Use of Ephedra-containing products and risk for hemorrhagic stroke

Allergies and Natural Alternatives

Complementary and integrative medicine therapies in the treatment of allergy and allergic rhinitis (AR) are divided broadly into the categories of nutritional supplements, herbal supplements, Ayurvedic, and Chinese traditional medicine. Some therapies are likely completely safe, such as Manuka honey, with no known side effects. Others have significant risks, such as ephedra, which was ultimately banned for use by the Food and Drug Administration. The efficacy of these therapies is varied and under-researched. The therapies with the strongest evidence in the treatment of allergy and AR are Manuka honey, butterbur, and Sinupret.

Metabolite Profile Changes in Different Regions of Rat Brain Affected by Ephedra sinica

Ephedra sinica Stapf (EP) has a long medication history dating back centuries in the world. There were some reports of adverse effects in the central nervous system (CNS) resulting from administration of a drug containing EP or ephedrine. Compared with alkaloid monomer compounds, the effects of EP on the CNS are usually neglected. It is necessary to explore CNS affection which is helpful to use EP rationally. However, the affection and the changes of substances by EP in the brain are still unknown because the effects of drug on the brain also exhibit different tendency and distribution and usually lead to diversity of metabolite alteration in different regions. In this study, metabolomics based on different brain regions was used to investigate the affection mechanism of EP in the CNS. The metabolites in 6 brain regions from a rat that underwent oral administration with EP for 14 days were determined by UPLC/Q-TOF-MS. Brain histological examinations showed that there were no obvious lesions in EP administration groups. Partial least square-discriminant analysis (PLS-DA) displayed that there were significant separations between control and EP administration groups. 7 CNS biomarkers were found and identified in different regions. 3 metabolic pathways were disturbed by EP, including amino acid metabolism, phospholipid metabolism, and amino sugar metabolism. Furthermore, all biomarkers were significantly changed in the cortex after administration. This study may be helpful to understand the affection mechanism of EP in the CNS and improve cognition of brain regional characteristics.

Comprehensive review of cardiovascular toxicity of drugs and related agents

Cardiovascular diseases are a leading cause of morbidity and mortality in most developed countries of the world. Pharmaceuticals, illicit drugs, and toxins can significantly contribute to the overall cardiovascular burden and thus deserve attention. The present article is a systematic overview of drugs that may induce distinct cardiovascular toxicity. The compounds are classified into agents that have significant effects on the heart, blood vessels, or both. The mechanism(s) of toxic action are discussed and treatment modalities are briefly mentioned in relevant cases. Due to the large number of clinically relevant compounds discussed, this article could be of interest to a broad audience including pharmacologists and toxicologists, pharmacists, physicians, and medicinal chemists. Particular emphasis is given to clinically relevant topics including the cardiovascular toxicity of illicit sympathomimetic drugs (e.g., cocaine, amphetamines, cathinones), drugs that prolong the QT interval, antidysrhythmic drugs, digoxin and other cardioactive steroids, beta-blockers, calcium channel blockers, female hormones, nonsteroidal anti-inflammatory, and anticancer compounds encompassing anthracyclines and novel targeted therapy interfering with the HER2 or the vascular endothelial growth factor pathway.

Herbal Product Contamination and Toxicity

Herbal poisoning exposures reported to poison centers increased by 344% after passage of the Dietary Supplement Health and Education Act, with 24412 exposures reported in 2003. Increased toxicity is speculated to be related to lack of child-resistant packaging, new issues of contamination, proliferation of multiple ingredient products, excessive concentration of active ingredients, and discovery of new drug-herb interactions. This review addresses contamination issues such as heavy metals, pharmaceuticals, homeopathic remedies, microbes, insects, environmental chemicals, and mis-identification of one plant for another. Toxicity issues covered include carcinogenicity, delay in seeking medical treatment when using herbs to treat serious illness, toxic components, hypersensitivity reactions, hepatotoxins, nephrotoxins, epileptogenic compounds, cardiac toxins, gastrointestinal toxins, and hematologic toxins. Common drug-herb interactions are discussed. The pharmacist plays an important role in patient education and evaluation of potential toxicities related to herbal supplements.

Adrenergic and dopaminergic modulation of immunity in multiple sclerosis: teaching old drugs new tricks?

Multiple sclerosis (MS) is an autoimmune disorder of the CNS characterized by inflammation, demyelination and axonal loss. Classical evidence in experimental allergic encephalomyelitis, the animal model of MS, support the relevance of sympatoadrenergic as well as of dopaminergic mechanisms. In MS patients, dysregulation of adrenergic and dopaminergic pathways contribute to the disease in immune system cells as well as in glial cells. Available evidence is summarized and discussed also in the light of the novel role of dopamine, noradrenaline and adrenaline as transmitters in immune cells, providing a conceptual frame to exploit the potential of several dopaminergic and adrenergic agents, already in clinical use for non-immune indications and with a usually favourable risk-benefit profile, as add-on drugs to conventional immunomodulating therapies in MS.

Combined Effects of Ephedrine-Containing Dietary Supplements, Caffeine, and Nicotine on Morphology and Ultrastructure of Rat Hearts

Cigarette smokers have an increased risk for coronary artery disease. Nicotine present in cigarettes can adversely affect the cardiovascular system via stimulation of both sympathetic and parasympathetic neurons. Caffeine, another cardiovascular and central nervous system (CNS) stimulant, is commonly found in Ephedra and Ephedra-free dietary supplements. These caffeine-containing supplements also have been linked to cardiovascular toxicities. Although no longer on the U.S market, Ephedra-containing supplements are another source of cardiovascular and CNS stimulants, namely the ephedrine alkaloids. Together caffeine, nicotine, and ephedrine can individually stress the cardiovascular system, and an overlap of these agents is predicted in smokers and dieters. To understand the collective effects of these stimulants on the heart morphology and ultrastructure, rats were exposed to synthetic combinations of nicotine (0.2 mg/kg/day), ephedrine (0-30 mg/kg/day), and/or caffeine (0-24 mg/kg/day) as well as an extract from a caffeine-containing Ephedra supplement (Metabolife 356). After exposure for 3 days, the hearts were removed and examined for hypersensitivity myocarditis and myocardial necrosis. None of the drugs tested alone affected heart tissue morphology, nor were atypical cardiac cells observed. However, in combination, significant interactions were found between caffeine and ephedrine; the interventricular septum was most susceptible, with a significant increase in atypical cardiac cells observed. Nicotine pretreatment caused greater susceptibility to cardiotoxicity associated with combinations of caffeine + ephedrine or Metabolife, particularly in the left ventricle wall. These results indicate that sympathomimetic combinations present in Ephedra supplements may have produced cardiotoxicity reported in consumers of these products. Moreover, the presence of nicotine exacerbates these toxic effects.

[Pharmacologically-induced neurocatastrophes]

Drug-induced adverse reactions represent a significant health problem in developed countries. These events cause 5% of hospital admissions and are one of the main causes of mortality. Neurological manifestations are among the most frequent. This article reviews catastrophic cerebrovascular situations and confusional syndromes, as well as epilepsy, structural encephalopathy, neuromuscular disorders, catastrophic movement disorders and infections, all of which can be drug-induced.

Life threatening intracerebral hemorrhage with isometheptene mucate, dichlorophenazine and acetaminophen combination therapy

A 45 year old female with no stroke risk factors suffered a massive intracerebral hemorrhage (ICH) after ingesting Midrin--a combination of isometheptene mucate, dichlorophenazine and acetaminophen. Neuroimaging revealed no evidence of structural disease or underlying vasculopathy. This is the first reported case of isometheptene induced ICH in the absence of underlying cerebrovascular disease. Physicians must be aware of the potential for this complication, and inquire about the use of isometheptene in unexplained cerebral hemorrhages. Neurological communities in countries with nonprescription isometheptene should discourage unsupervised or excessive use of the drug.

Use of a prescribed ephedrine/caffeine combination and the risk of serious cardiovascular events: a registry-based case-crossover study

Ephedrine and herbal ephedra preparations have been shown to induce a small-to-moderate weight loss. Owing to reports on serious cardiovascular events, they were banned from the US market in 2004. There have been no large controlled studies on the possible association between prescribed ephedrine/caffeine and cardiovascular events in general. The authors linked data from four different sources within Statistics Denmark, using data on 257,364 users of prescribed ephedrine/caffeine for the period 1995–2002. The data were analyzed using a case-crossover technique with a composite endpoint: death outside of a hospital, myocardial infarction, or stroke. To account for effects of chronic exposure and effects in naïve users, the authors performed a secondary case-control study nested within the cohort of ephedrine/caffeine ever users. Among 2,316 case subjects, 282 (12.2%) were current users of ephedrine/caffeine. The case-crossover analysis yielded an odds ratio of 0.84 (95% confidence interval: 0.71, 1.00); after adjustment for trends in ephedrine/caffeine use, it was 0.95 (95% confidence interval: 0.79, 1.16). Subgroup analyses revealed no strata with significantly elevated risk. In the case-control substudy, there was no increased risk among naïve users or users with large cumulative doses. Prescribed ephedrine/caffeine was not associated with a substantially increased risk of adverse cardiovascular outcomes in this study.

Peer review and the process of publishing of adverse drug event reports

Most doctors finish their careers without ever having published a scientific paper. The small percent that do mostly end up writing "case reports". But, unless the report describes some truly extraordinary event, very little ever comes of it, and their publication may do more harm than good. The problem is particularly acute in cases of alleged drug toxicity. Case reports are incomplete, uncontrolled, retrospective, lack operational criteria for identifying when an adverse event has actually occurred, and resemble nothing so much as hearsay evidence, a type of evidence that is prohibited in all courts in all of industrialized societies. When a journal, even a highly respected one, decides to publish hearsay, readers are utterly reliant on the integrity of the journal, the author, and the peer review process; such reliance may not always be warranted. Some recent examples of process failure are provided, as well as some suggestions about possible remedies, including the use of pharmaco-vigilance algorithms.

Why now? Moving from stroke risk factors to stroke triggers

PURPOSE OF REVIEW

While chronic risk factors for stroke are reasonably well understood, the acute precipitants, or triggers, of stroke, remain relatively understudied.

RECENT FINDINGS

Several converging lines of evidence indicate that transient perturbations in systemic metabolism may provoke the onset of cardiovascular events, including stroke. Epidemiologic data, including studies utilizing novel designs that consider intraindividual differences across different time periods, have been used to clarify triggers for myocardial ischemia, and these methods are beginning to be employed in stroke research. Acute infections, particularly upper respiratory infections, and other inflammatory stimuli have emerged as important triggers of acute ischemic stroke. The mechanisms involved include immunologically mediated activation of platelets and endothelial dysfunction. There also appears to be a period of time, or 'stroke-prone state', characterized by diffuse activation of the vasculature during which patients may be at increased risk of initial and recurrent ischemic events.

SUMMARY

Confirmation of these findings in further studies may help elucidate the mechanisms behind this short-term increase in stroke risk. Improved methods of assessment of this period of heightened susceptibility could lead to more temporally focused preventive interventions.

Safety of drug therapies used for weight loss and treatment of obesity

Some of the medications used for weight loss in the management of obesity have been associated with unacceptable morbidity and mortality. Safety concerns have led to the withdrawal of aminorex, followed by the fenfluramines in 1997, and phenylpropanolamine (norephedrine) in 2000. Aminorex was associated with an increased prevalence of primary pulmonary hypertension (PPH), fenfluramines with an increased prevalence of PPH and valvulopathy, and phenylpropanolamine with an increased risk of haemorrhagic stroke. Several studies have investigated the safety of the fenfluramines, yet the benefit-risk profile has not been conclusively quantified. This is due to several deficiencies in the published studies, including a lack of data on the baseline prevalences of comorbid conditions in obese subjects, and potential confounders and biases in the study designs. Although several studies and systematic reviews support an increased risk of PPH and valvulopathy in patients who have taken fenfluramines, without knowledge of the background prevalence it is not possible to determine if the exposure preceded the outcome. The population at higher risk of these adverse effects includes those taking higher doses or with a longer duration of exposure to fenfluramines and those with pre-existing cardiac disease or a genetic predisposition. Patients exposed to fenfluramines continue to be monitored, with some follow-up studies indicating no overall worsening in valvulopathy over time. There are limited efficacy and safety data for amfepramone (diethylpropion) and phentermine and their approval for the management of obesity is limited to short-term use. Orlistat and sibutramine are the only currently approved medications for long-term management of obesity. Although the benefit-risk profiles of sibutramine and orlistat appear positive, sibutramine continues to be monitored because of long-term safety concerns. The safety and efficacy of currently approved drug therapies have not been evaluated in children and elderly patient populations and there is limited information in adolescents, whilst the long-term safety of current and potential new drug therapies in adults will require several years of postmarketing surveillance to fully elucidate their adverse effect profiles.

Pre-exposure to a novel nutritional mixture containing a series of phytochemicals prevents acetaminophen-induced programmed and unprogrammed cell deaths by enhancing BCL-XL expression and minimizing oxidative stress in the liver

From a disease-prevention perspective, recent progress in phytochemical and nutraceutical research clearly suggests (benefits outweigh the risk pattern). Although powerful antioxidant properties have been the most acclaimed mechanism of action for these entities, the individual antioxidants studied in clinical trials do not appear to have consistent preventative effects. The actions of the antioxidant nutrients alone do not explain the observed health benefits of diets rich in fruits and vegetables for chronic diseases. Therefore, we proposed that the additive and synergistic effects of phytochemicals in fruits and vegetables are responsible for these potent antioxidant and anticancer activities, and that the benefit of a diet rich in fruits and vegetables is attributed to the complex mixture of phytochemicals present in plants [1]. Surprisingly, however, no studies have attempted to evaluate the combined antitoxic potential of a phytochemical-nutraceutical mixture (PNM) in in vivo models. Therefore, this study, for the first time, was designed to investigate whether pre-exposure to a unique PNM has the ability to impede mechanistic events involved in acetaminophen (APAP)-induced hepatotoxicity. Besides several vitamins and minerals in balanced proportions (approximately US RDA), the PNM used in this investigation contained several well-known phytochemicals such as citrus flavonoids, red wine polyphenols, Garcinia, Gymnema, Ginkgo, Ephedra sinica, Camellia sinensis, Silybum, Guarana, Eluthero, Allium sativum and Ocimum basilicum extracts. To evaluate PNM's antitoxic potential, groups of animals ICR mice, 3 months old) received either a control diet or PNM containing diets (1X and 10X) for 4 weeks. On day-28, animals were divided into two subgroups. Half the animals were administered normal saline and the other half received 400mg/kg ip injections of APAP. All the animals were sacrificed 24h after APAP exposure. Serum and tissue (liver and kidneys) samples were analyzed. APAP alone caused massive liver injury (nearly 495-fold increase in ALT) and oxidative stress (Lipid peroxidation: 268% increase in MDA) coupled with genomic DNA fragmentation (288% increase). Exposure to 1X-PNM for 28 days significantly reduced animal mortality and all the APAP-induced biochemical events (In 1X-PNM + AP: ALT leakage decreased to 54 fold; MDA accumulation decreased to 125%, and DNA fragmentation decreased to 122%), whereas 10X-PNM + APAP slightly escalated both oxidative stress and genomic DNA fragmentation preceding liver injury. Liver homogenates subjected to western blot analysis disclosed the ability of 1X-PNM to counteract APAP-induced decrease in Bcl-xL expression. Histopathological evaluation of stained liver tissue sections indicated anti-apoptogenic and anti-necrogenic reponses coupled with near complete prevention of glycogen depletion by 1X-PNM. Collectively, our investigation suggests that a mixture containing an assortment of phytochemicals/nutraceuticals may serve as a much more powerful blend in preventing drug or chemical-induced organ injuries than a single phytochemical or nutraceutical entity. In addition, ephedra and caffeine containing PNM-exposure in a controlled manner may potentially shield vital target organs from toxicities caused by intentional, unintentional or accidental exposures to structurally and functionally diverse drug and chemical entities.

Metal content of ephedra-containing dietary supplements and select botanicals

PURPOSE

The metal content of dietary supplements, including 13 ephedra-containing supplements, was studied.

METHODS

Samples of botanicals (black cohosh, echinacea, goldenseal, kava kava, milk thistle, saw palmetto, Synephrine, and valerian root), ephedra-containing dietary supplements (Amp II, EPH 833, Ephedra, Ephedra 1000, Hydroxycut, Metabolife 356, Metabolift, Ripped Fuel, Ripped Fuel Extreme, Ripped Fuel [ma huang-free], Stacker 2 [two lots], Super Stinger, Virgin Earth, Xenadrine RFA-1 [two lots], Yellow Jacket), and nonprescription reference agents (NoDoz and Primatene) were digested in acid, reacidified, and then spiked with internal standards. Metals were quantified using Environmental Protection Agency quality assurance and quality-control standards 6020 and 200.8. Forty-seven metals were analyzed by inductively coupled plasma-mass spectrometry, with subpart-per-trillion detection limits.

RESULTS

All metals detected were in concentrations below toxic levels or physiological limit levels for the daily doses specified by the products' labeling. Metals found in highest concentrations among all the supplements sampled were sodium, magnesium, calcium, potassium, aluminum, iron, titanium, mercury, strontium, lead, barium, and silver. Of the 27 supplements analyzed, those with the lowest metal concentrations were mostly single-ingredient botanical supplements, while multiple-component, ephedra-containing dietary supplements generally had higher metal concentrations. Significant lot-to-lot variations were found for two ephedra-containing dietary supplements.

CONCLUSION

None of 47 metals was found in highly toxic amounts in 23 brands of dietary supplements and two nonprescription reference preparations.

Dietary supplement-related adverse events reported to the California Poison Control System

PURPOSE

Dietary supplement (DS)-related adverse events (AEs) reported to the California Poison Control System (CPCS) were studied.

METHODS

The CPCS database was used to search for all telephone calls from consumers concerning DS-related AEs received during the six-month period between April and September 2002. The calls were characterized according to the substance involved, the caller's age (adult or pediatric), and the type of ingestion (accidental or intentional). Each exposure in which symptoms were reported was categorized as involving an AE. Each AE was assessed for severity and causality.

RESULTS

Data on a total of 1183 telephone calls were retrieved, of which 828 calls (70%) met the study's inclusion criteria. DS exposure occurred in 389 adults (47%) and 438 children (53%). DS ingestion was accidental in 360 patients (43%) and intentional in 467 patients (56%). Exposure resulted in an AE in 480 patients (58%). AEs were reported in 353 patients (74%) who ingested products containing ephedra; other exposures frequently involved zinc, kava, creatine, and valerian. AEs were classified as moderate in 198 patients (41%) who ingested a DS and as severe in 40 patients (8%). One patient had a fatal reaction. Among the 480 AEs in DS-exposed consumers, the DS was classified as the definite cause of 1 AE (<1%) and a probable cause of 237 (49.4%). The most frequently reported AE symptoms were increased heart rate (45%), agitation (30%), vomiting (30%), and nausea (15%).

CONCLUSION

A majority of DS-related AEs reported by consumers to CPCS involved ephedra-containing products.

The severity of toxic reactions to ephedra: comparisons to other botanical products and national trends from 1993-2002

OBJECTIVE

Ephedra is a botanical product widely used to enhance alertness, as a weight loss aide, and as a decongestant. Its reported adverse effects led the Food and Drug Administration (FDA) to ban ephedra-containing products in the United States in 2004. This study's purpose was to compare toxicity from botanical products containing ephedra to nonephedra products.

METHODS

The Toxic Exposure Surveillance System (TESS), a national poison center database, was utilized to determine the number and outcomes of cases involving botanical products reported from 1993-2002. Cases listing both a botanical product and any other drugs or chemicals were excluded a priori. Ten-year hazard rates (moderate outcomes + major outcomes + deaths per 1000 exposures) were used to compare botanical product categories.

RESULTS

There were 21,533 toxic exposures with definitive medical outcomes reported over the 10 yrs where a botanical product was the only substance involved. Of these, 4306 (19.9%) had moderate or major medical outcomes and there were two deaths, for an overall hazard score of 200 per 1000 exposures. The number of ephedra reports to poison centers increased 150-fold over the 10-yr period. The hazard rate for products that contained only ephedra was 250 per 1000 exposures and 267 per 1000 exposures for products that contained ephedra and additional ingredients; whereas the hazard score for only nonephedra botanical products was 96 per 1000 exposures. The rate ratios for multibotanical products with ephedra (RR 1.33; 95% C.I. 1.27-1.40) and for single-ingredient ephedra products (RR 1.25; 95% C.I. 1.11-1.40) were both two to six times higher than those of other common botanical products. Yohimbe-containing products had the highest hazard score (417) and rate ratio (2.08; 95% C.I. 1.59-2.80).

CONCLUSION

Ephedra-containing botanical products accounted for a significant number of toxic exposures with severe medical outcomes reported to poison centers. Hazard rate analysis suggests poison center-reported events involving ephedra-containing botanical products were much more likely to result in severe medical outcomes than those involving nonephedra-containing botanical products. These data support recommendations by policymakers that the sale of ephedra should be prohibited to protect consumers. Our data suggest that the botanical product, yohimbe, may also be associated with unacceptably high risks of toxicity and should receive close scrutiny from health policymakers.

Disorders of Fuel Metabolism: Medical Complications Associated with Starvation, Eating Disorders, Dietary Fads, and Supplements

Disorders of fuel metabolism as they relate to abnormal fuel intake,abnormal fuel expenditure, and dietary supplements are the focus of this article. The emergency physician should be aware of the medical complications that can occur as a result of starvation states,eating disorders, fad diets, hypermetabolic states, and ergogenic aids. Knowledge and understanding of the complications associated with these disorders will facilitate the diagnosis and management of patients who present to the emergency department with any of the disorders reviewed.

Short-term and long-term in vivo exposure to an ephedra- and caffeine-containing metabolic nutrition system does not induce cardiotoxicity in B6C3F1 mice

Although conventional biomedical research has largely focused on mechanisms of weight loss and genetic aspects of obesity, most medical solutions are plagued by side-effects and fraught with complex questions. As a consequence, consumers are seriously considering herbal products, nutraceuticals and functional foods as alternatives to conventional medications. This is evidently driven by a growing consumer understanding of diet/disease links, aging-related consequences, rising health care costs, and advances in food technology and nutrition. This study investigated the effects of up to 12 months exposure to a multinutrient and botanical extract supplement (Metabolic Nutrition System Orange (MNSO) - sold by AdvoCare, Carrollton, TX, USA) at five dietary concentrations on serum biochemistry and target organ histopathology of the hearts of B6C3F1 mice. The MNSO is a unique combination of vitamins, minerals, omega-3 fatty acids and herbal extracts designed to provide a strong foundation of nutritional support, and to enhance thermogenesis and perception of energy. The MNSO contain extracts of citrus, ephedra, guarana, gingko, green tea and Ocimum. In this study, female B6C3F1 mice were fed control (-MNSO) or MNSO (one time to ten times, one time = daily human dose) diets. Animals were sacrificed after 4, 8 and 12 months', at which time blood was collected for serum chemistry analysis, and hearts were prepared for histopathology and tissue biochemistry. Food consumption and body weight changes were also monitored throughout the study. The MNSO exposure did not significantly affect any of the cardiosensitive enzymes [including creatine kinase (CK), lactate dehydrogenase (LDH) and aspartate aminotransferase (AST)] and normal histopathological architecture of the heart was observed. Although animals given the MNSO diet consumed more food, they were relatively leaner and more active compared to controls. The results indicate that ingestion of ephedra and caffeine for one year in the doses used as part of a comprehensive metabolic nutrition system does not significantly alter normal serum chemistry or induce any irreversible histological changes in the mouse heart, since this study employed up to ten times the normal human consumption dose of ephedra and the metabolic nutrition system.

Adverse events of herbal food supplements for body weight reduction: systematic review

Herbal weight-loss supplements are marketed with claims of effectiveness. Our earlier systematic review identified data from double-blind, randomized controlled trials for a number of herbal supplements. The aim of this systematic review was to assess all clinical evidence of adverse events of herbal food supplements for body weight reduction for which effectiveness data from rigorous clinical trials exist. We assessed Ephedra sinica, Garcinia cambogia, Paullinia cupana, guar gum, Plantago psyllium, Ilex paraguariensis and Pausinystalia yohimbe. Literature searches were conducted on Medline, Embase, Amed and The Cochrane Library. Data were also requested from the spontaneous reporting scheme of the World Health Organization. We hand-searched relevant medical journals and our own files. There were no restrictions regarding the language of publication. The results show that adverse events including hepatic injury and death have been reported with the use of some herbal food supplements. For herbal ephedra and ephedrine-containing food supplements an increased risk of psychiatric, autonomic or gastrointestinal adverse events and heart palpitations has been reported. In conclusion, adverse events are reported for a number of herbal food supplements, which are used for reducing body weight. Although the quality of the data does not justify definitive attribution of causality in most cases, the reported risks are sufficient to shift the risk-benefit balance against the use of most of the reviewed herbal weight-loss supplements. Exceptions are Garcinia cambogia and yerba mate, which merit further investigation.

Molecular mechanisms of toxicity of important food-borne phytotoxins

At present, there is an increasing interest for plant ingredients and their use in drugs, for teas, or in food supplements. The present review describes the nature and mechanism of action of the phytochemicals presently receiving increased attention in the field of food toxicology. This relates to compounds including aristolochic acids, pyrrolizidine alkaloids, beta-carotene, coumarin, the alkenylbenzenes safrole, methyleugenol and estragole, ephedrine alkaloids and synephrine, kavalactones, anisatin, St. John's wort ingredients, cyanogenic glycosides, solanine and chaconine, thujone, and glycyrrhizinic acid. It can be concluded that several of these phytotoxins cause concern, because of their bioactivation to reactive alkylating intermediates that are able to react with cellular macromolecules causing cellular toxicity, and, upon their reaction with DNA, genotoxicity resulting in tumors. Another group of the phytotoxins presented is active without the requirement for bioactivation and, in most cases, these compounds appear to act as neurotoxins interacting with one of the neurotransmitter systems. Altogether, the examples presented illustrate that natural does not equal safe and that in modern society adverse health effects, upon either acute or chronic exposure to phytochemicals, can occur as a result of use of plant- or herb-based foods, teas, or other extracts.

Hemorrhagic stroke after naphazoline exposition: case report

Ten percent of all strokes are due to spontaneous cerebral hemorrhages. They are associated to drugs (licit and illicit) in 9.5% of all cases in young adults. This is a case report of a 44-year-old man, without previous morbidities, who presented a sudden onset headache and arterial hypertension 24 hours after use of naphazoline as nasal decongestant. Cranial tomography showed right thalamus hemorrhage. Cerebral angiography showed no aneurisms, vascular malformations or vasculitis. No other risk factors were found during investigation in this patient and the stroke was attributed to naphazoline exposition.

Complementary and alternative interventions in asthma, allergy, and immunology

OBJECTIVE

To review which herbs are most commonly used as complementary and alternative medicine (CAM) for treatment of asthma, allergy, and immunologic conditions.

DATA SOURCES

A review of the literature was performed using the PubMed and OVID databases searching the keywords asthma, allergy, and CAM to identify studies published between 1980 and 2003 that focused on Echinacea (Echinacea augustifolia, Echinacea pallida, and Echinacea purpurea); garlic (Allium); angelica; chamomile; ephedra; gingko; grape seed extract; licorice root (Glycyrrhiza); St. John's wort (Hypericum); kava kava (Piper); peppermint oil and leaf (Mentha); stinging nettle (Urtica); and ginseng (Panax) published in the English and German literature.

STUDY SELECTION

Studies included in vitro and in vivo clinical trials and case reports selected according to the expert opinion of the author.

RESULTS

Echinacea is one of the most common herbs used to treat symptoms of the "common cold" or upper respiratory tract allergies. Although no common drug interactions have been reported, there is a risk of hepatotoxicity, exacerbation of allergies and asthma, and anaphylactic reactions. Garlic is primarily used for cardiovascular health and relief of cough, colds, and rhinitis. Adverse effects commonly include gastrointestinal disturbances, change in body odor through the sweat and breath, and rarely allergic reactions or hypoglycemia. Other CAM agents, including angelica, German chamomile flower, ephedra, gingko, grape seed extract, licorice root, St. John's wort, kava kava rhizome, peppermint, stinging nettle, and ginseng, are also associated with significant adverse effects.

CONCLUSION

The specialty of allergy and immunology has seen the second largest increase in the popularity of CAM (second only to practitioners who treat lower back pain). Almost all of the CAM interventions have displayed adverse effects, usually in the form of a hypersensitivity reaction. Allergists and clinical immunologists need to become more knowledgeable about CAM so that they can inform patients about the use and possible abuse of these modalities.

Management of nonalcoholic fatty liver disease: weight control

With obesity reaching epidemic proportions in the United States, it is imperative that hepatologists have an understanding of the medical ramifications and methods of treatment. Evaluation of nonalcoholic fatty liver disease may get the patient into the office,but weight reduction may provide a therapeutic hurdle. This article provides an overview of current obesity treatment.

Safety of ephedra: lessons learned

The safe use of ephedra represents the best possible outcome of a convergence of variables, some with troubling potential outcomes. Commercially used ephedra and its products is prepared from Ephedra spp. and as such is subject to a variety of influences (including differences in species and strain; growth, harvest and storage conditions) all of which may influence the content of constituents (which may, in turn, affect the absorption, distribution, and metabolism of active constituents) and taken together, influences the net pharmacological effect. Further, as a natural substance with an easily perceived and desirable (i.e. weight-loss) pharmacological effect, ephedra is also susceptible to a variety of adulterants, both economic and efficacious. All of the foregoing represent potential for misadventure before ephedra even reaches the consumer. The consumer introduces a constellation of variables as well, including, but not limited to, acute and chronic diseases, inborn errors in metabolism, simultaneous use of prescription and over-the-counter drugs, dietary supplements, alcohol, illicit substances and certain foods (e.g. chocolate, caffeinated drinks), all or some of which may exert synergistic, additive or even antagonistic influences on the desired physiologic outcome. The foregoing not withstanding, the majority of the published nonclinical and clinical studies, and history of use, support the safety of ephedra at the proposed use levels. However, the reports of adverse events submitted to FDA raise concern about the risk associated with ephedra without establishing a direct causal relationship. Given the foregoing, how best can a decision on safety be made? Should the question actually be "can ephedra be as toxic as reported?"

Popular sports supplements and ergogenic aids

This article reviews the evidence-based ergogenic potential and adverse effects of 14 of the most common products in use by recreational and elite athletes today. Both legal and prohibited products are discussed. This is an aggressively marketed and controversial area of sports medicine worldwide. It is therefore prudent for the clinician to be well versed in the more popular supplements and drugs reputed to be ergogenic in order to distinguish fact from fiction.Antioxidants, proteins and amino acids are essential components of diet, but additional oral supplementation does not increase endurance or strength. Caffeine is ergogenic in certain aerobic activities. Creatine is ergogenic in repetitive anaerobic cycling sprints but not running or swimming. Ephedrine and pseudoephedrine may be ergogenic but have detrimental cardiovascular effects. Erythropoietin is ergogenic but increases the risk of thromboembolic events. beta-Hydroxy-beta-methylbutyrate has ergogenic potential in untrained individuals, but studies are needed on trained individuals. Human growth hormone and insulin growth factor-I decrease body fat and may increase lean muscle mass when given subcutaneously. Pyruvate is not ergogenic. The androgenic precursors androstenedione and dehydroepiandrosterone have not been shown to increase any parameters of strength and have potentially significant adverse effects. Anabolic steroids increase protein synthesis and muscle mass but with many adverse effects, some irreversible. Supplement claims on labels of product content and efficacy can be inaccurate and misleading.

Ischemic stroke after using over the counter products containing ephedra

Dietary supplements containing Ephedra used for weight loss and physical performance enhancement such as "herbal ecstasy" are widely available, and it is estimated that at least 1% of the adult population have taken these products. Ephedra products including Ephedra alkaloids such as phenylpropanolamine or other ephedrine compounds are sold under different names such as Metabolife 356, Ripped Fuel, Thermadrene, and Shape-Fast Plus. Over 2 years, five patients with ischemic infarctions associated with use of Ephedra products were evaluated at Indiana University Hospital. Ephedrine, like other sympathomimetic agents, predisposes patients to both ischemic and hemorrhagic strokes. People who take over the counter Ephedra products that claim to boost weight loss, increase energy, or bolster physical performance are at risk of adverse events including ischemic and hemorrhagic strokes.