What Is Ephedra Used for Today?

Although it can still be found in a few over-the-counter drugs for asthma and sinus congestion (in a safer form than the banned dietary supplements), physicians seldom prescribe ephedrine anymore. The problem is that ephedrine mimics the effects of adrenaline and causes symptoms such as rapid heartbeat, high blood pressure, agitation, insomnia, nausea, and loss of appetite. The newer asthma drugs are much safer and easier to tolerate.

Meaningful evidence suggests ephedrine/caffeine combinations can assist in weight loss.^1-5,19,31Note: Due to safety risks, we strongly recommend that you seek physician's supervision before attempting to lose weight with ephedrine/caffeine combination therapy. We do not recommend using herbal sources of ephedrine, which are now banned, for weight loss at all. (See Safety Issues.)

One highly preliminary study has been used to claim that ephedrine is helpful for women with sexual dysfunction.²⁰ However, this trial was very small, enrolled women without sexual problems, and only examined sexual responsiveness to visual stimuli; at this time, we do not recommend that women with sexual dysfunction use ephedra. Another study examined the possible benefits of ephedrine for treatment of female sexual dysfunction caused by antidepressants in the SSRI family (eg, Prozac).³² Ephedrine failed to prove more effective than placebo.

There is no meaningful evidence that ephedra enhances sports performance.²⁹

Note: Individuals taking ephedra or ephedrine may test positive for methamphetamine (speed) on drug screening.^21,33

What Is the Scientific Evidence for Ephedra?

Evidence suggests that ephedrine/caffeine combinations can aid weight loss and help keep the weight off for up to 6 months. However, the benefits are modest.

For example, in a double-blind, placebo-controlled trial, 180 overweight individuals were placed on a weight-loss diet and given either ephedrine/caffeine (20 mg/200 mg), ephedrine alone (20 mg), caffeine alone (200 mg), or placebo, 3 times daily for 24 weeks.⁶ The results showed that the ephedrine/caffeine treatment significantly enhanced weight loss, resulting in a loss of more than 36 pounds as compared to only 29 pounds in the placebo group, a 7-pound difference. Neither ephedrine nor caffeine alone produced any benefit. Contrary to some reports, participants did not develop tolerance to the treatment. For the whole 6 months of the trial, the treatment group maintained the same relative weight-loss advantage over the placebo group.

A few side effects were seen in this study, primarily insomnia, dizziness, and tremor, but they tended to fade away after a few weeks. Keep in mind that participants were screened prior to the study and were eliminated if they had high blood pressure or any other serious disease, or if they used medications or illegal drugs that might interact with stimulants.

Another study compared ephedrine/caffeine with the no-longer-available drug dexfenfluramine (Redux), related to fenfluramine of fen-phen fame.⁸ A total of 103 overweight individuals were enrolled in this 15-week, double-blind trial. All were placed on a weight-loss diet. Half were given ephedrine/caffeine at the usual dose, while the others were given 15 mg of dexfenfluramine. The results showed comparable weight loss in both groups.

Finally, a double-blind, placebo-controlled trial enrolled 225 heavy smokers who wanted to quit but were afraid of gaining weight.¹⁰ At 12 weeks after quitting smoking, individuals taking ephedrine and caffeine had gained significantly less weight. At that point, the dosage was gradually reduced, and the difference between the groups declined. (Contrary to the hopes of the experimenters, ephedrine/caffeine use did not help individuals quit smoking.)

Benefits have also been seen in smaller studies using herbal sources of ephedrine.⁹

We don't know exactly how ephedrine/caffeine works. However, caffeine has actions that cause fat breakdown and enhance metabolism.¹¹ Ephedrine suppresses appetite and increases energy expenditure. The combination appears to produce synergistic effects, with appetite suppression probably the most important overall factor.

Dosage

The dosage of ephedra should be adjusted according to the amount of the ephedrine it provides. For adults, no more than 25 mg should be taken at one time, and a total daily intake of 100 mg should not be exceeded.¹² However, a survey of ephedra-containing dietary supplements found that ephedrine content as listed on the label was frequently incorrect.¹³ In addition, other chemicals were often present that could increase safety risks (see Safety Issues). For this reason, we do not recommend using herbal ephedra at all.

Safety Issues

While ephedra is an herb with a long history of use in Chinese herbal medicine, Chinese tradition attaches numerous warnings: It should only be used by very robust people, for certain specific purposes, and only for a short period of time. These ancient warnings seem to have been disregarded in the transition of ephedra use from Asia to the United States, where it had often been sold for continuous use by overweight, relatively unhealthy people. Herbal products containing ephedra caused the majority (64%) of reported adverse effects from herbs in the US. This proportion is particularly impressive given that less than 1% of all herbal products sold in the US contained ephedra. On a per-use basis, for example, ephedra has 720 times the risk of causing harm as ginkgo biloba.

There are many reasons for this high rate of risk. While it is possible for healthy individuals under physician supervision to use ephedrine or ephedrine/caffeine combinations safely, in individuals with heart disease, and even occasionally in those with no known heart conditions, ephedrine can cause serious disturbances of the heart rhythm and possibly sudden death; strokes have also occurred.^15,18,22,23 Use of herbal ephedra, as opposed to ephedrine, may present additional dangers. As noted above, there is no ready way to be sure of the dose of the drug ephedrine you are getting when you purchase the herb ephedra, creating potential risk of overdosage. In addition, some ephedra products contain potentially more toxic chemicals related to ephedrine, such as (+)-norpseudoephedrine.¹⁶

There is some evidence, though, that counters this claim of cardiovascular risk. For example, researchers analyzed data on 257,236 Danish patients prescribed to take a combination of ephedrine and caffeine from 1995-2002.³⁹ These patients did not have increased rates of heart attack or stroke.

Use of ephedra has been associated with severe inflammation of the liver (in at least one case requiring a liver transplant)^24,25,35 and of the heart.²⁶ In these cases, it appears likely that ephedra (or an unidentified contaminant in the herb) triggered an autoimmune reaction.

In addition, people taking ephedra or ephedrine may develop an unusual form of kidney stones that actually contain ephedrine.²⁷ Temporary psychosis has also been linked to use of ephedra.³⁴

Finally, there are indications that certain preparations of ephedra may be toxic to the nervous system.²⁸

Based on the known risks of ephedrine,¹⁷ as well as the evidence described above, ephedra should definitely not be taken by a person with:

• Cardiovascular disease, including:
  • Angina
  • Abnormalities of heart rhythm
  • Hardening of the arteries
  • High blood pressure
  • High cholesterol
  • Intermittent claudication
  • History of stroke
• Enlargement of the prostate
• Diabetes
• Hepatitis
• Myocarditis
• Vasculitis
• Diseases of the nervous system
• Glaucoma
• Hyperthyroidism

• Young children
• Pregnant or nursing women
• People with kidney disease
• People with liver disease

Furthermore, one should never combine ephedra with monoamine-oxidase inhibitors (MAO inhibitors), such as Nardil (phenelzine), or fatal reactions may develop.

Interactions You Should Know About

If you are taking:

• MAO inhibitors: Do not take ephedra.
• Any stimulant drugs (including caffeine): Do not take ephedra except under physician supervision.