Lessons from ephedra

By Rajen M
By Rajen M

Let’s try to understand this herb a little. Ephedra sinica, also known as ma huang, is the plant most commonly used as a source of ephedra products. Ma huang has been used for thousands of years in Chinese medicine. Ephedra includes “ephedrine alkaloids”, which are naturally occurring compounds that are found in plants.  

There is a difference between ephedrine alkaloids and synthetic ephedrine. Ephedrine is only one of the naturally occurring alkaloids present in ephedra extracts. Other alkaloids include pseudoephedrine (which is less potent than ephedrine) and alkaloids that slow the absorption of ephedrine from the digestive tract and/or counteract the stimulant effects of the ephedrine in the extracts.  

However, synthetic ephedrine, which is used in a number of common cold remedies, is not a naturally occurring substance. Synthetic ephedrine can be easily identified on the label as “ephedrine hydrochloride”. 

Nevertheless, the blanket ban on all ephedra products is baffling when you compare this to the track record of a popular pharmaceutical product. It is called acetaminophen in the US but you are probably more familiar with the name we called it here in Malaysia, paracetamol. It is chemically known as N-acetyl-p-aminophenol (APAP). 


Liver damage 

Indeed, paracetamol is the most widely used pharmaceutical painkiller and fever relief agent in the US and indeed, the world. According to Dr Susan E. Farrell, instructor in Emergency Medicine at Harvard Medical School, paracetamol is contained in more than 200 products, either as a single agent or in combination. It even comes in various formulations such as syrups and chewable tablets meant for kids.  

According to Farrell, paracetamol is also one of the most common agents in overdose cases reported to the American Association of Poison Control Centres. It is the most common cause of liver failure requiring transplantation in the US and Great Britain.  

What more, it is advertised on television and the mass media. It has an OTC status. This means that it can be freely sold by the shop assistant of the corner provision shop. It is used for everything from a headache, muscle ache and fever to the flu and common cold. Most doctors will tell you that “it is just paracetamol”.  


Freely available 

According to the website, e-medicine.com, the maximum dose is 4g for adults and 90mg/kg body weight for children. If you are elderly, a child or liver compromised for some reason, you’re at increased risk of suffering complications with the drug. Nevertheless, when dosing recommendations are followed, the risk of liver toxicity is very rare.  

Yet, last year, an FDA review estimated that there are more than 14,000 cases of unintentional overdosage of acetaminophen every year, with about 100 of those cases resulting in death. It is the leading cost of accidental poisoning in the United Kingdom.  



Needless to say, no one is talking about a similar ban of paracetamol. Nor should they. Just like ephedra, no one makes you take acetaminophen. If you want to take it, that’s your right. Like ephedra, if you take acetaminophen as directed, you’ll probably experience little or no harm. However, if you take ephedra, acetaminophen, or any other herb or drug recklessly, you may pay a very high price.  


Pan saga 

A similar situation followed the recall of the products made by the now insolvent Pan Pharmaceuticals in May last year. All the supplements implicated were recalled from the shelves. The media, doctors and consumer associations went on an all-out onslaught of supplements. One doctor even wrote to the press calling for a ban on all supplements. 

This was ridiculous given the facts surrounding the case. According to the Malaysian Dietary Supplement Association (MADSA), the whole issue resulted from manufacturing irregularities involving a drug (not supplement) used to treat motion sickness. Yet, all supplements manufactured at the same facility took all the heat. Even till today, problems with regards to the recalled supplements have never been proven.  

In other cases involving herbal toxicity, like the now famous Slim 10 case, it was not the herb but the deliberate tainting with a drug that caused liver failure.  


Knowledge is power 

Sadly, most people probably have no idea that they could be abusing paracetamol. In 1995, a 23 year-old Philadelphia man named Marcus Trunk began taking a prescription drug that contained paracetamol to treat a sprained wrist. When his prescription ran out, he took an over-the-counter acetaminophen for another week. Within a few days he developed a fever and began vomiting. When he went to a hospital emergency room, doctors gave him further doses of acetaminophen. Within a week, Marcus died of liver failure caused by acetaminophen overdose.  

And there’s a good chance that the American footballer Steve Bechler was unaware that he was endangering his life last spring when he used ephedrine contrary to the manufacturer’s recommendations. After all, it was his death that resulted in the herb being maligned to the point of an FDA ban.  


User missteps 

Still, neither of these treatments should be banned because of the missteps of their users. Herbs and drugs should be used within prescribed bounds. Marcus Trunk’s mother told an Associated Press reporter that she wonders, “If I’d been more educated to acetaminophen products, could I have steered him clear?” The sad answer to that question is yes.  

Ultimately, it is you the consumer who decides. And it seems that the man on the street is deciding in favour of supplements. There is no census of the local supplement industry, so it is difficult to say what the long-term fallout of the local industry will be as a result of the Pan recall last year.  

Still, supplement industry executives meeting at a MADSA seminar in mid-January noted that there was no shrinkage and probably some growth after all.  



1. ‘Stronger Painkiller Warnings Possible’, Lauran Neergaard, Associated Press, 9/20/02 

2. ‘Clearer Liver Warning Urged for Painkillers’, Adam Marcus, Health Scout News, 9/20/02 

3. ‘Toxicity, Acetaminophen’, Susan E. Farrell, M.D., Emedicine.com 

4. ‘FDA Probes New Worry About Acetaminophen Overdose’, Associated Press, 3/27/01  

5. USFDA Press Release – Dec 30, 2003 

6. MADSA Press Release – June 10, 2003 

7. Ministry of Health and MADSA seminar, January 15, 2004 


  • Rajen M. is a pharmacist with a doctorate in holistic medicine. Write to him at starhealth@thestar.com.my The views expressed are those of the writer and readers are advised to always consult expert advice before undertaking any changes to their lifestyles. The views and opinions expressed in this column are solely that of the author’s. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to such information. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information. 

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