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On-line Ephedra

Scientific Name: Ephedra

Other Names: Ephedra sinica, Epitonin, Herbal Ecstasy, Ma Huang, Mahuang, Muzei, Popptillo

Who is this for?

NOTE: Effective in April 2004, the U.S. Food and Drug Administration (FDA) banned the sale of ephedra in the United States. Even though the ban did not go into effect immediately, all individuals using ephedra products were urged to stop taking them.

The risks associated with taking ephedra are not worth whatever small effectiveness it may have. Taking ephedra for any reason is discouraged strongly.

Ephedra contains active ingredients called alkaloids — with the main one being ephedrine. If ephedrine is produced in the laboratory, it is considered to be a drug by the FDA. Ephedrine and some of the other alkaloids in ephedra are central nervous system (CNS) stimulants that have been included in products for weight loss. In studies, some participants using ephedra experienced small to moderate weight loss. However, the results were mostly short-term and the side effects from ephedra caused a significant number of individuals to stop taking ephedra before the studies were scheduled to end.

Ephedra was also sold to improve exercise performance. However, clinical studies found that, at best, ephedra provides only limited enhancement of performance for short periods of time. Due to the possibly severe side effects associated with using ephedra, the U.S. military and several athletic organizations, including the International Olympic Committee (IOC), the U.S. National Football League (NFL), and the National Collegiate Athletic Association (NCAA) prohibited its use well before the FDA ban was announced.

While it has a tightening effect on blood vessels near the surface of the skin, ephedrine also widens bronchioles, which are small airways in the lungs. Therefore, it has been used in the past to relieve stuffy nose and chest tightness caused by allergies and colds. Formerly, ephedra was also used in drugs to treat asthma, but medications with greater effectiveness and less potential for side effects are now available.

When should I be careful taking it?

The use of ephedra is discouraged strongly.

Even though ephedra's risks have caused it to be forbidden to sell in the United States, some individuals will continue to take it. Certain individuals, though, should be particularly careful to avoid its use.

  • Taking ephedra causes blood vessels, especially those in the head, to tighten. Individuals who have ever had strokes, transient ischemic attacks (TIAs), cerebral insufficiency, or any other disorder of blood flow to the brain should avoid the use of ephedra.
  • Pregnant women should not use ephedra because it can cause uterine contractions, which may result in a miscarriage. It also passes into a developing fetus through the mother's blood, possibly causing the fetal heart beat to become rapid or erratic.
  • Due to its potential to affect the force, rate, and rhythm of heart beats, ephedra should not be taken by individuals with heart conditions, including high blood pressure.
  • Individuals with eating disorders such as anorexia nervosa and bulimia should not take ephedra because it may decrease the appetite. In addition, the poor nutritional status of many individuals who have eating disorders may increase the risk of side effects from ephedra.
  • Ephedra stimulates the central nervous system, possibly worsening some physical and emotional disorders, such as anxiety, insomnia, and essential tremors. Individuals with any of these conditions should not take ephedra.
  • Ephedra should also be avoided by individuals with benign prostate hyperplasia (BPH) or urinary retention, because it relaxes the detrusor muscle in the bladder. The detrusor is the muscle that contracts to push urine out of the body. When it is relaxed, urine collects in the bladder.
  • Similarly, ephedra causes the pupils of the eyes to widen. Narrow-angle glaucoma can be worsened by widened pupils; therefore, ephedra should not be taken by individuals with narrow-angle glaucoma.
  • Ephedra interferes with the way the body uses blood sugar. Blood sugar levels can be decreased or increased in unpredictable ways, thereby complicating the treatment of diabetes. Additionally, ephedra can raise blood pressure, which may increase the risk of complications such as eye, kidney, and nerve damage from diabetes. Individuals with diabetes should not take ephedra.
  • Individuals who have thyroid disorders should not take ephedra because it is thought to trigger the production of thyroid hormone, possibly leading to higher than needed amounts of thyroid hormone in the blood.
  • Kidney stones have been associated with the use of ephedra. Individuals who have or who have ever had kidney stones should not take ephedra.

Precautions

Using ephedra is not recommended.

Some evidence suggests that children are more likely to have side effects such as nausea and restlessness from taking ephedra. Children should not be given ephedra.

When ephedra is taken with other CNS stimulants, such as caffeine, the risk of side effects increases.

Ephedra is known to pass into breast milk and to cause changes in the heart rate and rhythm of breast-feeding infants. Women who are breast-feeding should not take it.

What side effects should I watch for?

Note: Not all of the severe effects associated with ephedra occurred in individuals with known medical conditions. Many side effects — some very serious ones — were experienced by healthy, young or middle-aged individuals who took low doses of ephedra for short periods of time.

Ephedra has been identified as the cause of over 150 deaths in the United States. Thousands of non-fatal side effects have also been attributed to its use. Some of ephedra's more serious potential side effects include:

Hemorrhagic strokes, the result of bleeding into the brain
Heart attacks
Psychoses and other mental disorders
Abnormalities of muscles, including the heart muscle
Seizures and unconsciousness
Kidney stones

Less Severe Side Effects

Taking ephedra has also been associated with:

  • Anxiety
  • Changes in blood sugar levels
  • Changes in heart rate
  • Changes in heart rhythm
  • Difficult urination
  • Dizziness
  • Dry mouth
  • Elevated blood pressure
  • Elevated body temperature
  • Flushing of the face
  • Headache
  • Heartburn
  • Inability to concentrate
  • Insomnia
  • Irritability
  • Loss of appetite
  • Nausea
  • Restlessness
  • Tingling fingers or toes
  • Vomiting

Stopping ephedra does not guarantee that side effects will also stop. In some reported cases, side effects such as mental disturbances or high blood pressure continued for several months after individuals stopped taking ephedra.

What interactions should I watch for?

Prescription Drugs

Dexamethasone

Ephedra has been shown to increase the elimination of a corticosteroid drug, dexamethasone, from the body. As a result the effects of dexamethasone may be reduced. Whether other corticosteroids are affected in similar ways is not known. Corticosteroids are used for a wide range of inflammatory conditions including arthritis, asthma, cancer, eye conditions, and skin infections.

Digoxin

Taking ephedra with the heart drug, digoxin (Lanoxin) may cause potentially dangerous changes in heart rhythm.

Drugs for High Blood Pressure

Due to the probability that it may raise blood pressure, ephedra is believed to decrease the effects of drugs that lower blood pressure. Some blood pressure-lowering drugs include:

  • ACE inhibitors such as captopril, enalapril, lisinopril, and Monopril
  • Beta blockers such as atenolol, metoprolol, and propranolol
  • Calcium channel blockers such as nifedipine, Norvasc, and verapamil
  • Diuretics such as Dyazide, furosemide, and hydrochlorothiazide

Drugs that Affect the Acidity of Urine

Drugs that change the levels of acid in the urine may interfere with the way ephedra is eliminated from the body, potentially increasing the risk of side effects. Drugs that change urinary acid levels include sodium bicarbonate, citric acid, and ammonium chloride.

Ergots

Ergot products are taken mainly to relieve migraine headaches. They work by constricting blood vessels in the brain. Since ephedra also tightens those blood vessels, they may become too narrow and high blood pressure or more serious conditions can result. Some ergots are:

  • dihydroergotamine (D.H.E., Migranal)
  • ergotamine (Ergomar)
  • ergotamine combinations (Cafergot, Wigraine)
  • methysergide (Sansert)

Other ergot products that should not be taken with ephedra include ergonovine (Ergotrate), used to stop excessive bleeding after childbirth; ergoloid mesylates (Gerimal, Hydergine), used to enhance cognitive function; and bromocriptine (Parlodel), used to treat a number of conditions including Parkinson's disease.

Insulin

Because blood sugar levels may either increase or decrease when ephedra is taken, insulin may not work as well to control diabetes.

Monoamine Oxidase Inhibitors

Dangerously high blood pressure may result if ephedra is taken with a type of antidepressants called monoamine oxidase inhibitors (MAOIs), which include:

  • isocarboxazid (Marplan
  • phenelzine (Nardil)
  • tranylcypromine (Parnate)

Selegiline (Eldepryl), a drug which is related to the MAOIs and which is used for Parkinson's disease, also should not be taken with ephedra.

Oral Antidiabetes Drugs

In some studies, ephedra altered the amount of sugar in the blood. Blood sugar levels went up or down in unpredictable ways. Therefore, the effectiveness of oral drugs taken to control diabetes may be affected when ephedra is taken.

Theophylline

Theophylline, a drug sometimes used to treat asthma, can cause side effects such as headaches, heart rhythm changes, insomnia, nausea, and seizures. If ephedra is taken at the same time as theophylline or related drugs, the risk of these and other side effects may increase. Some brand names for theophylline and related drugs are:

  • Dilor
  • Lufyllin
  • Quibron
  • Quinamm
  • Respbid
  • Theo-Dur
  • Uniphyl

Thyroid

Ephedra can increase the amount of thyroid hormone produced by the body. Taking it can interfere with therapy for both high and low thyroid levels. Ephedra should be avoided by individuals with thyroid conditions.

Non-prescription Drugs

Aspirin may increase the effects and possibly the risk of side effects from ephedra.

Some non-prescription products for colds and allergies contain pseudoephedrine or other ingredients that may have side effects similar to those caused by ephedra. If ephedra is taken at the same time as one of the ingredients similar to it, both the effects and the side effects of ephedra may be increased.

Herbal Products

Central nervous system (CNS) stimulation may be increased if ephedra is taken at the same time as other herbal products that also excite the CNS. Results could include anxiety, dizziness, headache, insomnia, restlessness, and changes in the ability to concentrate. Some CNS-stimulating herbal products are:

  • Cola nut
  • Caffeinated teas
  • Guarana
  • Mate

Foods

Caffeine — including caffeine in beverages such as coffee, soft drinks, and tea — increases the CNS stimulating effect of ephedra. Even though several commercial weight loss products combined ephedra with caffeine to increase the weight loss effect, the combination may have caused excessive nervousness and irritability along with other signs of over-stimulation in some individuals.

Some interactions between herbal products and medications can be more severe than others. The best way for you to avoid harmful interactions is to tell your doctor and/or pharmacist what medications you are currently taking, including any over-the-counter products, vitamins, and herbals.

Should I take it?

Many different types of ephedra plants grow all over the world, mainly as short bushy evergreens with small leaves and yellowish flowers. Generally, ephedra grows well in sandy, rocky, or other marginally unproductive areas. The plants smell somewhat like pine trees. The bark, stems, and sometimes the roots are used in medicine.

Traditional Asian healers have been using ephedra for hundreds of years to treat conditions as diverse as arthritis and fever. In the western world, ephedra has been a treatment for asthma and other breathing conditions, including allergies and colds. Most recently, it was promoted for losing weight and improving physical performance. Neither of these effects was believed to be great or long-lasting, however; and the risk of serious side effects is too great for ephedra to be recommended for any purpose.

Dosage and Administration

Ephedra should not be taken.

Many different types of the ephedra plant grow in various parts of the world. The amounts of active chemicals in ephedra cannot be guaranteed because they depend on which type of ephedra plants are used and how the plants are grown, harvested, processed, and stored. In addition, the makers of herbal preparations are not required to prove the safety or effectiveness — or even the content — of their products in the same ways that pharmaceutical manufacturers must provide proof. At least one laboratory analysis showed significant variations in the ephedra content listed on the labels of several commercial products and the actual amount of ephedra in the packages.

A recent study found that doses of ephedra above 32 mg per day were three times as likely as lower doses to result in hemorrhagic strokes (bleeding in the brain). In theory, the longer ephedra is taken, the higher the risk of severe side effects. However, many of the most severe side effects, including death, have been reported when individuals took small amounts of ephedra for short periods of time. In another small study, just one dose of a weight-loss product that contains ephedra, caffeine, and several other ingredients raised blood pressure and caused heart rhythm changes in overweight but otherwise healthy young adults.

Summary

The risks associated with the use of ephedra are too great to recommend that it be used for any purpose.

Although ephedra products were used widely to promote weight loss and to increase athletic ability, no substantial evidence exists to support these uses. Most studies of its use were small and none lasted longer than 6 months.

Risks

The use of ephedra should be avoided by all individuals, especially:

  • Pregnant women
  • Children
  • Individuals with:
    • Anxiety
    • Benign prostatic hyperplasia (BPH)
    • Diabetes
    • Eating disorders
    • High blood pressure
    • Insomnia
    • Kidney stones
    • Narrow-angle glaucoma
    • Thyroid conditions
    • Urinary retention

Side Effects

Serious side effects of ephedra include:

  • Death
  • Heart attack
  • Stroke

In addition, ephedra can cause:

  • Anxiety
  • Changes in blood sugar levels
  • Changes in heart rate or rhythm
  • Changes in the ability to concentrate
  • Difficult urination
  • Dizziness
  • Dry mouth
  • Elevated blood pressure
  • Elevated body temperature
  • Flushing of the face
  • Headache
  • Heartburn
  • Insomnia
  • Irritability
  • Loss of appetite
  • Nausea
  • Restlessness
  • Tingling fingers or toes
  • Vomiting

Interactions

Ephedra can interfere with:

  • Caffeine
  • CNS stimulants
  • Cold or allergy products that contain pseudoephedrine
  • Dexamethasone
  • Digoxin
  • Drugs for high blood pressure
  • Drugs that change the acid content of the urine
  • Ergotamine products
  • Insulin and oral drugs for diabetes
  • Monoamine oxidase inhibitors (MAOIs)
  • Theophylline and related drugs
  • Thyroid medications
Last Revised: February 13, 2004

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(Note: The above information is not intended to replace the advice of your physician, pharmacist, or other healthcare professional. It is not meant to indicate that the use of the product is safe, appropriate, or effective for you.)

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