Ma Huang: Appropriate vs. High-Risk Uses

To me one of the worst things about a cold is that feeling that I can’t breathe through my nose at night. Invariably, my sinuses will be clear all day, but as soon as I lie down, it’s as if someone stuffed a large cotton ball up each nostril. I try blowing my nose just right, I try turning this way, then that to get one nostril to drain and open up, but to no avail. Hours later, with little sound sleep, I reach for an herbal formula with the Chinese herb called ma huang, which I know will shortly open things up.

Of course, I could have gone to the drug store and bought one of the many over-the counter (OTC) preparations like SudafedÆ or PrimatineÆ that contain the same active ingredient as ma huang, ephedrine, but then I would have gotten a few other things that I might have to lie awake and worry about, like FD&C Blue dyes Nos. 1 and 2, Red No. 3 parabens and black ink.

Ma huang (Ephedra sinensis) is an important medicinal herb from China used for over 3,000 year in teas and other preparations to help with symptoms of asthma, colds and flu, and allergies. It has also found worldwide acceptance as an effective component of many herbal formulas, over-the-counter (OTC) medications, and as a source for the purified drugs ephedrine and pseudoephedrine used widely for upper respiratory tract ailments (such as allergies and asthma).

The broom-like stems of the herb are harvested by the tons in China and shipped to ports all over the world. Although there are several American species (known as Mormon Tea and used traditionally as a blood purifier), such as E. nevadensis, it is important to note that they contain little or no ephedrine.

The most common use of ma huang in traditional medicine is to relieve symptoms from the first stages of what we call “the common cold,” in western countries, especially the type that is due to exposure to cold, damp, and wind. It is also invaluable for helping to relieve the wheezing and breathing difficulties associated with some types of asthma and allergies.

A TCM herbalist or acupuncturist will always prescribe ma huang in combination with other herbs to help counteract possible side effects such as nervousness, sleeplessness, heart palpitations, high blood pressure, and directing energy away from the digestive organs.

The main active ingredient of ma huang, ephedrine, falls into a therapeutic category of “Adrenergic bronchodilators.” (Opens up the bronchial tree by stimulating the sympathetic nervous system) and is the only adrenergic bronchodilator that is available without a doctor’s prescription. Ephedrine can shrink congested mucous membranes, helping to dry up the watery discharge and open the stuffed nasal passages which so often accompany the common cold or some flu.

The alkaloid acts in similar ways to the body’s own stimulant, adrenaline, but is milder and longer-lasting and, unlike adrenaline, works orally.

Pseudoephedrine, a natural variant of ephedrine from ma huang, is found as a main ingredient in such well-known products as Sudafed, Actifed, Contac, Robitussin-PE, Sinutab, and others, because it causes less of a blood-pressure rise than ephedrine, while maintaining a similar strength for bronchodilation.

In current medical practice in the United States, ephedrine is approved for the following conditions:

• “Symptoms of bronchial asthma, chronic bronchitis, emphysema and other lung diseases”
• cough, wheezing, shortness of breath, and troubled breathing (increases the flow of air through the bronchial tubes by dilating them).
• Narcolepsy (“uncontrolled desire for sleep, or sudden attacks of sleep”).

Presently, there is a controversy “brewing” over ma huang. The problem is that some herbal product manufacturers tend at times to disregard the traditional use of ephedra. A number of popular weight-loss and energy products include pure ephedra concentrates, which stimulate the nervous system and metabolism (by stimulating the thyroid gland). There is evidence that the herb works for these purposes, but there are possible dangers… side effects such as a weakening of the digestion, blood pressure increases with an extra demand on the heart, as well as sleep disturbances, nervousness, and anxiety. Some manufacturers do try to add tonic herbs to help counteract these effects.

David Litell from Excell Products, a popular line of “human energy” products containing ma huang said that some of the formulas blended with tonic herbs “are good enough to use on an as needed basis” and that “….ma huang formulas give many people what they want [in the way of extra energy] without draining their reserves.”

He adds that when blended with tonic herbs, ma huang is safer to use than other popular (and legal) stimulants like coffee, kola nut, or guarana, all of which contain caffeine.

However, the uncontrolled and possibly uneducated sale of ma huang is concerning many licensed practitioners of Traditional Chinese Medicine (TCM) who worry that the herb (and perhaps others) will become unavailable to them for use in their clinics because of restrictions by the Food and Drug Administration (FDA). Harvey Kaltsis, the President of the American Association of Acupuncture and Oriental Medicine (AAAOM) told me that if ma huang is used in commercial formulas for weight loss or energy products, the contraindications should be on the bottle, and it should be properly formulated with other herbs that help counteract its possible side-effects.

“Ephedra should be determined by a TCM differential diagnosis to be appropriate for the person who is using it. Because ephedra is warm in nature, it is inappropriate for people with high blood pressure, spontaneous sweating, and other heat conditions because it will aggravate them.”

Michael Tierra, author of The Way of Herbs is a licensed acupuncturist and western herbalist who feels that ephedra should not be taken long-term. He feels that it is also not appropriate for use in people who have “yin deficiency,” or stress-related adrenal weakness disorders like chronic fatigue.

Currently, the Food and Drug Administration (FDA) has an import alert on ephedra extracts, and the herb was recently mentioned in testimony before a House Sub-Committee hearing on dietary supplements (Proxmire hearings) as a substance about which unsubstantiated claims and documented hazards had occurred in the marketplace. They state that serious side effects have been reported to them from products containing ma huang.

Traditional contraindications for ephedra include general weakness, poor digestion, high blood pressure, nervousness, sleeping difficulties, cardiac arrythmias, and heart disease. It may also contract the uterus, which means it should not be used during pregnancy.

As an OTC and pharmaceutical drug, a number of cautions must be included in labels and instructions for products containing ephedrine, including tremors, nervousness, insomnia, hypertension, heart palpitations, diabetes, hyperthyroidism, and prostatic enlargement. Ephedrine is classified by the FDA for pregnancy in category C (no studies on adverse effects on the fetus exist for humans or animals). It passes through mother’s milk to the infant and should not be taken during breast-feeding. It should not be taken with monoamine oxidase (MAO) inhibitors (such as isocarboxazid, phenelzine, or tranylcypromine or possibly the herb St. John’s wort—Hypericum perforatum) which can potentiate the stimulating effects of ephedra.

Despite the number of side effects listed for purified ephedrine in therapeutic doses, studies show that the whole herb ma huang has a very low toxicity and potential for side effects, when used properly (Tang). Animal studies also have failed to demonstrate carcinogenic or mutagenic potential for ephedrine, and the alkaloid is rapidly eliminated from the human body (88% of an oral dose is excreted in the urine within 24 hours, 97% after 48 hours).

Traditional Uses

Herbalists have been saying for years that ma huang should not be used out of the context of a system of medicine that considers its possible side effects as well as clearly defining what kind of person can safely take the herb and for what kind of conditions. Some herbalists feel like manufacturing and advertising products containing ma huang for energy or weight loss are irresponsible and can do nothing but hurt the industry in the long run. This may not have been an easy controversy to clear up without outside intervention, because ephedra makes fantastic profits for manufacturers promising quick energy and slimmer torsos.

Manufacturers of diet and energy products containing ma huang say that ephedra really works to burn fat by stimulating the thyroid gland, a major player in determining the rate of metabolism. They add that when blended with “tonic” herbs that help to counteract its side effects, ma huang is safer to use than other popular (and legal) stimulants like coffee, kola nut, or guarana, all of which contain caffeine.

In TCM, it is known as “Ma Huang,” which means, literally, “hemp yellow,” because of its color. Botanically, it is more closely related to the conifers like pine and firs than to familiar flowering plants such as the mints or dandelions.

The broom-like stems are harvested by the tons in China and shipped to ports all over the world. Although there are several American species (known as Mormon Tea and used traditionally as a blood purifier), such as E. nevadensis, they contain little or no ephedrine or its natural variants.

For coughs and wheezing, it is often combined with apricot seed; for retention of fluids (such as around the eyes) with symptoms of flu or colds, it is combined with ginger; and to counteract its tendency to aggravate inflammation or “heat” during colds and flu, combined with gypsum (Shi Gao) and scullcap root (Huang Qin).

Traditionally, the contraindications (times when it is inappropriate to take ma huang) are listed as:

• people who are weakened by excessive sweating (ma huang increases sweating
  to help “push out” the virus pathogen)
• people who have colds in the summer during hot weather, or colds and
  flu with steady fever (no chills), or more-deeply seated ailments such
  as bronchitis accompanied by thick yellow mucus,
• people with high blood pressure
• people who are nervous or
• people who have trouble sleeping
• people with cardiac arrhythmia.
• people with heart disease

Medical Cautions

Additionally, western medicine gives these cautions for the use of ephedra:

• tremor, nervousness, insomnia, transient hypertension, and heart palpitations.
• Allergic reactions are rare, but do occur
• Ephedrine-containing products should be used cautiously with people with heart disease, diabetes, hypertension, or hyperthyroidism.
• Urinary retention can occur in men with prostatic enlargement.
• Ephedrine is classified by the FDA for pregnancy in category C (no studies on adverse effects on the fetus exist for humans or animals).
• Ephedrine passes through mother’s milk to the infant and should not
  be taken during breast-feeding.
• Can trigger anxiety attacks
• Can cause tremors and is contraindicated for people with epilepsy
• Monoamine oxidase (MAO) inhibitors (such as isocarboxazid, phenelzine
  or tranylcypromine or possibly the herb St. John’s wort—Hypericum perforatum) can potentiate the stimulating effects of ephedra.
• Studies with animals show that ephedrine has a low toxic potential and
  is not carcinogenic or mutagenic (Tang).
• In humans, 88% of an oral dose is excreted in the urine within 24 hours,
  97% after 48 hours

Bibliography

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• Chang, H.-M. & P.P.-H. But. 1986. Pharmacology and Applications of Chinese Materia Medica. Philadelphia: World Scientific.
• Hsu, H.-Y. 1986. Oriental Materia Medica. Long Beach: Oriental Healing Arts Institute.
• Huang, K.C. 1993. The Pharmacology of Chinese Herbs. Boca Raton: CRC Press.
• Tang, W.& G. Eisenbrand. 1992. Chinese Drugs of Plant Origin. Berlin: Springer-Verlag.
• United States Pharmacopeial Convention. 1992. Complete Drug Reference. Yonkers, NY: Consumer Reports Books.