Ma-huang/ Ephedra (Ephedra sinica),
Be aware that the U.S. Food and Drug Administration does not strictly
regulate herbs and dietary supplements. There is no guarantee of strength,
purity or safety of products containing or claiming to contain ephedra. Decisions
to use herbs or supplements should be carefully considered. Individuals using
prescription drugs should discuss taking herbs or supplements with their
pharmacist and other health care providers before starting.
Ephedra is also known as Ma-huang. Ephedra and the chemicals ephedrine and
pseudoephedrine in ephedra have been associated with many reports of serious
toxicity, including death, and with numerous interactions with drugs, herbs
Note: On February 6th, 2004, the U.S. Food and Drug Administration
(FDA) issued a final rule prohibiting the sale of
dietary supplements containing ephedrine alkaloids (ephedra) because such
supplements present an unreasonable risk of illness or injury.
The rule became effective 60 days from the date of publication. Sales of
ephedra have also been banned in several European countries.
On April 14, 2005, a Federal District Court in Utah under Judge Tena Campbell
struck down an FDA ban on ephedra. The
ruling is specific only to Utah, although it calls into question the FDA
ban in general. The suit in question was brought by the dietary supplement
manufacturing company Nutraceutical Corporation. The decision specifically
questioned the ability of the FDA to ban ephedra completely without conclusively
demonstrating danger at low doses.
Although most evidence around the risks associated with ephedra use is based
on higher doses or combination use with caffeine, a universal ban was implemented
by the FDA, as it would be unethical to conduct human studies of lower doses
in order to establish safety. Therefore, Judge Campbell felt there is inadequate
safety data at lower doses. This places the FDA in a bind under current dietary
supplement regulatory law it suspects dangers at low doses, but cannot
seek to prove these dangers.
It remains unclear whether ephedra will find its way back onto shelves, despite
widespread acknowledgement of significant safety risks, including serious
potential cardiovascular events or death.
Scientists have studied ephedra for the following health problems:
Ephedra contains the chemical ephedrine, which appears to cause weight loss
when used in combination with caffeine. However, there are weaknesses with
the design of most available studies. There are variable amounts of ephedrine
in commercially available products, and thousands of adverse reactions have
been reported to the FDA with ephedrine use, including heart attack, stroke,
seizure, serious psychiatric symptoms, and death. Before the official ban,
the FDA issued a policy that ephedrine products had to be labeled with possible
adverse effects, contain no more than 8 milligrams of ephedrine per serving,
and be used for no longer than seven days.
Ephedra contains the chemicals ephedrine and pseudoephedrine. It was used
for many years as a treatment for asthma and chronic obstructive pulmonary
disease in both children and adults, before the development of more modern
treatments. Although ephedrine is an effective bronchodilator, there are
drugs that are considered to be safer with less risk of toxicity.
Low blood pressure
Chemicals in ephedra can stimulate the heart, increase heart rate and raise
blood pressure. The chemical ephedrine in ephedra has been used in hospitals
to control blood pressure during delivery in women receiving spinal anesthesia.
However, these effects have not been evaluated for ephedra supplements taken
Nasal allergies (used as a nose wash)
Preliminary study suggests possible benefits of ephedrine, a chemical in
ephedra, when used as a nasal spray for treating symptoms of nasal allergies.
Although results seem promising, further research is needed.
Preliminary study suggests that ephedra may increase sexual arousal in women.
Further research is needed to confirm these results.
Ephedra has been suggested for many other uses, based on tradition or
on scientific theories. However, these uses have not been thoroughly studied
in humans, and there is limited scientific evidence about safety or
effectiveness. Some of these suggested uses are for conditions that are
potentially very serious and even life-threatening. You should consult a
health care provider before taking ephedra for any use.
|Acute coryza (rhinitis)
Anaphylaxis (a severe allergic reaction)
Congenital myasthenic syndrome
Dyspnea (shortness of breath)
Lack of perspiration
Shortness of breath
Upper respiratory tract infection
People should avoid ephedra if they have a known allergy. Signs of allergy
may include rash, itching or red, flaking skin.
Ephedra has been associated with thousands of reports of serious toxicity,
including over 100 deaths. Ephedra is not considered safe, despite its possible
effectiveness for treating certain conditions. Before the official ban of
ephedra sales altogether, the FDA issued a policy that ephedrine products
be labeled with possible adverse effects, contain no more than 8 milligrams
of ephedrine per serving, and be used for no longer than seven days.
Stomach discomfort, including diarrhea, nausea, vomiting, anorexia, constipation,
diuresis (increased urine production), and dry mouth may occur. Liver damage
has been reported. Ephedra may also cause seizures, stroke, dizziness,
irritability, restlessness, anxiety, nervousness, excitation, euphoria, delirium,
confusion, fainting, difficulty sleeping, and headache. There have been cases
of psychosis, mania, confusion, and hallucinations after using ephedra. If
you have a history of a psychotic illness and are considering using ephedra
or other herbs and supplements, discuss this with your health care providers.
Ephedra may also affect the heart and lungs. Inflammation of the heart; fluid
retention in the lungs; breathing difficulties; irregular heart rhythms,
including rapid or slowed heartbeats; alterations in blood pressure; heart
attack; dilated cardiomyopathy; left ventricular systolic dysfunction; coronary
dissection; thrombosis; and cardiac arrest have been reported. Rare side
effects include kidney stones, difficulty passing urine or pain when urinating.
In theory, ephedra may lower blood sugar levels. Caution is advised if you
take prescription drugs to control your blood sugar levels. Ephedra may also
lower potassium levels in the blood, cause uterine contractions and lead
to tremors, hyperactive reflexes, weakness, muscle aches, degeneration of
muscle tissue, depression, mania, agitation, hallucinations, suicidal ideas,
and Parkinson's disease-like syndromes.
If too much ephedra is taken suddenly, symptoms of toxicity may include anxiety,
dizziness, difficulty sleeping, chest tightness, decreased appetite, high
blood pressure, rapid heartbeats, irregular heart rhythms, stroke, difficulty
urinating, vomiting, psychosis or death. When ephedra is used for prolonged
periods of time, even at recommended doses, chronic toxicity may lead to
weight loss, difficulty sleeping, high blood pressure, dry mouth, irregular
heart rhythms, rapid heartbeats, anxiety, obsessive-compulsive disorder,
flare, nervousness, and heart damage.
It has been recommended that ephedra and Ma-huang use be stopped at least
one week prior to major surgical or diagnostic procedures.
Pregnancy And Breast-Feeding
Ephedra cannot be recommended during pregnancy and breast-feeding because
of the risk of adverse effects. Ephedra is believed to cross the placenta
and increase fetal heart rate. It may also stimulate uterine contractions,
which could cause abortion or premature labor. Ephedra is excreted in breast
milk and may cause irritability, crying and difficulty sleeping in infants.
Interactions with drugs, supplements and other herbs have not been thoroughly
studied. The interactions listed below have been reported in scientific
publications. If you are taking prescription drugs, speak with your health
care provider or pharmacist before using herbs or dietary supplements.
Interactions With Drugs
Combined ingestion of caffeine and ephedrine has been observed to increase
blood glucose and lactate concentrations. Ephedrine and dopamine concentrations
are significantly increased. A case report exists of ephedra use associated
with the onset of psychosis and autonomic hyperactivity after administration
Many drugs can cause increased stimulant effects when used with ephedra or
ephedrine. Some examples include central nervous system stimulants, theophylline
and caffeine. In combination with ephedra, these drugs may lead to sleeping
difficulties, nervousness, stomach upset or even death. The combination of
ephedrine and caffeine may be fatal. Many products contain both ephedrine
Bronchodilators used for asthma or the decongestant pseudoephedrine may have
increased bronchodilating effects when used with ephedra. Increased adverse
effects, including dangerously high blood pressure, muscle breakdown, fever
and irregular heartbeats, may occur if ephedra is used with monoamine oxidase
inhibitor antidepressants, such as phenelzine (Nardil). Some antipsychotics
and other types of antidepressants may reduce the effects of ephedra and
cause low blood pressure and rapid heartbeat.
Because ephedra usually increases blood pressure and can affect heart rate,
it may decrease the effectiveness of blood pressure-lowering drugs and some
antiarrhythmic drugs, including digoxin (Lanoxin). The adverse effects of
ephedra may be increased with guanethidine, ergot alkaloids such as ergotamine,
oxytocin, diuretics, urinary acidifiers such as ammonium chloride, thyroid
hormones, morphine, halothane or other types of anesthesia, and drugs that
reduce blood sugar levels. Because ephedra may lower blood sugar levels,
caution is advised if you are taking prescription drugs that may also lower
blood sugar levels. Patients taking oral drugs for diabetes or using insulin
should be monitored closely by their health care provider while using ephedra.
Dosing adjustments may be necessary. The effects of corticosteroids such
as dexamethasone may be lessened when taking ephedra, and ephedra may be
less effective when used with urinary alkalinizers.
Phenylpropanolamine, also removed from the U.S. market, may lead to additive
effects when taken with ephedra. Effects of cholesterol-lowering medications
may be altered by ephedra, although this has not been proven. One study of
Metabolife 356, a product containing ephedra and other ingredients, was
associated with heart-rhythm abnormalities (arrhythmias, QT prolongation)
and may therefore interact with other agents with similar side effects like
haloperidol (Haldol) and metoclopramide (Reglan).
Interactions With Herbs And Dietary Supplements
The stimulant properties of ephedra may be increased when used with herbs
and supplements that have stimulant properties or with those that contain
caffeine, such as guarana, mate or cola nut. Ephedra may alter thyroid hormones
and should be used cautiously with other herbs or supplements that affect
thyroid hormones, such as bladderwrack. Ephedra may decrease the effectiveness
of cardiac glycosides, such as
and lead to irregular heart rhythms. Ephedra may raise blood pressure and
may increase the blood pressure-raising effects of herbs such as blue cohosh
(Caulophyllum thalictroides) or may lessen the effects of blood
pressure-lowering herbs such as
Ephedra may lower blood sugar levels. People using other herbs or supplements
that may alter blood sugar levels, such as
melon (Momordica charantia), should be monitored closely by their
health care provider while using ephedra. Dosing adjustments may be necessary.
Ephedra may increase the diuretic effects of herbs such as
Increased adverse effects, including dangerously high blood pressure, muscle
breakdown, fever and irregular heartbeats, may occur if ephedra is used with
herbs with possible monoamine oxidase inhibitor antidepressant activity,
Effects of cholesterol-lowering herbs and supplements may be altered by ephedra,
although this has not been proven. One study of Metabolife 356, a product
containing ephedra, reports that it may cause heart-rhythmn abnormalities
(arrythmias, QT prolongation) and may therefore interact with other agents
with similar side effects.
Interactions With Food: Ephedra and caffeine may curb appetite.
The doses listed below are based on scientific research, publications
or traditional use. Because most herbs and supplements have not been thoroughly
studied or monitored, safety and effectiveness may not be proven. Brands
may be made differently, with variable ingredients even within the same brand.
Combination products often contain small amounts of each ingredient and may
not be effective. Appropriate dosing should be discussed with a health care
provider before starting therapy; always read the recommendations on a product's
label. The dosing for unproven uses should be approached cautiously, because
scientific information is limited in these areas.
Wide variations have been found in the amounts of the active chemicals ephedrine
and pseudoephedrine in commercial ephedra products. Before the official ban,
the FDA issued a policy that ephedrine products be labeled with possible
adverse effects, contain no more than 8 milligrams of ephedrine per serving
and be used for no longer than seven days. The FDA banned all sales of the
product in 2004. Ephedrine or ephedra is often used in combination with caffeine,
but this combination has been associated with significant adverse effects,
Adults (Aged 18 Or Older)
Oral use: Ephedra may cause serious adverse effects in any dose,
particularly when used with other drugs such as caffeine. Because of serious
safety concerns, ephedra cannot be recommended in any dose. Regulatory agencies
have recommended a maximum of 8 milligrams taken by mouth up to every six
hours (not exceeding 24 milligrams in a 24-hour period) for up to seven days.
Higher doses have been used in some studies and are available in over-the-counter
products. Doses of 25 to 50 milligrams of total ephedra alkaloids up to three
times daily have been used in some studies. Note that ephedra sales have
been banned in many countries, including the United States.
Children (Younger Than 18): There is not enough scientific data
to recommend ephedra for use in children, and it is not recommended due to
potential serious side effects. Purified ephedrine has been given to children
in a controlled setting under direct medical supervision.
Ephedra has been suggested as a treatment for many conditions. Although there
is evidence that ephedra is effective for weight loss, bronchodilation, and
elevating blood pressure, ephedra has been associated with thousands of reports
of adverse effects, including death. There is not enough scientific evidence
to support the use of ephedra for any other medical condition. Ephedra may
cause heart problems, including irregular heart rhythms and even death. It
should be avoided in pregnant and breast-feeding women and in children. Ephedra
may lower blood sugar. Use caution if you take insulin or drugs by mouth
to control your blood sugar levels. Ephedra may interact with many other
drugs, herbs, or supplements, and you should check with your health care
provider or pharmacist to screen for dangerous interactions. Consult your
health care provider immediately if you have any side effects.
The information in this monograph was prepared by the professional staff
at Natural Standard, based on thorough systematic review of scientific evidence.
The material was reviewed by the Faculty of the Harvard Medical School with
final editing approved by Natural Standard.
Standard: An organization that produces scientifically based reviews
of complementary and alternative medicine (CAM) topics
for Complementary and Alternative Medicine (NCCAM): A division of the
U.S. Department of Health & Human Services dedicated to research
FDA Press Release, HHS Acts to Reduce Potential Risks of
Dietary Supplements Containing Ephedra.
Selected Scientific Studies: Ephedra
Natural Standard reviewed more than 400 articles to prepare the professional
monograph from which this version was created.
Some of the more recent studies are listed below:
Backer R, Tautman D, Lowry S, et al. Fatal ephedrine intoxication. J Forensic
Baker JI, Zhang X, Boucher TA, Keyler DE. Investigation of quality in
ephedrine-containing dietary supplements. J Herb Pharmacother 2003;3(2):5-17.
Bell DG, Jacobs I, Ellerington K. Effect of caffeine and ephedrine ingestion
on anaerobic exercise performance. Med Sci Sports Exerc 2001;33(8):1399-1403.
Bell DG, McLellan TM, Sabiston CM. Effect of ingesting caffeine and ephedrine
on 10-km run performance. Med Sci Sports Exerc 2002;34(2):344-349.
Boozer CN, Nasser JA, Heymsfield SB, et al. An herbal supplement containing
Ma Huang-Guarana for weight loss: a randomized, double-blind trial. Int J
Obes Relat Metab Disord 2001;25(3):316-324.
Bouchard NC, Howland MA, Greller HA, et al. Ischemic stroke associated with
use of an ephedra-free dietary supplement containing synephrine. Mayo Clin
Proc 2005;Apr, 80(4):541-545.
Breum L, Pedersen JK, Ahlstrom F, et al. Comparison of an ephedrine/caffeine
combination and dexfenfluramine in the treatment of obesity: a double-blind
multi-centre trial in general practice. Int J Obes Relat Metab Disord
Coffey CS, Steiner D, Baker BA, Allison DB. A randomized double-blind
placebo-controlled clinical trial of a product containing ephedrine, caffeine,
and other ingredients from herbal sources for treatment of overweight and
obesity in the absence of lifestyle treatment. Int J Obes Relat Metab Disord
Cohen SN. Five young patients with cryptogenic stroke who used an ephedra
containing compound in a time window prior to suffering a stroke. J Neurol
Sci 2004;Aug 30, 223(2):203-204 Author reply, 205-206. Comment in: J Neurol
Sci 2004;Jan 15, 217(1):55-60.
Corrigan FM, Jennett J. Ephedra alkaloids and brief relapse in EMDR-treated
obsessive compulsive disorder. Acta Psychiatr Scand 2004;Aug, 110(2):158.
Author reply, 159.
Gardner SF, Franks AM, Gurley BJ, et al. Effect of a multicomponent,
ephedra-containing dietary supplement (Metabolife Am J Cardiol
Greenway FL, De Jonge L, Blanchard D, et al. Effect of a dietary herbal
supplement containing caffeine and ephedra on weight, metabolic rate, and
body composition. Obes Res 2004;Jul, 12(7):1152-1157.
Gurley BJ, Gardner SF, White LM, et al. Ephedrine pharmacokinetics after
the ingestion of nutritional supplements containing Ephedra sinica (ma huang).
Ther Drug Monit 1998;20(4):439-445.
Haller CA, Jacob P 3rd, Benowitz NL. Pharmacology of ephedra alkaloids and
caffeine after single-dose dietary supplement use. Clin Pharmacol Ther 2002
Kalman D, Incledon T, Gaunaurd I, et al. An acute clinical trial evaluating
the cardiovascular effects of an herbal ephedra-caffeine weight loss product
in healthy overweight adults. Int J Obes Relat Metab Disord
Lee A, Ngan Kee WD, Gin T. A quantitative, systematic review of randomized
controlled trials of ephedrine versus phenylephrine for the management of
hypotension during spinal anesthesia for cesarean delivery. Anesth Analg
Long C, Kakiuchi N, Zhong G, Mikage M. Survey on resources of ephedra plants
in Xinjiang. Biol Pharm Bull 2005;Feb, 28(2):285-288.
Meersschaert K, Brun L, Gourdin M, et al. Terlipressin-ephedrine versus ephedrine
to treat hypotension at the induction of anesthesia in patients chronically
treated with angiotensin converting-enzyme inhibitors: a prospective, randomized,
double-blinded, crossover study. Anesth Analg 2002;94(4):835-840.
Meston CM, Heiman JR. Ephedrine-activated physiological sexual arousal in
women. Arch Gen Psychiatry 1998;55(7):652-656.
Molnar D, Torok K, Erhardt E, et al. Safety and efficacy of treatment with
an ephedrine/caffeine mixture: the first double-blind placebo-controlled
pilot study in adolescents. Int J Obes Relat Metab Disord 2000;24(12):1573-1578.
Morgenstern LB, Viscoli CM, Kernan WN, et al. Use of ephedra-containing products
and risk for hemorrhagic stroke. Neurology 2003;60(1):132-5.
Ngan Kee WD, Lau TK, Khaw KS, et al. Comparison of metaraminol and ephedrine
infusions for maintaining arterial pressure during spinal anesthesia for
elective cesarean section. Anesthesiology 2001;95(2):307-313.
Nyska A, Murphy E, Foley JF, et al. Acute hemorrhagic myocardial necrosis
and sudden death of rats exposed to a combination of ephedrine and caffeine.
Toxicol Sci 2005;Feb, 83(2):388-396.
Perrotta DM. From the Centers for Disease Control and Prevention. Adverse
events associated with ephedrine-containing products: Texas, December
1993--September 1995. JAMA 1996;276(21):1711-1712.
Samenuk D, Link MS, Homoud MK, et al. Adverse cardiovascular events temporarily
associated with ma huang, an herbal source of ephedrine. Mayo Clin Proc
Shaikh WA. Ephedrine-saline nasal wash in allergic rhinitis. J Allergy Clin
Immunol 1995;96(5 Pt 1):597-600.
Shekelle P, Morton S, Maglione M, et al. Ephedra and ephedrine for weight
loss and athletic performance enhancement: clinical efficacy and side effects.
Evidence Report/Technology Assessment No. 76 (Prepared by Southern California
Evidence-based Practice Center, RAND, under Contract No 290-97-0001, Task
Order No. 9). AHRQ Publication No. 03-E022. Rockville, MD: Agency for Healthcare
Research and Quality. February 2003.
Sola S, Helmy T, Kacharava A. Coronary dissection and thrombosis after ingestion
of ephedra. Am J Med 2004;May 1, 116(9):645-646.
White LM, Gardner SF, Gurley BJ, et al. Pharmacokinetics and cardiovascular
effects of ma-huang (Ephedra sinica) in normotensive adults. J Clin Pharmacol
Last updated June 17, 2005