Note: Ephedra containing supplements sold over the counter have been banned by the FDA, effective May 2004. See below for additional information.

Ephedra (Ephedra sinica), also called ma huang, has been used in Traditional Chinese Medicine (TCM) for more than 5,000 years. Used in TCM primarily to treat asthma or bronchitis, ephedra is also prescribed for symptoms of cold and flu including nasal congestion, cough, fever, and chills.

While ephedra is a naturally occurring herb, its main active ingredient ephedrine can also be synthesized as a medication. Synthetic ephedrine compounds, such as pseudoephedrine, are widely used in over-the-counter cold remedies and are regulated as a drug. This is unlike the regulation of ephedrine alkaloids derived from the herb itself. These are regulated as a dietary supplements.

Until May 2004, ephedra had been sold commercially as an energy-booster, weight-loss supplement, and athletic performance enhancer. Although some scientific evidence suggests that this herbal supplement may improve weight, the information overall regarding its effectiveness for weight loss, energy, or athletic performance has been inconclusive and controversial. In addition, ephedra-containing products sold for these purposes have been linked to many cases of stroke, heart arrhythmia (irregular heart rhythm), and even death. A number of these products also contain caffeine; the combination of ephedra with caffeine dramatically increases the chances of adverse side effects.

It is important to note that ephedrine containing products are banned from amateur sporting events and evidence of ephedra on drug testing will likely disqualify athletes from competition.

In addition, due to a large body of evidence to support the conclusion, the Food and Drug Administration (FDA) has banned the sale of ephedra-containing dietary supplements, effective May 2004. This ban includes any dietary supplements that contain ephedra, ephedrine, norephedrine, ma huang, Sida cordifolia, or pinellia. This does not pertain to teas (which are regulated as a conventional food) or to traditional Chinese herbal remedies prescribed by traditional Chinese physician.

Ephedra grows on the tundra and on the rocky and sandy slopes of Europe, Asia, and America. The ephedra plant is a perennial evergreen that stands, on average, one foot high but may grow up to four feet. Nearly leafless, the plant has slender, cylindrical, yellow-green branches and underground runners. In August, the flowers bear poisonous, fleshy red cones resembling berries.

The young stems and branchlets are the parts used for medicinal preparations.

Ephedra is primarily used to treat:

• Asthma
• Cough
• Bronchitis
• Allergic rhinitis
• Sinusitis
• Nasal congestion

Ephedra can be prescribed in dried or liquid form. The American Society of Health-System Pharmacists conducted a study evaluating 20 different ephedra-containing products. The results showed wide variation in the amount of ephedra alkaloids present in the supplements and the actual amount in the products often differed markedly from the amount stated on the label. Follow the advice of a knowledgeable healthcare professional with experience in botanical medicine.

Ephedra should only be used on a short-term basis because prolonged use may lead to addiction. The amount of time considered safe, however, is not clear; sources report anywhere from no longer than seven days to up to twelve consecutive weeks. Use of ephedra should take place ONLY under the guidance and supervision of an appropriately trained specialist. Ephedra should be taken between meals, without food.

Pediatric

The American Botanical Council warns that ephedra SHOULD NOT be used in anyone under the age of 18 without strict medical supervision.

Adult

The German Commission E concluded in 1991 that single adult doses of ephedra should correspond to 15 to 30 mg of total ephedrine alkaloid. Current clinical practices are often more conservative. The doses below specify the standard Commission E recommendations and indicate the more conservative amounts often recommended by specialists when applicable.

• Infusion or decoction: 1.2 to 2.3 g of cut, dried ephedra herb containing 1.3% (13 mg/g) total alkaloids steeped in 1 cup freshly boiled water three times per day as needed for upper respiratory symptoms
• Fluid extract 1:1 (g/mL): 1.2 to 2.3 mL (24 to 46 drops) three times per day as needed for upper respiratory symptoms -- this alcohol free liquid form is generally not available in the United States
• Tincture 1:5 (g/mL): 5.75 to 11.5 mL (115 to 230 drops) three times per day as needed for upper respiratory symptoms; more commonly recommended dose, 1:1.5 g/mL: 0.75 mL to 1.5 mL (15 to 30 drops) three times per day as needed for upper respiratory symptoms
• Capsules: 12 to 25 mg of total ephedrine alkaloid three times per day as needed for upper respiratory symptoms – used clinically by herbal specialists

Herbs contain active substances that can trigger side effects and that can interact with other herbs, supplements, or medications. For these reasons, herbs should be taken with care, under the supervision of a practitioner knowledgeable in the field of botanical medicine.

Ephedra can produce side effects such as irritability, restlessness, anxiety, insomnia, headaches, nausea, vomiting, and urinary problems. More serious side effects include high blood pressure, rapid and/or irregular heart beat, stroke, seizures, addiction, and even death. Use of ephedra should be discontinued and your healthcare professional contacted immediately if you experience any of these adverse effects.

Individuals with certain health conditions including anxiety, depression, high blood pressure, glaucoma, heart disease, prostate enlargement, difficulty urinating, seizure disorder, impaired circulation to the brain, psychiatric disorders, thyroid disorders, or diabetes should not take ephedra. Those taking medications for high blood pressure or depression, and women who are pregnant or breastfeeding, should avoid ephedra and ephedra alkaloids such as ephedrine. To determine whether ephedra is safe and appropriate for you, consult a knowledgeable healthcare provider.

While no specific interactions (positive or negative) between the herb ephedra and conventional medications have been reported in the literature, the active ingredients of ephedra, ephedrine and pseudoephedrine (available in a number of over-the-counter and prescription products for weight loss or nasal congestion), have been associated with several serious drug interactions. We may assume, for safety's sake, that those drugs that interact with ephedra's active ingredients may also interact with the herb ephedra. Medications for which there are well-documented interactions with ephedra's active ingredients include:

• Amphetamine and Amphetamine derivatives (such as dextroamphetamine sometimes used for attention deficit hyperactivity disorder and narcolepsy)
• Antidepressants; namely, those in the class of tricyclics (such as clomipramine, desipramine, doxepin, imipramine, and nortriptyline) and monoamine oxidase inhibitors (MAOIs, including phenelzine and trancylcypromine)
• Aspirin 
• Blood Pressure Medications, particularly clonidine
• Caffeine and Guarana (a caffeine-containing herb)
• Narcotics, such as morphine and codeine, prescribed for pain; codeine may also be prescribed for cough
• Phenylpropanolamine (also known as norephedrine, found in certain supplements); formerly in many over the counter and prescription remedies for cough and cold; was removed from the market by the FDA because of risk of bleeding stroke. Norephedrine found in certain dietary supplements for weight loss can cause liver damage.
• Theophylline (used for asthma)

American Herbal Products Association. Citizens Petition 10/25/00. Accessed at http://www.ahpa.org/citizenspetition.html on October 25, 2001.

Ang-Lee MK, Moss J, Yuan C-S. Herbal medicines and perioperative care [review]. JAMA. 2001;286(2):208-216.

Bahner DR, Frenia ML, Augenstein WL. Theophylline toxicity from an over-the-counter preparation. J Emerg Med. 1993;11:427-430.

Blanck HM, Khan LK, Serdula MK. Use of nonprescription weight loss products: results from a multistate survey. JAMA. 2001;286:930-935.

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston: Integrative Medicine Communications; 1998:125-126.

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

Boada S, Solsona B, Papaceit J, Saludes J, Rull M. Hypotension refractory to ephedrine after sympathetic blockade in a patient on long-term therapy with tricyclic antidepressants [in Spanish]. Rev Esp Anestesiol Reanim. 1999;46(8):364-366.

Boozer CN, Nasser JA, Hemsfield SB, Wang V, Chen G, Solomon JL. An herbal supplement containing Ma Huang-Guarana for weight loss: a randomized, double-blind trial. Int J Obes. 2001;25(3):316-324.

Bucci LR. Selected herbals and human exercise performance. Am J Clin Nutr. 2000;72(2):624S-636S.

Clarkson PM, Thompson HS. Drugs and sport. Research findings and limitations. Sports Med. 1997;24(6):366-384.

Council for Responsible Nutrition. Cantox Health Sciences International Safety Assessment and Determination of a Tolerable Upper Limit for Ephedra. Accessed at http://www.crnusa.org/CRNCantoxreportindex.html on October 25, 2001.

Dambisya YM, Wong CL, Chan K. Ephedrine and phenylpropanolamine potentiate the lethal toxicity of morphine and codeine in naïve mice. Asia Pacific J Pharmacol. 1991;6(3):255-258.

Dawson JK, Earnshaw SM, Graham CS. Dangerous monoamine oxidase inhibitor interactions are still occurring in the 1990s. J Accid Emerg Med. 1995;12(1):49-51.

Dingemanse J, Guentert T, Gieschke R, Stabl M. Modification of the cardiovascular effects of ephedrine by the reversible monoamine oxidase A—inhibitor moclobemide. J Cardiovasc Pharmacol. 1996;28:856-861.

Dingemanse J. An update of recent moclobemide interaction data. Int Clin Psychopharmacol. 1993;7(3&4):167-180.

Federal Register. Department of Health and Human Services. Food and Drug Administration. Dietary supplements containing ephedrine alkaloids. April 3, 2000;65(64):17509-17512.

Food and Drug Administration. Consumer Alert: FDA plans regulation prohibiting sale of ephedra-containing dietary supplements and advises consumers to stop using these products. December 30, 2003. Accessed at www.fda.gov/oc/initiatives/ephedra/december 2003/advisory.html on May 5, 2004.

Food and Drug Administration. Dietary supplements containing ephedrine alkaloids final rule summary. February 2004. Accessed at http://www.fda.gov/oc/initiatives/ephedra/february 2004/finalsummary.html on May 5, 2004.

Food and Drug Administration. FDA announces rule prohibiting sale of dietary supplements containing ephedrine alkaloids effective April 12. April 12, 2004. Accessed at http://www.fda.gov/bbs/topics/news/2004/NEW01050.html on May 5, 2004.

Food and Drug Administration. FDA announces the availability of new ephedrine and "street drug alternative" documents. March 31, 2000. Talk Paper TOO-15. Accessed at http://vm.cfsan.fda.gov/~lrd/tpephedr.html on October 16, 2001.

Food and Drug Administration. FDA issues public health warning on phenylpropanolamine. November 6, 2000. Talk Paper T00-58. Accessed at http://www.fda.gov/bbs/topics/ANSWERS/ANS01051.html on April 23, 2002.

Food and Drug Administration. FDA warns consumers not to use the dietary supplement Lipokinetix®. November 20, 2001. Talk Paper T01-59. Accessed at http://www.fda.gov/bbs/topics/ANSWERS/2001/ANS01120.html on April 23, 2002.

Food and Drug Administration. Questions and answers about FDA's actions on dietary supplements containing ephedrine alkaloids. February 6, 2004. Accessed at http://www.fda.gov/oc/initiatives/ephedra/february2004/qa_020604.html on May 5, 2004.

Goyagi T, Tanaka M, Nishikawa T. Oral clonidine premedication enhances the pressor response to ephedrine during spinal anesthesia. Anesth Analg. 1998;87(6):1336-1339.

Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal Medicines. Montvale, NJ: Medical Economics Company; 1998:826-827.

Gurley BJ, Gardner SF, Hubbard MA. Content versus label claims in ephedra-containing dietary supplements [see comments]. Am J Health Syst Pharm. 2000;57(10):963-969.

Haller CA and Benowitz NL. Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids. NEJM. 2000;343:1833-1838.

Hayakawa-Fujii Y, Iida H, Dohi S. Propofol anesthesia enhances pressor response to ephedrine in patients given clonidine. Anesth Analg. 1999;89(1):37-41.

Health Canada. Advisory not to use products containing Ephedra or ephedrine. June 14, 2001. Accessed at http://www.hc-sc.gc.ca/english/ on 10/25/01.

HHS News. US Department of Health and Human Services. FDA proposes safety measures for ephedrine dietary supplements. June 2, 1997. Accessed at http://vm.cfsan.fda.gov/~lrd/hhsephed.html on October 25, 2001.

Horton TJ, Geissler CA. Aspirin potentiates the effect of ephedrine on the thermogenic response to a meal in obese but not lean women. Int J Obes. 1991;15:359-366.

Larkin M. Surgery patients at risk for herb-anaesthesia interactions. Lancet. 1999;354(9187):1362.

Public Citizen calls on FDA to ban dietary supplements containing ephedra [press release]. September 5, 2001. Accessed at http://www.citizen.org/pressroom on October 25, 2001.

Robbers JE, Tyler VE. Tyler's Herbs of Choice: The Therapeutic Use of Phytomedicinals. New York: Haworth Herbal Press; 1999:112-116.

Shulz V, Hansel R, Tyler V. Rational Phytotherapy: A Physician's Guide to Herbal Medicine. 3rd ed. Berlin: Springer; 1998:151-152.

United States General Accounting Office. Dietary supplements: uncertainties in analyses underlying FDA's proposed rule on ephedrine alkaloids. July 2, 1999. Publication GAO/HEHS/GGD-99-90.

Vahedi K, Domigo V, Amarenco P, Bousser MG. Ischaemic stroke in sportsman who consumed MaHuang extract and creatine monohydrate for body building. J Neurol Neurosurg Psychiatry. 2000;68(1):112-113.