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de Jonge MLL, Kieviet LC, Sierts M, Egberink LB, van der Heyden MAG. Review of Case Reports on Adverse Events Related to Pre-workout Supplements Containing Synephrine. Cardiovasc Toxicol 2023; 23:1-9. [PMID: 36639595 PMCID: PMC9859859 DOI: 10.1007/s12012-022-09777-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 12/27/2022] [Indexed: 01/15/2023]
Abstract
The use of pre-workout supplements has become increasingly popular, including the use of supplements containing synephrine. Synephrine might stimulate weight loss and improve sports performance by its proposed adrenergic properties. However, with its increasing popularity, numerous cases of adverse events related to synephrine use have been reported. This study provides a comprehensive overview and analysis of current case reports related to the supplemental use of synephrine. The scientific literature on cases of adverse events related to synephrine intake was collected through August 2021 using Pubmed and Google Scholar and subsequently reviewed and analysed. We obtained 30 case reports describing a total of 35 patients who suffered from medical complaints following use of synephrine-containing supplements. The patients most often presented with chest pain, palpitations, syncope and dizziness. Commonly raised diagnoses were ischaemic heart disease, cardiac arrhythmias and cerebrovascular disease. Five patients were left disabled or remained on medication at last follow-up. We here show an association between the use of pre-workout supplements containing synephrine and adverse events, mainly related to the cardiovascular system. However, we cannot exclude a role of possible confounding factors such as caffeine. Thus, the use of pre-workout supplements containing synephrine may lead to serious adverse health events, and therefore, caution is needed.
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Affiliation(s)
- M L L de Jonge
- Honours Program CRU+, University Medical Center Utrecht, Heidelberglaan 100, 3584 CM, Utrecht, The Netherlands
| | - L C Kieviet
- Honours Program CRU+, University Medical Center Utrecht, Heidelberglaan 100, 3584 CM, Utrecht, The Netherlands
| | - M Sierts
- Honours Program CRU+, University Medical Center Utrecht, Heidelberglaan 100, 3584 CM, Utrecht, The Netherlands
| | - L B Egberink
- Honours Program CRU+, University Medical Center Utrecht, Heidelberglaan 100, 3584 CM, Utrecht, The Netherlands
| | - M A G van der Heyden
- Division of Heart & Lungs, Department of Medical Physiology, University Medical Center Utrecht, Yalelaan 50, 3584 CM, Utrecht, The Netherlands.
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Stohs SJ, Ray SD. Review of Published Bitter Orange Extract and p-Synephrine Adverse Event Clinical Study Case Reports. J Diet Suppl 2019; 17:355-363. [DOI: 10.1080/19390211.2019.1577936] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Sidney J. Stohs
- Creighton University Medical Center, Omaha, NE, USA Kitsto Consulting LLC, Frisco, TX, USA
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Bakhiya N, Ziegenhagen R, Hirsch-Ernst KI, Dusemund B, Richter K, Schultrich K, Pevny S, Schäfer B, Lampen A. Phytochemical compounds in sport nutrition: Synephrine and hydroxycitric acid (HCA) as examples for evaluation of possible health risks. Mol Nutr Food Res 2017; 61. [DOI: 10.1002/mnfr.201601020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 02/10/2017] [Accepted: 02/13/2017] [Indexed: 01/17/2023]
Affiliation(s)
- Nadiya Bakhiya
- Department of Food Safety; Federal Institute for Risk Assessment (BfR); Berlin Germany
| | - Rainer Ziegenhagen
- Department of Food Safety; Federal Institute for Risk Assessment (BfR); Berlin Germany
| | - Karen I. Hirsch-Ernst
- Department of Food Safety; Federal Institute for Risk Assessment (BfR); Berlin Germany
| | - Birgit Dusemund
- Department of Food Safety; Federal Institute for Risk Assessment (BfR); Berlin Germany
| | - Klaus Richter
- Department of Food Safety; Federal Institute for Risk Assessment (BfR); Berlin Germany
| | - Katharina Schultrich
- Department of Food Safety; Federal Institute for Risk Assessment (BfR); Berlin Germany
| | - Sophie Pevny
- Department of Food Safety; Federal Institute for Risk Assessment (BfR); Berlin Germany
| | - Bernd Schäfer
- Department of Food Safety; Federal Institute for Risk Assessment (BfR); Berlin Germany
| | - Alfonso Lampen
- Department of Food Safety; Federal Institute for Risk Assessment (BfR); Berlin Germany
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Endothelium- and smooth muscle-dependent vasodilator effects of Citrus aurantium L. var. amara: Focus on Ca(2+) modulation. Biomed Pharmacother 2016; 82:467-71. [PMID: 27470386 DOI: 10.1016/j.biopha.2016.05.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 05/19/2016] [Accepted: 05/19/2016] [Indexed: 11/20/2022] Open
Abstract
Neroli, the essential oil of Citrus aurantium L. var. amara, is a well-characterized alleviative agent used to treat cardiovascular symptoms. However, because it has been found to have multiple effects, its mechanism of action requires further exploration. We sought to clarify the mechanism underlying the actions of neroli in mouse aorta. In aortic rings from mice precontracted with prostaglandin F2 alpha, neroli induced vasodilation. However, relaxation effect of neroli was decreased in endothelium-denuded ring or pre-incubation with the nitric oxide synthase inhibitor NG-Nitro-l-arginine-methyl ester (L-NAME). And also, neroli-induced relaxation was also partially reversed by 1H-[1,2,4] oxadiazolo [4,3-a] quinoxalin-1-one (ODQ), a soluble guanylyl cyclase (sGC) inhibitor. In addition, neroli inhibited extracellular Ca(2+)-dependent, depolarization-induced contraction, an effect that was concentration dependent. Pretreatment with the non-selective cation channel blocker, Ni(2+), attenuated neroli-induced relaxation, whereas the K(+) channel blocker, tetraethylammonium chloride, had no effect. In the presence of verapamil, added to prevent Ca(2+) influx via smooth muscle voltage-gated Ca(2+) channels, neroli-induced relaxation was reduced by the ryanodine receptor (RyR) inhibitor ruthenium red. Our findings further indicate that the endothelial component of neroli-induced vasodilation is partly mediated by the NO-sGC pathway, whereas the smooth muscle component involves modulation of intracellular Ca(2+) concentration through inhibition of cation channel-mediated extracellular Ca(2+) influx and store-operated Ca(2+) release mediated by the RyR signaling pathway.
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Ulbricht C, Costa D, Giese N, Isaac R, Liu A, Liu Y, Osho O, Poon L, Rusie E, Stock T, Weissner W, Windsor RC. An evidence-based systematic review of bitter orange (Citrus aurantium) by the Natural Standard Research Collaboration. J Diet Suppl 2014; 10:391-431. [PMID: 24237193 DOI: 10.3109/19390211.2013.830821] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
An evidence-based systematic review of bitter orange (Citrus aurantium) by the Natural Standard Research Collaboration consolidates the safety and efficacy data available in the scientific literature using a validated, reproducible grading rationale. This article includes written and statistical analysis of clinical trials, plus a compilation of expert opinion, folkloric precedent, history, pharmacology, kinetics/dynamics, interactions, adverse effects, toxicology, and dosing.
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Investigating herb–drug interactions: The effect of Citrus aurantium fruit extract on the pharmacokinetics of amiodarone in rats. Food Chem Toxicol 2013; 60:153-9. [DOI: 10.1016/j.fct.2013.07.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 07/09/2013] [Accepted: 07/15/2013] [Indexed: 11/19/2022]
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Physiological effects following administration of Citrus aurantium for 28days in rats. Toxicol Appl Pharmacol 2012; 261:236-47. [DOI: 10.1016/j.taap.2012.04.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 04/02/2012] [Accepted: 04/05/2012] [Indexed: 11/18/2022]
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Stohs SJ, Preuss HG, Shara M. The safety of Citrus aurantium (bitter orange) and its primary protoalkaloid p-synephrine. Phytother Res 2011; 25:1421-8. [PMID: 21480414 DOI: 10.1002/ptr.3490] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 03/04/2011] [Accepted: 03/08/2011] [Indexed: 11/07/2022]
Abstract
Citrus aurantium (bitter orange) extract and its principal protoalkaloidal constituent p-synephrine are widely used in weight loss and weight management as well as in sports performance products. However, questions are raised frequently regarding the safety of these ingredients. The potential inherent dangers associated with the use of products containing C. aurantium extract are frequently touted, while conversely, millions of doses of dietary supplements have been consumed by possibly millions of individuals in recent years. Furthermore, millions of people consume on a daily basis various juices and food products from Citrus species that contain p-synephrine. This review summarizes current information regarding the safety of C. aurantium (bitter orange) extract and p-synephrine based on human, animal and in vitro assessments as well as receptor binding and mechanistic studies. The data indicate that based on current knowledge, the use of bitter orange extract and p-synephrine appears to be exceedingly safe with no serious adverse effects being directly attributable to these ingredients.
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Affiliation(s)
- Sidney J Stohs
- School of Pharmacy and Health Professions, Creighton University Medical Center, Omaha, NE 68178, USA.
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Seifert JG, Nelson A, Devonish J, Burke ER, Stohs SJ. Effect of acute administration of an herbal preparation on blood pressure and heart rate in humans. Int J Med Sci 2011; 8:192-7. [PMID: 21448304 PMCID: PMC3053490 DOI: 10.7150/ijms.8.192] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Accepted: 01/31/2011] [Indexed: 11/06/2022] Open
Abstract
Confusion and controversy exist regarding the cardiovascular effects of dietary supplements containing caffeine and Citrus aurantium (bitter orange) extract. The primary protoalkaloidal ingredient in bitter orange extract is p-synephrine which has some structural similarities to ephedrine and nor-epinephrine, but exhibits markedly different pharmacokinetic and receptor binding properties. The goal of this study was to investigate the cardiovascular effects of a product containing caffeine, bitter orange extract (p-synephrine) and green tea extract in mildly overweight individuals. Fourteen female and nine male subjects (age 24.7 ±7.4 yrs, BMI: 26.6 ±3.8) volunteered in this randomized, placebo-controlled, crossover, double-blind designed study. On day one, subjects entered the laboratory following an overnight fast. Heart rate and blood pressure were recorded at 60 min. Expired air was analyzed for the next 10 min of the session. At each of three meals, subjects ingested one capsule that was either a non-caloric placebo or a dietary supplement that contained 13 mg p-synephrine and 176 mg caffeine. On the following day, the subjects returned and repeated the protocol for data collection beginning 60 min after consuming one capsule of the placebo or the dietary supplement. No effects of the dietary supplement on heart rate, systolic and diastolic blood pressure or mean arterial pressure were observed. No between or within group differences were observed when data were analyzed for gender and caffeine usage. A small but significant decrease in resting respiratory exchange ratio was observed for the low caffeine user group in response to the product containing caffeine and p-synephrine. The results of this study indicate that ingestion of a product containing bitter orange extract, caffeine and green tea extract does not lead to increased cardiovascular stress and that fat oxidation may increase in certain populations.
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Affiliation(s)
- John G. Seifert
- 1. Movement Science/Human Performance Laboratory, Montana State University, Bozeman, MT, USA
| | - Aaron Nelson
- 2. Human Performance Laboratory, St. Cloud State University, St. Cloud, MN, USA
| | - Julia Devonish
- 2. Human Performance Laboratory, St. Cloud State University, St. Cloud, MN, USA
| | - Edmund R. Burke
- 3. Dept of Biology, Colorado University - Colorado Springs, Colorado Springs, CO, USA
| | - Sidney J. Stohs
- 4. School of Pharmacy and Health Professions, Creighton University Medical Center, Omaha, NE, USA
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Assessment of the adverse event reports associated with Citrus aurantium (bitter orange) from April 2004 to October 2009. J Funct Foods 2010. [DOI: 10.1016/j.jff.2010.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Arbo MD, Braun P, Leal MB, Larentis ER, Aboy AL, Bulcão RP, Garcia SC, Limberger RP. Presence of p-synephrine in teas commercialized in Porto Alegre (RS/Brazil). BRAZ J PHARM SCI 2009. [DOI: 10.1590/s1984-82502009000200012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Citrus aurantium (bitter orange) is characterized by the presence of p-synephrine, an amine structurally and pharmacologically related to ephedrine. Besides the same adverse effects as ephedrine, nowadays it is believed that altered levels of p-synephrine can be associated to the occurrence of migraine and cluster headaches. Leaves and fruits of this species are highly commercialized in form of teas and herbal preparations, but without taking into account the risks associated with its use. This work describes a survey of teas and herbal preparations containing C. aurantium, commercialized in Porto Alegre (RS/Brazil), in order to verify the presence of p-synephrine. Comparing with the mean amount available in the supermarkets, around 20% of the teas and 10% of the herbal preparations declared the presence of C. aurantium in their labels. In a sampling of 15 teas and 2 herbal preparations selected for the analysis, the presence of p-synephrine was characterized in all samples, with levels between 0.0040 to 0.2308%, leading to a caution that even being natural products, they are not free of adverse effects.
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