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Ephedra (ma huang)

Ephedra, commonly referred to by its Chinese name, ma huang, has received so much publicity recently that it's hard to read a newspaper or magazine without coming across the name. The herb consists of the green stems of several species of ephedra native to Central Asia.

Ma huang has been used in China for the treatment of bronchial asthma and related conditions for more than 5,000 years. The therapeutic value of ephedra is due to several closely related alkaloids, of which ephedrine is both the most active and the one present in the largest amount. North American species of ephedra, one of which is referred to as Mormon tea, contain no active alkaloids. Ephedrine was researched here in the United States during the 1920s and was a standard over-the-counter medication for many years.

Dual effects

Like all other medications, ephedra has both an upside and a downside. The alkaloid's vasoconstricting effect makes it a useful nasal decongestant, but it also raises blood pressure and increases heart rate. It is an effective bronchodilator, but it also stimulates the central nervous system (CNS), with side effects ranging from nervousness to insomnia. This stimulation is greatly increased by consumption of caffeine or caffeine beverages such as coffee, tea, or cola.

Consequently, ephedrine has been replaced to a large extent in OTC cold and cough products by related chemicals, such as pseudoephedrine or phenylpropanolamine. These have a similar action but much reduced CNS effects.

In recent years, ephedra and caffeine combination products have been much ballyhooed as appetite suppressants, metabolic stimulants for weight loss, athletic performance enhancers, and, in very large doses, legal euphoriants or intoxicants. There is considerable literature about the effects of ephedra on weight loss, with some modestly favorable results.

As one of my pharmacologist friends quipped, "You're bound to lose weight if you take ephedra and caffeine, because you'll be so hyper the soup will slop out of the spoon before it reaches your mouth." That is a slight exaggeration.

Detailed studies of the herb's effect on athletic performance or its euphoriant activities do not exist. Regardless, ephedra should not be taken chronically (on a continual basis) for any purpose unless the consumer is under the care of a competent physician. Many herbal products do not list the concentration of ephedrine present. Some manufacturers almost certainly "spike" their dosage forms with additional quantities of synthetic ephedrine.

Serious attention

Because of such problems in the marketplace, the Food and Drug Administration (FDA) convened a special advisory group on ephedra in October 1995. That committee of experts made a number of recommendations regarding the sale of ephedra products, including strict dosage limitations, appropriate warning labels preventing chronic use, prohibition of sale to persons under age 18, and warnings to individuals with specific health risks.

For some reason, the recommendations were never implemented, al-though in April 1996, the FDA did is-sue a warning cautioning consumers not to buy any high-dose ephedra products marketed as "legal highs." By August 1996, the FDA had compiled a list of some 800 adverse reactions, including 22 deaths and a number of serious cardiovascular and nervous system effects, including heart attack, stroke, and seizures, which they attributed to the consumption of ephedra, often in combination with caffeine-containing herbs. Consequently, another special advisory group meeting was held at that time. But after lengthy discussion, no consensus was reached, and no concrete recommendations were made.

FDA Commissioner David A. Kessler, who attended the meeting, said the agency would consider the matter and act quickly on ephedra's marketability, almost certainly before the end of 1996. In the meantime, he indicated his intention to resign, and no action was taken before the self-imposed deadline.

Most of the problems with ephedra have stemmed from improper use or abuse of the herb. Improper consumption, which could have been greatly reduced by proper labeling, would include chronic use, taking with caffeine, employment by persons under age 18, unnecessarily large doses, and use by persons with heart disease, hypertension, diabetes, or thyroid abnormalities. There is absolutely no excuse for the addition of ephedra to soda pop or cookies or for the sale of large doses in combination with caffeine as a euphoriant. If there is any doubt about whether you have any of the medical conditions, do not try ephedra. And if you do have asthma, make sure you check with your doctor before using ephedra.

Several states have now acted, or are considering action, to control ephedra products. Most authorities continue to believe that small doses of ephedra, equivalent to not more than 40 milligrams (mg) of ephed-rine per day, consumed on an occasional, not chronic, basis for the relief of bronchial asthma, are safe for otherwise normal persons.

Another concern often expressed about ephedra is the possibility that the contained ephedrine may be illegally converted to methamphetamine, or "speed," a common drug of abuse, by basement chemists. Although this is possible, it is not likely because of the difficulty in separating the product from the accompanying plant material.

Ephedra remains a prime example of an age-old dilemma in medicine. Must a useful therapeutic agent be banned because of its abuse potential? In many cases, this has been proven to be necessary. Whether ephedra herb falls in this category remains to be seen.

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