Ephedra (Ephedra sinica), also called ma huang, has been used in Traditional Chinese Medicine for more than 5,000 years. Used primarily to treat asthma or bronchitis, ephedra is also prescribed for symptoms of cold and flu including nasal congestion, cough, fever, and chills. Synthetic ephedrine compounds, such as pseudoephedrine, are widely used in over-the-counter cold remedies.

In addition, ephedra is 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. It is important to note that many ephedra-containing products sold for these purposes also contain caffeine; the combination of ephedra with caffeine increases the chances of adverse side effects dramatically.

Ephedrine containing products are banned from amateur sporting events and evidence of ephedra on drug testing will likely disqualify athletes from competition.

Controversies

Ephedra (and its main active ingredient, ephedrine, an ephedra alkaloid used in many supplements) is not without its dangers. It has the potentially dangerous effects of stimulating the central nervous system, raising blood pressure, and boosting heart rate. Moreover, ephedra is used in making illegal street drugs such as methamphetamine. In fact, ephedra has been the center of a major controversy between the herb industry and the U.S. Food and Drug Administration (FDA) since the 1990s.

Between 1997 and 1999, the FDA received 140 reports of adverse reactions associated with the use of ephedra and supplements containing ephedra alkaloids. Irregular heart rhythm with heart palpitations or extremely high blood pressure are among the most commonly reported adverse events; other outcomes reported included stroke, seizures, and death (10 fatalities have been reported in connection to use of ephedra). A New England Journal of Medicine analysis of these reports concluded that dietary supplements for weight loss or increasing exercise capacity that contain ephedra and its related alkaloids have no apparent benefits and "pose a serious health risk to some users."

Also beware of supplements containing norephedrine (another ephedra alkaloid, often called phenylpropanolamine), which can cause liver damage. The FDA issued a warning against norephedrine in November of 2001. (In addition, phenylpropanolamine can cause bleeding stroke and, therefore, the FDA issued a public health warning and requested that drug companies remove this product from the market on November 6, 2000.)

Regulation

In 2001, the national consumer research and advocacy organization Public Citizen Health Research Group petitioned the FDA to ban the production and sale of all dietary supplements containing ephedra and related compounds, calling them the "most lethal of all dietary supplements." The nutritional supplement industry, including the American Herbal Products Association (AHPA) and the Council for Responsible Nutrition (CRN), countered with their own proposal for much clearer labeling of the potential risks and appropriate dosing on ephedra-containing products. The AHPA and CRN claim that if these warnings and precautionary measures are taken, that ephedra is generally safe. For example, the CRN advocates that there be strict guidelines established regarding a Tolerable Upper Intake Level (UL) for substances containing ephedra; their expert recommendation, based on scientific studies, is that absolutely no more than 90 milligrams (mg) per day of ephedra be taken in three divided doses for no longer than 6 months. The CRN reports that use of amounts below this UL should avoid any dangerous adverse effects.

On the other hand, with a position similar to that of the Public Citizen, the Canadian health agency, Health Canada, issued an advisory in 2001 "warning consumers not to use products containing the herb ephedra, either alone or in combination with caffeine and other stimulants, for purposes of weight loss, body building or increased energy."

No final regulatory decisions have been made, however, in regards to ephedra products to date. Until more conclusive evidence becomes available, any supplements containing ephedra or its related compounds should only be used under the guidance and supervision of an appropriate healthcare professional.

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 is available in dried and liquid preparations. 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. Given this wide variation and given that there is no good manufacturing practice established for supplements over the counter, it is difficult to know what precautions to take when purchasing ephedra-containing supplements. Follow the advice of a knowledgeable healthcare professional with experience in botanical medicine. Also, try to purchase products from established companies with good reputations, although this is not a guarantee that the contents listed on the label accurately reflect what the supplement contains.

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 recommended dosage ranges from 0.5 mg daily total ephedrine alkaloid (which is equivalent to 40 mg of cut ephedra herb) per kg of body weight up to a maximum total daily dose of 2 mg/kg. Although ephedra, at the dose described, was approved in 1991 by a German authoritative body, known as the Commission E, for the treatment of respiratory symptoms in children over age 6, particular caution should be exercised if used in this population because of the serious side effects associated with this herb. In fact, 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)

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