Note: Ephedra containing supplements sold over the counter were banned by the U.S. Food and Drug Administration in 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 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.

The FDA ban on this substance 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 a 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 4 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 health care professional with experience in botanical medicine.

Ephedra should be used only on a short-term basis because prolonged use may lead to addiction. The amount of time considered safe, however, is not clear. 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 - 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 - 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 - 2.3 mL (24 - 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 - 11.5 mL (115 - 230 drops) three times per day as needed for upper respiratory symptoms; more commonly recommended dose, 1:1.5 g/mL: 0.75 - 1.5 mL (15 - 30 drops), three times per day as needed for upper respiratory symptoms
• Capsules: 12 - 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 interact with other herbs, supplements, or medications. For these reasons, you should take herbs with care, under the supervision of a health care provider 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 or irregular heart beat, stroke, seizures, addiction, and even death. Use of ephedra should be discontinued and your health care provider contacted immediately if you experience any of these adverse effects.

You should not take ephedra if you have the following health conditions: 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. Those taking medications for high blood pressure or depression, and women who are pregnant or breast-feeding, should avoid ephedra and ephedra alkaloids such as ephedrine. To determine whether ephedra is safe and appropriate for you, consult a knowledgeable health care provider.

While no specific interactions (positive or negative) between the herb ephedra and conventional medications have been reported, the active ingredients of ephedra, ephedrine, and pseudoephedrine 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 -- Amphetamine and amphetamine derivatives (such as dextroamphetamine, sometimes used for attention deficit hyperactivity disorder and narcolepsy) should not be used with ephedra. Ephedra may cause increased effects of amphetamines on the body, such as increased heart rate and blood pressure.
• Antidepressants -- Ephedra may interact with 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).
• Aspirinand blood-thinning medications -- Ephedra may increase bleeding in sensitive individuals, such as those taking aspirin or other blood thinning medications.
• Blood pressure medications -- Ephedra may interact with blood pressure lowering medications, particularly clonidine.
• Caffeine and guarana (a caffeine-containing herb)
• Narcotics -- Ephedra may interact with narcotices prescribed for pain, such as morphine and codeine; codeine may also be prescribed for cough.
• Theophylline -- Ephedra may interact with theophylline (used for asthma).

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