Natural Standard® Patient Monograph, Copyright © 2014 (www.naturalstandard.com). All Rights Reserved. Commercial distribution prohibited. This monograph is intended for informational purposes only, and should not be interpreted as specific medical advice. You should consult with a qualified healthcare provider before making decisions about therapies and/or health conditions.

Background

In 2003, there was a death of a U.S. major league baseball pitcher which was thought to be related to ephedra. The U.S. Food and Drug Administration (FDA) has collected more than 800 reports of serious toxicity, including more than 22 deaths. On February 6, 2004, the FDA issued a rule prohibiting the sale of dietary supplements containing ephedrine alkaloids (ephedra). This rule was issued because supplements with ephedra present a serious risk of illness or injury.

In 2005 this rule was struck down in Utah but reversed again four months later. Ephedra is currently banned throughout the United States. It remains unclear whether ephedra will re-appear on the market, despite serious safety risks, including heart events or death.

Ephedra sinica, a species of ephedra (ma huang), contains ephedrine and pseudoephedrine. Ephedra has been found to stimulate the nervous system, increase airflow into the lungs and constrict blood vessels. In combination with caffeine, ephedra appears to cause weight loss. However, effects of ephedra or ephedrine monotherapy have been mixed. Ephedrine has been widely studied for asthma and low blood pressure. However, quality research of commercial supplements with ephedra is lacking.

Major safety concerns have been associated with ephedra or ephedrine use, including high blood pressure, increased heart rate, nervous system excitation, irregular heartbeat, heart attack, and stroke.

Dosing

The below doses are based on scientific research, publications, traditional use, or expert opinion. Many herbs and supplements have not been thoroughly tested, and safety and effectiveness may not be proven. Brands may be made differently, with variable ingredients, even within the same brand. The below doses may not apply to all products. You should read product labels, and discuss doses with a qualified healthcare provider before starting therapy.

Adults (18 years or older)

Note: The U.S. Federal Government has banned the sale of ephedra since 2004. Ephedra may cause serious adverse effects at any dose, particularly when used with other drugs, such as caffeine. Because of serious safety concerns, ephedra cannot be suggested in any dose.

Traditionally, herbalists have suggested a wide range of doses (8-100 milligrams ephedra by mouth three times daily). Previously, over-the-counter drugs containing ephedra advised taking 12.5-25 milligrams ephedra by mouth every four to six hours and not to exceed 150 milligrams in 24 hours.

For allergic nasal symptoms, a 1% ephedrine-saline liquid has been used as a nose wash every 48 hours for four weeks.

For athletic performance enhancement, 1 milligram of ephedrine per kilogram body weight has been taken by mouth 90 minutes prior to exercise once weekly for four weeks.

For low blood pressure, 5-45 milligrams ephedrine has been injected into the vein or muscle.

For sexual arousal, 50 milligrams of ephedrine sulfate has been taken by mouth prior to exposure to erotic stimuli.

For weight loss, 2 grams of ephedra extract has been taken by mouth three times daily for eight weeks, 20-50 milligrams of ephedrine has been taken by mouth three times daily for 2-3 months.

Children (younger than 18 years)

Ephedrine is not recommended in children due to the risk of toxicity and death.

For asthma, 24-25 milligrams ephedrine or 0.65-2.1 milligrams ephedrine per kilogram has been taken by mouth every 6-8 hours for 1-8 weeks.

Evidence

These uses have been tested in humans or animals.  Safety and effectiveness have not always been proven.  Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider.

Key to grades

A
Strong scientific evidence for this use
B
Good scientific evidence for this use
C
Unclear scientific evidence for this use
D
Fair scientific evidence against this use (it may not work)
F
Strong scientific evidence against this use (it likely does not work)

Grading rationale

Evidence gradeCondition to which grade level applies
B

Weight loss

In human research, ephedra caused weight loss when used in combination with caffeine. The research on ephedra alone is limited and results are mixed. The amounts of ephedra in commercially available products varied widely and numerous adverse effects have been reported. Further research is necessary.
C

Allergic nasal symptoms (used as a nose wash)

Early studies suggest that ephedrine nasal spray may help treat symptoms of nasal allergies. Additional research is needed before a firm conclusion can be made.
C

Asthma

Ephedra contains the chemicals ephedrine and pseudoephedrine, which are bronchodilators (expand the airways for easier breathing). It has been used and studied to treat asthma and chronic lung diseases in both children and adults. Other treatments, such as inhalers (for example albuterol), are more commonly recommended due to safety concerns with ephedra or ephedrine. Further research is needed.
C

Athletic performance enhancement

Early research demonstrates mixed findings regarding the effects of ephedra on athletic performance. Further research is needed in this area.
C

Low blood pressure

Chemicals in ephedra may stimulate the heart, increase heart rate, and raise blood pressure. Ephedrine, a component of ephedra, is sometimes used in hospitals to help control blood pressure. However, the effects of over-the-counter ephedra supplements lack sufficient study. Further research is needed.
C

Respiratory infections

Limited research shows that ephedra in combination with other herbs commonly used in traditional Chinese medicine (TCM) may be beneficial for infections of the upper respiratory tract (nose, throat, and mouth). Further research of ephedra alone is needed before conclusions can be made.
C

Sexual arousal

Early research suggests that ephedra may increase sexual arousal in women. Further well-designed research is needed to confirm these results.

Uses based on tradition or theory

The below uses are based on tradition or scientific theories. They often have not been thoroughly tested in humans, and safety and effectiveness have not always been proven. Some of these conditions are potentially serious, and should be evaluated by a qualified healthcare provider.

Alertness, anaphylaxis (a severe allergic reaction), anti-inflammatory, antiviral, appetite suppressant, arthritis, bed-wetting, body building, colds, cough, depression, diaphoretic (causing sweating), diuretic (increasing urine flow), fatigue, fevers, flu, gonorrhea, gout, hives, joint pain, kidney disease, kidney inflammation, liver spots, metabolic enhancement, narcolepsy (daytime sleep attacks), nasal congestion, neuromuscular disorders (nerve and muscle disorders), shortness of breath, skin conditions (freckles), stimulant, swelling, syphilis, uterine stimulant, water retention.

Interactions

Interactions with Drugs

Ephedra may raise blood pressure. Caution is advised in people taking drugs that affect blood pressure.

Ephedra may lower blood sugar levels, although ephedra-caffeine combinations may increase blood sugar. Caution is advised when using medications that may also alter blood sugar. Patients taking drugs for diabetes by mouth or insulin should be monitored closely by a qualified healthcare provider. Medication adjustments may be necessary.

Ephedra may interfere with the way the body processes certain drugs using the liver's "cytochrome P450" enzyme system. As a result, the levels of these drugs may be altered in the blood, and may cause altered effects or potentially serious adverse reactions. People using any medications should check the package insert, and speak with a qualified healthcare professional, including a pharmacist, about possible interactions.

Ephedra may also interact with acidifying agents, agents eliminated by the kidneys, agents that affect the immune system, agents that affect the stomach or intestines, agents that alter heart rate, agents that cause muscle breakdown, agents that lower seizure threshold, agents toxic to the liver, alcohol, alkalinizing agents, anesthetics, antiadrenergic drugs (alpha blockers), antiadrogens, antiasthma agents, antidepressant agents (monoamine oxidase inhibitors, tricyclic antidepressants, selective serotonin reuptake inhibitors), antigout agents, anti-inflammatory agents, aspirin, cardiac glycosides, cholesterol agents, central nervous system stimulants, diuretics (increasing urine flow), ergot derivatives, hormonal agents, methylxanthines (theophylline, caffeine), oxytocics, phenothiazines, phenylpropranolamine, steroids, thyroid hormones, and weight loss agents.

Interactions with Herbs and Dietary Supplements

Ephedra may raise blood pressure. Caution is advised in people taking herbs or supplements that affect blood pressure.

Ephedra may lower blood sugar levels, although ephedra-caffeine combinations may increase blood sugar. Caution is advised when using herbs and supplements that may also alter blood sugar. Blood glucose levels may require monitoring, and doses may need adjustment.

Ephedra may interfere with the way the body processes certain herbs or supplements using the liver's "cytochrome P450" enzyme system. As a result, the levels of other herbs or supplements may be altered in the blood. It may also alter the effects that other herbs or supplements possibly have on the P450 system.

Ephedra may also interact with anesthetics, antiadrenergic herbs and supplements (alpha blockers), antiadrogens, antiasthma herbs and supplements, antidepressant herbs and supplements (monoamine oxidase inhibitors, selective serotonin reuptake inhibitors), antigout herbs and supplements, anti-inflammatory herbs and supplements, appetite stimulants, caffeine-containing herbs and supplements, cardiac glycosides, cholesterol herbs and supplements, central nervous system stimulants, diuretics (increasing urine flow), herbs and supplements eliminated by the kidneys, herbs and supplements that affect the immune system, herbs and supplements that affect the stomach or intestines, herbs and supplements that alter heart rate, herbs and supplements that cause muscle breakdown, herbs and supplements that change the urine pH, herbs and supplements that lower seizure threshold, herbs and supplements toxic to the liver, hormonal herbs and supplements, potassium, steroids, stimulant herbs and supplements, and weight loss herbs and supplements.

Methodology

This patient information is based on a professional level monograph edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Monograph methodology

Related terms

6-hydroxykynurenic acid, amp II, amsania, brigham tea, budshur, cao ma huang (Chinese), cathine, chewa, Chinese ephedra, Chinese joint fir, D-pseudoephedrine, desert herb, desert tea, dextro-rotatory, Ephedra altissima, Ephedra americana, Ephedra anti-syphilitica, Ephedra distachya, Ephedra equisetina, Ephedra fasciculata, Ephedra geradiana, Ephedra helvetica, Ephedra intermedia, Ephedra major, Ephedra nevadensis, Ephedra shennungiana, Ephedra sinica, Ephedra trifurca, Ephedra viridis, Ephedra vulgaris, Ephedraceae (family), ephedra herba, ephedrae herba, ephedrine, ephedrine alkaloids, epitonin, European ephedra, Gnetales, herba ephedrae, herbal ecstasy, horsetail, hum, huma, Indian joint fir, intermediate ephedra, isoephedrine, joint fir, khama, khat, L-ephedrine, levo-rotatory ephedrine, mahoàng, máhuáng, mahuuanggen, Mao (Chinese), mao-kon, methylephedrine, methylpseudoephedrine, Mexican tea, môc tac ma hoàng, Mongolian ephedra, Mormon tea, mu-tsei-ma-huang, muzei mu huang, natural ecstasy, norephedrine, norpseudoephedrine, phenylpropanolamine, phok, popotillo, pseudo-ephedrine, pseudoepehdrine, quinoline, san-ma-huang, sea grape, shrubby, soma, song tuê ma hoàng, squaw tea, synephrine, tannins, teamster's tea, trun aa hoàng, tsao-ma-huang, tutgantha, yellow astringent, yellow horse, zhong ma huang.

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Note: There are approximately 40 species of ephedra.

Safety

The U.S. Food and Drug Administration does not strictly regulate herbs and supplements. There is no guarantee of strength, purity or safety of products, and effects may vary. You should always read product labels. If you have a medical condition, or are taking other drugs, herbs, or supplements, you should speak with a qualified healthcare provider before starting a new therapy. Consult a healthcare provider immediately if you experience side effects.

Allergies

Avoid in people with a known allergy or sensitivity to ephedra, ephedrine, or pseudoephedrine (Sudafed®). Signs of allergy may include rash, itching, or red, flaking skin.

Side Effects and Warnings

The U.S. Food and Drug Administration (FDA) has collected more than 800 reports of serious toxicity, including more than 22 deaths. The U.S. Federal Government has banned the sale of ephedra in the United States since 2004.

Ephedra may affect blood sugar levels. Caution is advised when using medications that may also affect blood sugar. People taking drugs for diabetes by mouth or insulin should be monitored closely by a qualified healthcare professional, including a pharmacist. Medication adjustments may be necessary.

Ephedra may cause high blood pressure. Caution is advised in people taking drugs that affect blood pressure.

Use cautiously in people sensitive to stimulants or in combination with other known stimulant agents (e.g. coffee).

Use cautiously in people with kidney, thyroid, liver, or peptic ulcer disease.

Use cautiously in people with heart disease, such as structural heart disease, irregular heart rhythms, clogged arteries, high blood pressure, stroke, or in those taking agents for the heart.

Use cautiously in people with glaucoma, problems with the stomach or intestines, or seizure disorders.

Use cautiously in people with depression, anxiety disorders, anorexia/bulimia, a history of suicidal ideation, or previous use of monoamine oxidase inhibitor (MAOI) anti-depressants.

Use cautiously in people that have difficulty urinating or have an enlarged prostate.

Avoid use during major medical procedures (such as surgery), as ephedra may decrease effectiveness of anesthetics. Discontinue use at least one week prior to major surgery or other procedures.

Avoid using doses higher than suggested or using for a long duration (over seven days), due to risk of toxicity.

Avoid use in children due to risk of toxicity and death.

Avoid use during pregnancy or breastfeeding since ephedra may pass into breast milk.

Avoid in people with known allergy or sensitivity to ephedra or its parts.

Adverse effects of ephedra may include abdominal discomfort, agitation, anxiety, blindness (transient), blood clots, bloody diarrhea, brain disease, breathing difficulties, changes in liver enzymes, chest tightness, clogged arteries, confusion, constipation, contractions of the uterus, damage, damage to the heart muscle, death, delirium, depression, diarrhea, dizziness, dry mouth, dull headedness, euphoria, exaggerated reflexes, excitation, fainting, fluid build-up in the lungs, hallucinations, headache, hearing loss, heart attack, heart problems, heartburn, inability to urinate, increased thyroid hormone, increased urination, inflammation of the heart, insomnia, irregular heart rhythms, irritability, liver damage, liver inflammation, loss of appetite, loss of consciousness, low potassium levels in the blood, kidney failure, kidney stones, mania, muscle aches, muscle breakdown, nausea, obsessive-compulsive disorder (OCD), organ failure, overly active reflexes, painful urination, Parkinson's disease-like symptoms, psychosis, rapid heartbeat, restlessness, satiety, seizures, shortness of breath, skin inflammation, skin tingling, spasm in blood vessels, stomach pain, stroke, suicidal ideas, tiredness, tremor, vomiting, weakened and enlarged heart, weakness, and weight loss.

Pregnancy and Breastfeeding

Avoid in pregnant and breastfeeding women. Ephedra may cause uterine contractions or problems in babies such as crying, increased heart rate, irritability, and sleep difficulties.

Selected references

  1. Chen WL, Tsai TH, Yang CC, et al. Effects of ephedra on autonomic nervous modulation in healthy young adults. J.Ethnopharmacol. 8-9-2010;130(3):563-568.
  2. Chen ZX and Hu GH. [Effect of modified shegan mahuang decoction on cytokines in children patients with cough and variant asthma]. Zhongguo Zhong.Xi.Yi.Jie.He.Za Zhi. 2010;30(2):208-210.
  3. Choi JH, Chung MJ, and Oh DH. Classification of Sasang constitutional body types using immunostimulatory activities of constitution-specific herbal extracts in human primary immune cells. J.Med.Food 2012;15(9):824-834.
  4. Cohen PA and Ernst E. Safety of herbal supplements: a guide for cardiologists. Cardiovasc.Ther. 2010;28(4):246-253.
  5. Flanagan CM, Kaesberg JL, Mitchell ES, et al. Coronary artery aneurysm and thrombosis following chronic ephedra use. Int.J.Cardiol. 2-18-2010;139(1):e11-e13.
  6. Hallas J, Bjerrum L, Stovring H, et al. Use of a prescribed ephedrine/caffeine combination and the risk of serious cardiovascular events: a registry-based case-crossover study. Am.J.Epidemiol. 10-15-2008;168(8):966-973.
  7. Hasani-Ranjbar S, Nayebi N, Larijani B, et al. A systematic review of the efficacy and safety of herbal medicines used in the treatment of obesity. World J.Gastroenterol. 7-7-2009;15(25):3073-3085.
  8. Jing H, Luo L, Li H, et al. Ephedrine controls heart rhythms by activating cardiac I(ks) currents. J.Cardiovasc.Pharmacol. 2010;55(2):145-152.
  9. Kim HJ, Park JM, Kim JA, et al. Effect of herbal Ephedra sinica and Evodia rutaecarpa on body composition and resting metabolic rate: a randomized, double-blind clinical trial in Korean premenopausal women. J.Acupunct.Meridian.Stud. 2008;1(2):128-138.
  10. Martinez-Quintana E, Rodriguez-Gonzalez F, and Cuba-Herrera J. [Myocardial necrosis and severe biventricular dysfunction in the context of chronic ephedrine abuse]. Adicciones. 2010;22(1):25-28.
  11. Palamar J. How ephedrine escaped regulation in the United States: a historical review of misuse and associated policy. Health Policy 2011;99(1):1-9.
  12. Retamero C, Rivera T, and Murphy K. "Ephedra-free" diet pill-induced psychosis. Psychosomatics 2011;52(6):579-582.
  13. Singh A, Rajeev AG, and Dohrmann ML. Cardiomyopathy associated with ephedra-containing nutritional supplements. Congest.Heart Fail. 2008;14(2):89-90.
  14. Thomas JE, Munir JA, McIntyre PZ, et al. STEMI in a 24-year-old man after use of a synephrine-containing dietary supplement: a case report and review of the literature. Tex.Heart Inst.J. 2009;36(6):586-590.
  15. Vigano M, Lampertico P, and Colombo M. Acute hepatitis following assumption of a herbal remedy. Eur.J.Gastroenterol.Hepatol. 2008;20(4):364-365.

This evidence-based monograph was prepared by The Natural Standard Research Collaboration

www.naturalstandard.com