as heat stroke, are caused by ephedrine’s ability to increase body temperature; this effect is intensified by caffeine. Ephedrine should never be used by someone with hypertension, diabetes, thyroid disease or an enlarged prostate, taking antidepressant medications or breast feeding. Adverse effects do not always depend on the dose consumed.

Tracking the adverse effects of ephedrine, the FDA noted 17 deaths and 800 adverse effects from 1993-1996. Ephedrine use has been banned by the International Olympic Committee (IOC) and the National Collegiate Athletics Association (NCAA). However, the Dietary Supplement and Health Education Act (DSHEA), passed in 1994, allows dietary supplements to be sold without being proven safe or effective. In 1996, the FDA recommended that the maximum daily dose of the 24 mg supplement should contain no more than 8 mg of ephedrine per serving, that ephedrine should not be taken longer than 1 week, and that all ephedrine-containing products should carry a warning label indicating that more than the recommended dose may cause heart attack, stroke, seizures and death.

Not all products are marked correctly for content, which causes a significant public health risk. The Texas Department of Public Health analyzed a product that indicated it only contained Chinese ginseng and found that it contained 45 mg of ephedrine and 20 mg of caffeine. A study by Gurley et al in 2000 looked at 20 ephedrine-containing supplements and found that the true range was 0–18.5 mg per dosage unit with significant variation in 4 products, 10 products showed label discrepancies for content and 1 product was totally devoid of ephedra alkaloids.

Dietary supplements with ephedra alkaloids are widely promoted; over 3 billion servings were sold in 1999. Ephedra can be dangerous if not taken in consultation with a physician.

References: www.fda.gov

Haller et al. Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids. NEJM 2000 Dec 21; 34325): 1833-8.
Gurley et al. Content versus label claims in ephedra-containing dietary supplements. Am J Health Syst Pharm 2000;57:963-9. 02/03