Ephedra - Warning

The safety of herbal supplements and products is a topic of interest to many. Athletes currently taking herbal supplements, as well as those who may be contemplating their use, are curious about how safe these supplements really are. Unfortunately the question of safety is easier to ask than it is to answer. Since dietary supplements do not have to comply with U.S. Food and Drug Administration (FDA) standards there is very little information available regarding safety. It has been estimated that current surveillance methods, which rely on poison control reports and physician reports, identify less than 1% of the actual adverse events that supplement users experience. Most adverse events are mild but some are severe or even lethal. Regardless of severity, over 99% of these side effects are unreported. Clearly, more thorough methods are needed. Accordingly, there have been attempts to better categorize the safety profile of individual supplements. The application of well-designed and controlled research will help identify which supplements are safe and which are not. This sort of scrutiny will help avoid the popular tendency to lump all supplements together and then label them “bad” (or “good”).

One herbal supplement that deserves close scrutiny is ephedra. Ephedra, which is also known by the herbal extract name ma huang, has been used for thousands of years. This herbal preparation contains ephedrine as well as several related compounds (e.g., phenylpropanolamine, methylephedrine). It first became popular in the U.S. in the 1920s and was widely used as a stimulant, nasal decongestant, and treatment for asthma. Use of ephedra subsequently declined when safer alternatives were discovered. However, use of ephedra has once again become popular, and it has been touted as a weight-loss aid and an energizing stimulant.

A well-designed study (1) regarding ephedra was recently published and it is important for all athletes to be made aware of the results. Given the inherent difficulties presented by under-reporting of adverse events, this study strove to compare the relative risk of ephedra use to use of other herbal supplements. An adverse reaction was defined as toxicity that results from use of a product within labeled or recommended guidelines -- as opposed to deliberate or accidental misuse or over-dosage. For ephedra, adverse reactions ranged from nervousness to heart attack and stroke. Compared to adverse reactions attributable to other herbal products use of ephedra conveyed more than a 100-fold increased risk. Examples of these other herbal supplements include Ginkgo biloba, ginseng, and Echinacea. Examining Ginkgo biloba specifically, ephedra was over 720-times more likely to cause an adverse reaction.

Given that ephedra comprises less than 1% of all herbal product sales in the U.S. yet accounts for more then 60% of adverse reactions it is no wonder that so many sports organizations have banned its use. The National Collegiate Athletics Association (NCAA), the National Football League (NFL), and the International Olympic Committee (IOC) are all examples of organizations that have banned ephedra use. These bans were in place before this most recent study was published. Considering the mounting data – including the recent deaths of a few high-profile professional athletes – it is likely that more groups will ban use of ephedra. Some medical organizations are even pressing for a complete withdrawal of ephedra from all store shelves in the U.S., and a ban on all sales (i.e., internet and mail-order). Whatever the ultimate regulatory decision this is one herbal supplement that should be avoided.

reference (1) - The Relative Safety of Ephedra. Annals of Internal Medicine. 18 March 2003. Vol. 138 (4).
Copyright 2003 ©

Mark Jenkins, MD

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