Human pharmacology of a performance-enhancing dietary supplement under resting and exercise conditions

Non-invasive assessment of proarrhythmic risks associated with isoprenaline and the dietary supplement ingredient synephrine using human induced pluripotent stem cell-derived cardiomyocytes

Background

There have been conflicting reports about the proarrhythmic risk of p-synephrine (SYN). To address this, human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) combined with the microelectrode array (MEA) system have been utilized to assess arrhythmia risks, particularly in the context of adrenomimetic drugs.

Aim

This study aims to determine whether MEA recordings from hiPSC-CMs could predict the proarrhythmic risk of adrenomimetic drugs and to investigate the cardiovascular effects and mechanisms of SYN.

Materials and methods

We employed MEA recordings to assess the electrophysiological properties of hiPSC-CMs and conducted concentration-response analyses to evaluate the effects of SYN and Isoprenaline (ISO) on beating rate and contractility. A risk scoring system for proarrhythmic risks was established based on hiPSC-CMs in this study. ISO, a classic beta-adrenergic drug, was also evaluated. Furthermore, the study evaluated the risk of SYN and recorded the concentration-response of beating rate, contractility and the change in the presence or absence of selective β1, β2 and β3 adrenergic blockers.

Results

Our results suggested that ISO carries a high risk of inducing arrhythmias, aligning with existing literature. SYN caused a 30% prolongation of the field potential duration (FPD) at a concentration of 206.326 μM, a change significantly different from baseline measurements and control treatments. The half maximal effective concentration (EC50) of SYN (3.31 μM) to affect hiPSC-CM beating rate is much higher than that of ISO (18.00 nM). The effect of SYN at an EC50 of 3.31 μM is about ten times more potent in hiPSC-CMs compared to neonatal rat cardiomyocytes (34.12 μM). SYN increased the contractility of cardiomyocytes by 29.97 ± 11.65%, compared to ISO's increase of 50.56 ± 24.15%. β1 receptor blockers almost eliminated the beating rate increase induced by both ISO and SYN, while neither β2 nor β3 blockers had a complete inhibitory effect.

Conclusion

The MEA and hiPSC-CM system could effectively predict the risk of adrenomimetic drugs. The study concludes that the proarrhythmia risk of SYN at conventional doses is low. SYN is more sensitive in increasing beating rate and contractility in human cardiomyocytes compared to rats, primarily activating β1 receptor.

In Vitro Activation of Human Adrenergic Receptors and Trace Amine-Associated Receptor 1 by Phenethylamine Analogues Present in Food Supplements

Pre-workout supplements are popular among sport athletes and overweight individuals. Phenethylamines (PEAs) and alkylamines (AA) are widely present in these supplements. Although the health effects of these analogues are not well understood yet, they are hypothesised to be agonists of adrenergic (ADR) and trace amine-associated receptors (TAARs). Therefore, we aimed to pharmacologically characterise these compounds by investigating their activating properties of ADRs and TAAR1 in vitro. The potency and efficacy of the selected PEAs and AAs was studied by using cell lines overexpressing human ADRα1A/α1B/α1D/α2a/α2B/β1/β2 or TAAR1. Concentration-response relationships are expressed as percentages of the maximal signal obtained by the full ADR agonist adrenaline or the full TAAR1 agonist phenethylamine. Multiple PEAs activated ADRs (EC50 = 34 nM-690 µM; Emax = 8-105%). Almost all PEAs activated TAAR1 (EC50 = 1.8-92 µM; Emax = 40-104%). Our results reveal the pharmacological profile of PEAs and AAs that are often used in food supplements. Several PEAs have strong agonistic properties on multiple receptors and resemble potencies of the endogenous ligands, indicating that they might further stimulate the already activated sympathetic nervous system in exercising athletes via multiple mechanisms. The use of supplements containing one, or a combination of, PEA(s) may pose a health risk for their consumers.

Iranian traditional medicinal plants for management of chronic heart failure: A review

Chronic heart failure is a public health problem with a high prevalence worldwide and an important topic in clinical cardiology. Despite of advances in the drug treatment strategy for heart failure, the number of deaths from this condition continues to rise. It will be a renewed focus on preventing heart failure using proven and perhaps novel drugs. Management will also focus on comorbid conditions that may influence the progression of the disease. Traditional medicine has a potential to introduce different approaches for treatment of some disorders. We here reviewed top medicinal plants, according to traditional medicine to experimental studies, and their potency for the treatment of chronic heart failure based on the evidence of their functions.

A review of citrus plants as functional foods and dietary supplements for human health, with an emphasis on meta-analyses, clinical trials, and their chemical composition

Fruits, flowers, leaves, essential oils, hydrosols, and juices of citrus spp. Are utilized to prepare various forms of food products. Along with their nutritional values, in the health industry, different parts of the plants of the citrus genus have been used as supplements or remedies to prevent or control diseases. This review focused on reported meta-analyses and clinical trials on the health benefits of citrus plants as functional foods. Also, chemical compounds of various citrus species were reviewed. The following information sources were used for data collection: Google Scholar, the Web of Science, Scopus, and PubMed. Various keywords, including "citrus AND chemical compounds," "citrus AND phytochemicals," "citrus species," "citrus AND meta-analysis," "nutritional and therapeutical values of citrus spp.," "clinical trials AND citrus," "clinical trials AND Rutaceae," "health benefits of citrus spp.," "citrus edible or non-edible applications," and scientific names of the citrus plants were utilized to collect data for the review. The scientific name and common name of all twenty-eight citrus species, along with any of the above keywords, were also searched in the mentioned databases. Scientific papers and data sources were sought to review and discuss the citrus plant's nutritional and therapeutic importance. Several meta-analyses and clinical trials have reported beneficial effects of citrus spices on a variety of cancer risks, cardiovascular risk factors, neurologic disorders, urinary tract conditions, and gastrointestinal tract conditions. They have shown anxiolytic, antimicrobial, and pain-alleviating effects. Some of them can be helpful in managing obesity and cardiovascular risk factors.

Profound Hyperthermia Associated With Fentanyl and Cocaine Use With Suspected Synephrine Adulteration

BACKGROUND

Although hyperthermia is described after cocaine intoxication, the two hyperthermic cases discussed were unusual in severity and duration for cocaine alone. Synephrine was found in biological samples of these patients in high concentrations and was suspected to be an adulterant in illicitly obtained drugs.

CASE REPORT

Two patients presented to a tertiary care university hospital within 2 days of each other after recreational drug use with delayed and protracted hyperthermia. Synephrine was later found in high concentrations in biological samples as an unexpected drug adulterant. The first patient's presentation came with delayed recognition of hyperthermia and implementation of aggressive cooling measures; he entered multisystem organ failure with prolonged intensive care unit stay and significant morbidity. The second patient's hyperthermia was recognized promptly, and she received early, aggressive cooling, including deep sedation and ice water submersion. She left against medical advice from the hospital at her baseline 3 days after presentation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Synephrine is a suspected adulterant that may be associated with profound hyperthermia. Early recognition of drug overdose and working knowledge of common adulterants can facilitate early targeted management, such as aggressive cooling measures, which may prevent morbidity and mortality.

Phytochemical Profiles and Biological Studies of Selected Botanical Dietary Supplements Used in the United States

Based on their current wide bioavailability, botanical dietary supplements have become an important component of the United States healthcare system, although most of these products have limited scientific evidence for their use. The most recent American Botanical Council Market Report estimated for 2020 a 17.3% increase in sales of these products when compared to 2019, for a total sales volume of $11,261 billion. The use of botanical dietary supplements products in the United States is guided by the Dietary Supplement Health and Education Act (DSHEA) from 1994, enacted by the U.S. Congress with the aim of providing more information to consumers and to facilitate access to a larger number of botanical dietary supplements available on the market than previously. Botanical dietary supplements may be formulated for and use only using crude plant samples (e.g., plant parts such as the bark, leaves, or roots) that can be processed by grinding into a dried powder. Plant parts can also be extracted with hot water to form an "herbal tea." Other preparations of botanical dietary supplements include capsules, essential oils, gummies, powders, tablets, and tinctures. Overall, botanical dietary supplements contain bioactive secondary metabolites with diverse chemotypes that typically are found at low concentration levels. These bioactive constituents usually occur in combination with inactive molecules that may induce synergy and potentiation of the effects observed when botanical dietary supplements are taken in their different forms. Most of the botanical dietary supplements available on the U.S. market have been used previously as herbal remedies or as part of traditional medicine systems from around the world. Their prior use in these systems also provides a certain level of assurance in regard to lower toxicity levels. This chapter will focus on the importance and diversity of the chemical features of bioactive secondary metabolites found in botanical dietary supplements that are responsible for their applications. Many of the active principles of botanical dietary substances are phenolics and isoprenoids, but glycosides and some alkaloids are also present. Biological studies on the active constituents of selected botanical dietary supplements will be discussed. Thus, the present chapter should be of interest for both members of the natural products scientific community, who may be performing development studies of the products available, as well as for healthcare professionals who are directly involved in the analysis of botanical interactions and evaluation of the suitability of botanical dietary supplements for human consumption.

The Safety and Efficacy of Citrus aurantium (Bitter Orange) Extracts and p-Synephrine: A Systematic Review and Meta-Analysis

Synephrine has been used to promote weight loss; however, its safety and efficacy have not been fully established. The goals of our study were to give an overview of the safety and efficacy of p-synephrine, to systematically evaluate its efficacy regarding weight loss and to assess its safety, focusing on its cardiovascular side effects in a meta-analysis. PubMed, the Cochrane Library, Web of Science and Embase were searched for relevant studies. Only placebo-controlled, human clinical trials with synephrine intervention were included in the meta-analysis. The meta-analysis was reported according to the PRISMA guidelines using the PICOS format and taking into account the CONSORT recommendations. Altogether, 18 articles were included in the meta-analysis. Both systolic and diastolic blood pressure (DBP) increased significantly after prolonged use (6.37 mmHg, 95% CI: 1.02–11.72, p = 0.02 and 4.33 mmHg, 95% CI: 0.48–8.18, p = 0.03, respectively). The weight loss in the synephrine group was non-significant after prolonged treatment, and it did not influence body composition parameters. Based on the analyzed clinical studies, synephrine tends to raise blood pressure and heart rate, and there is no evidence that synephrine can facilitate weight loss. Further studies are needed to confirm evidence of its safety and efficacy.

Effects of p-Synephrine during Exercise: A Brief Narrative Review

The p-synephrine is the principal phytochemical found in bitter orange (Citrus aurantium). This substance is widely included in dietary supplements for weight loss/body fat reduction due to its potential benefits of increasing fat oxidation. For years, p-synephrine-containing dietary supplements have been marketed without proper knowledge of their true effectiveness to enhance fat utilization, especially when combined with exercise. However, the effects of p-synephrine on fat oxidation during exercise have been investigated in the last few years. The aim of the current discussion is to summarize the evidence on the effects of p-synephrine intake on fat oxidation and performance during exercise. Previous investigations have demonstrated that the acute intake of p-synephrine does not modify running sprint performance, jumping capacity, or aerobic capacity. However, the acute intake of p-synephrine, in a dose of 2-3 mg/kg of body mass, has been effective to enhance the rate of fat oxidation during incremental and continuous exercise. This effect has been observed in a range of exercise workloads between 30% and 80% of peak oxygen uptake (VO_2peak). The p-synephrine has the ability to increase the maximal rate of fat oxidation during exercise of increasing intensity without affecting the workload at which maximal fat oxidation is obtained (Fatmax). The effect of p-synephrine on fat oxidation is normally accompanied by a concomitant reduction of carbohydrate utilization during exercise, without modifying the energy expended during exercise. The shifting in substrate oxidation is obtained without any effect on heart rate during exercise and the prevalence of adverse effects is negligible. Thus, the acute use of p-synephrine, or p-synephrine-containing products, might offer some benefits for those individuals seeking higher fat utilization during exercise at low to moderate intensities. However, more research is still necessary to determine if the effect of p-synephrine on fat oxidation during exercise is maintained with chronic ingestion, in order to ascertain the utility of this substance in conjunction with exercise programs to produce an effective body fat/weight loss reduction.

p-Synephrine, the main protoalkaloid of Citrus aurantium, raises fat oxidation during exercise in elite cyclists

The aim of this study was to investigate the acute effects of p-synephrine ingestion on substrate oxidation during exercise in elite cyclists. Fifteen elite cyclists volunteered to participate in a double blind, crossover, randomized and placebo-controlled experimental trial. During two different trials, participants either ingested a placebo (cellulose) or 3 mg/kg of p-synephrine. After 60 min for substances absorption, participants performed an incremental maximal cycle ergometer test until volitional fatigue (25 W/min). Breath-by-breath gas exchange data was continuously recorded during the entire test to estimate energy expenditure, carbohydrate oxidation, and fat oxidation rates by stoichiometric equations. Heart rate was continuously measured by using a heart rate monitor. The ingestion of p-synephrine had no significant effects on energy expenditure (F = 0.71, P = 0.40) or heart rate (F = 0.66, P = 0.43) during exercise. However, there was a main effect of p-synephrine to increase the rate of fat oxidation over the placebo (F = 5.1, P = 0.04) and the rate of fat oxidation was higher with p-synephrine in the following loads: 45 ± 2%, 51 ± 3%, 62 ± 3%, 67 ± 4%, 79 ± 5% and 85 ± 5% of the maximum wattage obtained in the test (all P < 0.05). The ingestion of p-synephrine did not modify the maximal rate of fat oxidation during the ramp test (mean value; 95%CI =  0.91; 0.79-1.03 vs 1.01; 0.91-1.11 g/min, respectively, P = 0.06) nor the exercise intensity at which maximal fat oxidation was achieved (i.e. Fatmax =  49; 48-53 vs 50; 47-51% Wmax, P = 0.52). Acute p-synephrine ingestion moved the fat oxidation-exercise intensity curve upwards during an incremental cycling test without affecting Fatmax.

p-Synephrine, ephedrine, p-octopamine and m-synephrine: Comparative mechanistic, physiological and pharmacological properties

Confusion and misunderstanding exist regarding the lack of cardiovascular and other adverse health effects of p-synephrine and p-octopamine relative to ephedrine and m-synephrine (phenylephrine) which are known for their effects on the cardiovascular system. These four molecules have some structural similarities. However, the structural and stereochemical differences of p-synephrine and p-octopamine as related to ephedrine and m-synephrine result in markedly different adrenergic receptor binding characteristics as well as other mechanistic differences which are reviewed. p-Synephrine and p-octopamine exhibit little binding to α-1, α-2, β-1 and β-2 adrenergic receptors, nor are they known to exhibit indirect actions leading to an increase in available levels of endogenous norepinephrine and epinephrine at commonly used doses. The relative absence of these mechanistic actions provides an explanation for their lack of production of cardiovascular effects at commonly used oral doses as compared to ephedrine and m-synephrine. As a consequence, the effects of ephedrine and m-synephrine cannot be directly extrapolated to p-synephrine and p-octopamine which exhibit significantly different pharmacokinetic, and physiological/pharmacological properties. These conclusions are supported by human, animal and in vitro studies that are discussed.

Praiseworthiness and Motivational Enhancement: 'No Pain, No Praise'?

The view that exertion of effort determines praiseworthiness for an achievement is implicit in 'no pain, no praise'-style objections to biomedical enhancement. On such views, if enhancements were to reduce the need for effort, agents would be less praiseworthy. Motivational enhancement would appear to be the most problematic in this respect, given that increased motivation reduces the need for agents to rally themselves and to exert effort in activity. We use the prospect of motivational enhancement to re-examine the grounds of praiseworthiness for achievements. We consider the place of effort amongst the grounds for praise, whether effort exhausts these grounds, and how they can be better specified. We argue that praiseworthiness depends on (i) the voluntariness and strength of the agent's committed pursuit of a valuable end (E), (ii) the costliness of the committed pursuit of E, and (iii) the value of E. Effort is just one cost amongst many, and costs of activities can be traded-off. Motivational enhancement reduces the praise due to an agent only when it reduces the net cost to the agent (without strengthening the voluntary commitment). We emphasize the importance of a diachronic perspective on active agency for praiseworthiness, to include training, prior planning, and deliberate strategies to overcome weakness of will, even where this reduces the need for effort.

Effects of p-Synephrine and Caffeine Ingestion on Substrate Oxidation during Exercise

PURPOSE

Caffeine and p-synephrine are substances usually included in commercially available products for weight loss because of their purported thermogenic effects. However, scientific information is lacking about the effects of combining these substances on substrate oxidation during exercise. The purpose of this investigation was to determine the isolated and combined effects of p-synephrine and caffeine on fat oxidation rate during exercise.

METHODS

In a double-blind randomized experiment, 13 healthy subjects participated in four experimental trials after the ingestion of a capsule containing a placebo, 3 mg·kg of caffeine, 3 mg·kg of p-synephrine, or the combination of these doses of caffeine and p-synephrine. Energy expenditure and substrate oxidation rates were measured by indirect calorimetry during a cycle ergometer ramp test from 30% to 90% of V˙O2max.

RESULTS

In comparison with the placebo, the ingestion of caffeine, p-synephrine, or p-synephrine + caffeine did not alter total energy expenditure or heart rate during the whole exercise test. However, the ingestion of caffeine (0.44 ± 0.15 g·min, P = 0.03), p-synephrine (0.43 ± 0.19 g·min, P < 0.01), and p-synephrine + caffeine (0.45 ± 0.15 g·min, P = 0.02) increased the maximal rate of fat oxidation during exercise when compared with the placebo (0.30 ± 0.12 g·min). The exercise intensity that elicited maximal fat oxidation was similar in all trials (~46.2% ± 10.2% of V˙O2max).

CONCLUSION

Caffeine, p-synephrine, and p-synephrine + caffeine increased the maximal rate of fat oxidation during exercise compared with a placebo, without modifying energy expenditure or heart rate. However, the coingestion of p-synephrine and caffeine did not present an additive effect to further increase fat oxidation during exercise.

Analysis of the cytotoxic, genotoxic, mutagenic, and pro-oxidant effect of synephrine, a component of thermogenic supplements, in human hepatic cells in vitro

Thermogenic supplements containing synephrine (SN) are widely used to weight loss. SN is a proto-alkaloid naturally found in the bark of immature fruits of Citrus aurantium (bitter orange) that has been added to thermogenic supplements due to its chemical and pharmacological similarity with adrenergic amines, such as ephedrine and amphetamines. Although orally ingested SN is mainly metabolized in the liver, it remains unclear whether it affects the redox status and genetic material of human hepatic cells. The present study aims to examine whether SN affects cell viability, cell cycle, redox balance, genomic stability, and expression of the DNA damage response (DDR)-related genes ATM, ATR, CHEK1, CHECK2, TP53, and SIRT1 in HepG2 cells - used as in vitro hepatocyte model. SN induced overproduction of intracellular reactive oxygen species (ROS) after 6 h of treatment with the three concentrations tested (2, 20 and 200 μM). After 24 h of treatment, SN at 200 μM induced intracellular ROS overproduction and exerted cytostatic effects, while SN at 20 and 200 μM increased the levels of GPx and GSH. SN was not cytotoxic (2-5000 μM), genotoxic, and mutagenic and did not alter the expression of DDR-related genes (2-200 μM), indicating that the fast/specific SN metabolization and upregulation of antioxidant defense components to detoxify intracellular ROS were sufficient to prevent intracellular damage in HepG2 cells. In conclusion, SN showed no cytotoxic, genotoxic, and mutagenic potential at relevant concentrations for thermogenic users in human hepatic cells in vitro, although, it plays pro-oxidative action, and cytostatic effects. Taken together, our results suggest that other investigations about the hazard absence of this thermogenic compound should be performed.

The influence of citrus aurantium and caffeine complex versus placebo on the cardiac autonomic response: a double blind crossover design

Background

The purpose of this study was to examine the resting cardiac autonomic nervous system’s response to the ingestion of a complex containing Citrus aurantium + Caffeine (CA + C) and its influence on recovery following a high-intensity anaerobic exercise bout in habitual caffeine users.

Methods

Ten physically active males (25.1 ± 3.9 years; weight 78.71 ± 9.53 kg; height 177.2 ± 4.6 cm; body fat 15.5 ± 3.13%) participated in this study, which consisted of two exhaustive exercise protocols in a randomized crossover design. On each visit the participants consumed either a CA + C (100 mg of CA and 100 mg of C) or placebo (dextrose) capsule. After consumption, participants were monitored throughout a 45-min ingestion period, then completed a repeated Wingate protocol, and were then monitored throughout a 45-min recovery period. Cardiac autonomic function (Heart Rate (HR) and Heart Rate Variability (HRV)) and plasma epinephrine (E) and norepinephrine (NE) were taken at four different time points; Ingestion period: baseline (I1), post-ingestion period (I2); Recovery period: immediately post-exercise (R1), post-recovery period (R2). Heart rate variability was assessed in 5-min increments.

Results

A repeated measures ANOVA revealed significant time-dependent increases in HR, sympathetic related markers of HRV, and plasma E and NE at I2 only in the CA + C trial (p < 0.05); however, no meaningful changes in parasympathetic markers of HRV were observed. Participants recovered in a similar time-dependent manner in all markers of HRV and catecholamines following the PLA and CA + C trials.

Conclusion

The consumption of CA + C results in an increase of sympathetic activity during resting conditions without influencing parasympathetic activity. CA + C provides no influence over cardiac autonomic recovery.

Acute hematological and mood perception effects of bitter orange extract (p-synephrine) consumed alone and in combination with caffeine: A placebo-controlled, double-blind study

The purpose of this study was to examine acute hematological and mood perception responses to supplementation with p-synephrine alone and in combination with caffeine during quiet sitting. Sixteen subjects visited the laboratory on 6 occasions and were given (in randomized double-blind manner) 103-mg p-synephrine (S), 233-mg caffeine + 104-mg p-synephrine, 240-mg caffeine, 337-mg caffeine + 46-mg p-synephrine, 325-mg caffeine, or a placebo (PL). The subjects sat quietly for 3 hr while completing mood state questionnaires every 30 min. Venous blood samples were collected at baseline (pre) and 3 hr (post) to determine immune, lipid, and chemistry panels. Compared with PL, no significant supplement differences were observed during the S trial with the exception of differential time effects seen in hematocrit (decrease in PL, no change in S), triglycerides and very low-density lipoproteins (no changes in PL, significant decreases in S), and iron (no change in PL, significant elevation in S). Supplements containing caffeine showed increased feelings of attention, excitement, energy, and vigor. These data indicate that consumption of 103-mg p-synephrine does not negatively impact acute blood parameters, does not augment the effects of caffeine, or produce stimulant-like perceptual mood effects.

Safety evaluation of p-synephrine following 15 days of oral administration to healthy subjects: A clinical study

Extracts of bitter orange (BOE, Citrus aurantium L.) and its primary protoalkaloid p-synephrine are extensively consumed as dietary supplements. p-Synephrine is also present in foods and juices prepared from various Citrus species. The safety of p-synephrine has been questioned as a result of structural similarities with ephedrine. This study assessed the cardiovascular (stimulant) and hemodynamic effects of BOE (49 mg p-synephrine) daily given to 16 healthy subjects for 15 days in a placebo-controlled, cross-over, double-blinded study. A physical evaluation by a cardiologist, as well as heart rates, blood pressures, and electrocardiograms were determined, and blood samples were drawn at baseline, and Days 5, 10, and 15. Serum levels for caffeine and p-synephrine were measured at 1 and 2 weeks. Subjects completed a 10-item health and metabolic questionnaire at baseline and on Day 15. No significant changes occurred in heart rate, electrocardiograms, systolic blood or diastolic pressures, blood cell counts, or blood chemistries in either the control or p-synephrine treated groups at any time point. No adverse effects were reported in response to the bitter orange (p-synephrine). Caffeine consumed by the participants varied markedly. Under these experimental conditions, BOE and p-synephrine were without stimulant (cardiovascular) and adverse effects.

Safety, Efficacy, and Mechanistic Studies Regarding Citrus aurantium (Bitter Orange) Extract and p-Synephrine

Citrus aurantium L. (bitter orange) extracts that contain p-synephrine as the primary protoalkaloid are widely used for weight loss/weight management, sports performance, appetite control, energy, and mental focus and cognition. Questions have been raised about the safety of p-synephrine because it has some structural similarity to ephedrine. This review focuses on current human, animal, in vitro, and mechanistic studies that address the safety, efficacy, and mechanisms of action of bitter orange extracts and p-synephrine. Numerous studies have been conducted with respect to p-synephrine and bitter orange extract because ephedra and ephedrine were banned from use in dietary supplements in 2004. Approximately 30 human studies indicate that p-synephrine and bitter orange extracts do not result in cardiovascular effects and do not act as stimulants at commonly used doses. Mechanistic studies suggest that p-synephrine exerts its effects through multiple actions, which are discussed. Because p-synephrine exhibits greater adrenergic receptor binding in rodents than humans, data from animals cannot be directly extrapolated to humans. This review, as well as several other assessments published in recent years, has concluded that bitter orange extract and p-synephrine are safe for use in dietary supplements and foods at the commonly used doses. Copyright © 2017 The Authors Phytotherapy Research Published by John Wiley & Sons Ltd.

Combined Effects of Phytochemicals and Exercise on Fatty Acid Oxidation

[Purpose]

The purpose of this review is to discuss current views regarding the acute effects of phytochemicals, exercise, and exercise plus phytochemicals on fatty acid oxidation.

[Methods]

Data acquired from human and animal studies were comprehensively assessed to determine the single and combined effects of phytochemicals and exercise on fatty acid oxidation. In addition, underlying mechanisms associated with those conditions that may contribute to the regulation of fat metabolism are discussed.

[Results]

Although not all phytochemicals are effective at increasing fatty acid oxidation, some significantly improve the rate of fatty acid oxidation at rest. In addition, dietary supplementation of p-synephrine, catechins, or anthocyanins in combination with moderately intense exercise has the additive effect of increasing fatty acid oxidation, but not total energy expenditure during exercise.

[Conclusion]

The data reported from current reviewed studies suggest positive outcomes regarding facilitation of fatty acid oxidation from the combined effects of certain phytochemicals with exercise. Those data provide new insight for developing a strategy to boost fat loss and control weight in obese patients.

Acute p-synephrine ingestion increases fat oxidation rate during exercise

AIMS

p-Synephrine is a protoalkaloid widely used in dietary supplements for weight management because of its purported thermogenic effects. However, there is a lack of scientific information about its effectiveness to increase fat metabolism during exercise. The purpose of this investigation was to determine the effects of an acute ingestion of p-synephrine on fat oxidation at rest and during exercise.

METHODS

In a double-blind, randomized and counterbalanced experimental design, 18 healthy subjects performed two acute experimental trials after the ingestion of p-synephrine (3 mg kg(-1) ) or after the ingestion of a placebo (cellulose). Energy expenditure and fat oxidation rates were measured by indirect calorimetry at rest and during a cycle ergometer ramp exercise test (increases of 25 W every 3 min) until volitional fatigue.

RESULTS

In comparison with the placebo, the ingestion of p-synephrine did not change energy consumption (1.6 ± 0.3 vs. 1.6 ± 0.3 kcal min(-1) ; P = 0.69) or fat oxidation rate at rest (0.08 ± 0.02 vs. 0.10 ± 0.04 g min(-1) ; P = 0.15). However, the intake of p-synephrine moved the fat oxidation-exercise intensity curve upwards during the incremental exercise (P < 0.05) without affecting energy expenditure. Moreover, p-synephrine increased maximal fat oxidation rate (0.29 ± 0.15 vs. 0.40 ± 0.18 g min(-1) ; P = 0.01) during exercise although it did not affect the intensity at which maximal fat oxidation was achieved (55.8 ± 7.7 vs. 56.7 ± 8.2% VO2peak ; P = 0.51).

CONCLUSIONS

The acute ingestion of p-synephrine increased the fat oxidation rate while it reduced the carbohydrate oxidation rate when exercising at low-to-moderate exercise intensities.

Acute consumption of p-synephrine does not enhance performance in sprint athletes

P-Synephrine is a protoalkaloid widely used as an ergogenic aid in sports. This substance has been included in the World Anti-Doping Agency monitoring program, although scientific information about its effects on performance and athletes’ well-being is scarce. The purpose of this investigation was to determine the effectiveness of p-synephrine to increase performance in sprint athletes. In a randomized and counterbalanced order, 13 experienced sprinters performed 2 acute experimental trials after the ingestion of p-synephrine (3 mg·kg−1) or after the ingestion of a placebo (control trial). Forty-five minutes after the ingestion of the substances, the sprinters performed a squat jump, a countermovement jump, a 15-s repeated jump test, and subsequently performed 60-m and 100-m simulated sprint competitions. Self-reported questionnaires were used to assess side-effect prevalence. In comparison with the control trial, the ingestion of p-synephrine did not change countermovement jump height (37.4 ± 4.2 vs 36.7 ± 3.3 cm, respectively; P = 0.52), squat jump height (34.4 ± 3.6 vs 33.9 ± 3.7 cm; P = 0.34), or average 15-s repeated jumps height (31.8 ± 4.1 vs 32.2 ± 3.6 cm; P = 0.18). P-Synephrine did not modify maximal running speed during the 60-m (9.0 ± 0.5 vs 9.0 ± 0.4 m·s−1, respectively; P = 0.55) and 100-m sprint competitions (8.8 ± 0.5 vs 8.8 ± 0.5 m·s−1, respectively; P = 0.92). The ingestion of p-synephrine did not alter the prevalence of headache, gastrointestinal discomforts, muscle pain, or insomnia during the hours following the tests. Acute consumption of 3 mg·kg−1 of p-synephrine was ineffective to increase performance in competitive sprint athletes. Moreover, p-synephrine did not increase the occurrence of side effects after the competition.

The effects of supplementation with P-Synephrine alone and in combination with caffeine on resistance exercise performance

BACKGROUND

Little is known concerning the potential ergogenic effects of p-synephrine supplementation. Therefore, the purpose of the present study was to examine the effects of supplementation with p-synephrine alone and in combination with caffeine on free-weight resistance exercise performance.

METHODS

Twelve healthy, college-aged men performed a control (CT) resistance exercise protocol consisting of 6 sets of squats for up to 10 repetitions per set using 80% of their one repetition-maximum (1RM) with 2 min of rest in between sets. Each subject was randomly assigned (in double-blind, balanced manner) to a treatment sequence consisting of use of 3 supplements: p-synephrine (S; 100 mg), p-synephrine + caffeine (SCF; 100 mg of p-synephrine plus 100 mg of caffeine), or a placebo (P). For each supplement treatment (separated by 1 week), subjects consumed the supplement for 3 days prior to each protocol and the morning of each protocol, and subsequently did not consume any supplements for 3 days following (i.e. wash-out period). On each protocol day, subjects reported to the lab at a standard time, consumed a supplement, sat quietly for 45 min, performed the resistance exercise protocol, and sat quietly for 30 min post exercise. Performance (repetition number, force, velocity and power), blood lactate, and ratings of perceived exertion (RPE) data were collected during each protocol.

RESULTS

Supplements SCF and S produced a significantly (P < 0.05) greater number of repetitions performed than CT (by 11.0 ± 8.0%) and P (by 6.0 ± 7.0%) and a 10.6 ± 12.0% greater increase in volume load per protocol than CT and P. Most of the differences were seen during the last 3 sets. Mean power and velocity for all 6 sets were significantly higher in SCF compared to CT and P by ~6.2 ± 8.0%. No supplement effects were observed in RPE or blood lactate, and no adverse side effects were observed or reported.

CONCLUSIONS

S and SCF augmented resistance exercise performance (total repetitions, volume load) without increasing blood lactate or RPE. The addition of caffeine in SCF increased mean power and velocity of squat performance. These results indicate supplementation with S and SCF can enhance local muscle endurance during resistance exercise.

Efficacy and Safety of White Willow Bark (Salix alba) Extracts

Willow bark extract has been used for thousands of years as an anti-inflammatory, antipyretic, and analgesic. In spite of its long history of use, relatively few human and animal studies have been published that confirm anecdotal observations. A small number of clinical studies have been conducted that support the use of willow bark extracts in chronic lower back and joint pain and osteoarthritis. Willow bark extracts also are widely used in sports performance and weight loss products presumably because of anti-inflammatory and analgesic activities, although no human studies have been published that specifically and directly document beneficial effects. In recent years, various in vitro and animal studies have demonstrated that the anti-inflammatory activity of willow bark extract is associated with down regulation of the inflammatory mediators tumor necrosis factor-α and nuclear factor-kappa B. Although willow bark extracts are generally standardized to salicin, other ingredients in the extracts including other salicylates as well as polyphenols, and flavonoids may also play prominent roles in the therapeutic actions. Adverse effects appear to be minimal as compared to non-steroidal anti-inflammatory drugs including aspirin. The primary cause for concern may relate to allergic reactions in salicylate-sensitive individuals.

An evidence-based systematic review of bitter orange (Citrus aurantium) by the Natural Standard Research Collaboration

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.

The action of p-synephrine on hepatic carbohydrate metabolism and respiration occurs via both Ca(2+)-mobilization and cAMP production

Citrus aurantium extracts, which contain large amounts of p-synephrine, are widely used for weight loss purposes and as appetite suppressants. In the liver, C. aurantium (bitter orange) extracts affect hemodynamics, carbohydrate metabolism, and oxygen uptake. The purpose of the present work was to quantify the action of p-synephrine and also to obtain indications about its mechanism of action, a task that would be difficult to accomplish with C. aurantium extracts due to their rather complex composition. The experimental system was the isolated perfused rat liver. p-Synephrine significantly stimulated glycogenolysis, glycolysis, gluconeogenesis, and oxygen uptake. The compound also increased the portal perfusion pressure and the redox state of the cytosolic NAD(+)/NADH couple. A Ca(2+)-dependency for both the hemodynamic and the metabolic effects of p-synephrine was found. p-Synephrine stimulated both cAMP overflow and the initial Ca(2+) release from the cellular stores previously labeled with (45)Ca(2+). The metabolic and hemodynamic actions of p-synephrine were strongly inhibited by α-adrenergic antagonists and moderately affected by β-adrenergic antagonists. The results allow to conclude that p-synephrine presents important metabolic and hemodynamic effects in the liver. These effects can be considered as both catabolic (glycogenolysis) and anabolic (gluconeogenesis), they are mediated by both α- and β-adrenergic signaling, require the simultaneous participation of both Ca(2+) and cAMP, and could be contributing to the overall stimulation of metabolism that usually occurs during weight loss periods.

A 60day double-blind, placebo-controlled safety study involving Citrus aurantium (bitter orange) extract

Bitter orange (Citrus aurantium) extract and its primary protoalkaloid p-synephrine are widely consumed in dietary supplements for weight management and sports performance. p-Synephrine is also present in foods derived from a variety of Citrus species. Bitter orange extract is commonly used in combination with multiple herbal ingredients. Most clinical studies conducted on bitter orange extract alone have involved single doses. The purpose of this study was to assess the safety of bitter orange extract (approximately 49mg p-synephrine) alone or in combination with naringin and hesperidin twice daily given to 25 healthy subjects per group for 60days in a double-blinded, placebo-controlled protocol. No significant changes occurred in systolic or diastolic blood pressures, blood chemistries or blood cell counts in control or p-synephrine treated groups. Small, clinically insignificant differences in heart rates were observed between the p-synephrine plus naringin and hesperidin group and the p-synephrine alone as well as the placebo group. No adverse effects were reported in the three groups. Bitter orange extract and p-synephrine appear to be without adverse effects at a dose of up to 98mg daily for 60days based on the parameters measured.

A review of the human clinical studies involving Citrus aurantium (bitter orange) extract and its primary protoalkaloid p-synephrine

This review summarizes the published as well as unpublished human studies involving Citrus aurantium (bitter orange) extract and its primary protoalkaloid p-synephrine, providing information and an assessment of the safety and efficacy of these widely used products. The results of over 20 studies involving a total of approximately 360 subjects that consumed p-synephrine alone or in combination with other ingredients are reviewed and critiqued. Over 50 % of the subjects involved in these studies were overweight/obese, and approximately two-thirds of these overweight/obese subjects consumed caffeine (132-528 mg/day) in conjunction with p-synephrine (10-53 mg/day). Bitter orange/p-synephrine containing products were consumed for up to 12 weeks. Approximately 44 % of the subjects consumed a bitter orange/p-synephrine only product, while the remainder consumed a complex product that contained multiple ingredients in addition to p-synephrine. In general, bitter orange extract alone (p-synephrine) or in combination with other herbal ingredients did not produce significant adverse events as an increase in heart rate or blood pressure, or alter electrocardiographic data, serum chemistry, blood cell counts or urinalysis. p-Synephrine alone as well as in combination products were shown to increase resting metabolic rate and energy expenditure, and modest increases in weight loss were observed with bitter orange extract/p-synephrine-containing products when given for six to 12 weeks. Longer term studies are needed to further assess the efficacy of these products and affirm their safety under these conditions.

Toxicological effects of a mixture used in weight loss products: p-synephrine associated with ephedrine, salicin, and caffeine

p-Synephrine is an adrenergic amine found in Citrus aurantium L. fruits and has been used for weight loss in dietary supplements. There are commercial products containing this substance associated to caffeine, salicin, and ephedrine. The aim of this study was to evaluate the acute toxicity of this mixture in mice of both sexes. The significative results observed after acute oral administration to male and female mice of 300, 350, and 400 mg/kg total of p-synephrine, ephedrine, salicin, plus caffeine in a 10:4:6:80 w/w ratio included a reduction in locomotor activity and ptosis in all treated groups for both sexes. Seizures were also observed in male (400 mg/kg) and female groups (350 and 400 mg/kg). Gasping and tearing were observed in males. Salivation (400 mg/kg), agitation (350 and 400 mg/kg), and piloerection (all treated groups) were significantly observed only in females. Deaths occurred in males at 350 and 400 mg/kg treated groups and the necropsy showed cardiopulmonary hemorrhage. A reduction in locomotor activity was confirmed through the spontaneous locomotor activity test, in which the number of crossings considerably decreased (P < .01) in all treated groups. The rotarod test showed a decrease in motor coordination at 400 mg/kg. Body temperature decreased significantly (P < .01) in all treated groups compared to controls. The results suggested clear signs of toxicity of p-synephrine, ephedrine, salicin, and caffeine association; this toxicity augments the attentiveness on commercial products containing this mixture, given the expressive number of adverse events related to its utilization.

A review of the receptor-binding properties of p-synephrine as related to its pharmacological effects

Bitter orange (Citrus aurantium) extract and its primary protoalkaloid p-synephrine are used widely in weight loss/weight management and sports performance products. Because of structural similarities, the pharmacological effects of p-synephrine are widely assumed to be similar to those of ephedrine, m-synephrine (phenylephrine), and endogenous amine neurotransmitters as norepinephrine and epinephrine. However, small structural changes result in the receptor binding characteristics of these amines that are markedly different, providing a plausible explanation for the paucity of adverse effects associated with the wide-spread consumption of p-synephrine in the form of dietary supplements as well as in various Citrus foods and juices. This paper summarizes the adrenoreceptor binding characteristics of p-synephrine relative to m-synephrine, norepinephrine, and other amines as related to the observed pharmacological effects.

Effects of p-synephrine alone and in combination with selected bioflavonoids on resting metabolism, blood pressure, heart rate and self-reported mood changes

Bitter orange (Citrus aurantium) extract is widely used in dietary supplements for weight management and sports performance. Its primary protoalkaloid is p-synephrine. Most studies involving bitter orange extract and p-synephrine have used products with multiple ingredients. The current study assessed the thermogenic effects of p-synephrine alone and in conjunction with the flavonoids naringin and hesperidin in a double-blinded, randomized, placebo-controlled protocol with 10 subjects per treatment group. Resting metabolic rates (RMR), blood pressure, heart rates and a self-reported rating scale were determined at baseline and 75 min after oral ingestion of the test products in V-8 juice. A decrease of 30 kcal occurred in the placebo control relative to baseline. The group receiving p-synephrine (50 mg) alone exhibited a 65 kcal increase in RMR as compared to the placebo group. The consumption of 600 mg naringin with 50 mg p-synephrine resulted in a 129 kcal increase in RMR relative to the placebo group. In the group receiving 100 mg hesperidin in addition to the 50 mg p-synephrine plus 600 mg naringin, the RMR increased by 183 kcal, an increase that was statistically significant with respect to the placebo control (p<0.02). However, consuming 1000 mg hesperidin with 50 mg p-synephrine plus 600 mg naringin resulted in a RMR that was only 79 kcal greater than the placebo group. None of the treatment groups exhibited changes in heart rate or blood pressure relative to the control group, nor there were no differences in self-reported ratings of 10 symptoms between the treatment groups and the control group. This unusual finding of a thermogenic combination of ingredients that elevated metabolic rates without corresponding elevations in blood pressure and heart-rates warrants longer term studies to assess its value as a weight control agent.

The safety of Citrus aurantium (bitter orange) and its primary protoalkaloid p-synephrine

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.

Effect of acute administration of an herbal preparation on blood pressure and heart rate in humans

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.

Isopropylnorsynephrine is a stronger lipolytic agent in human adipocytes than synephrine and other amines present in Citrus aurantium

The weight loss observed in consumers of extracts of Citrus aurantium (bitter orange) has been tentatively attributed to the lipolytic and thermogenic effects of the alkaloids abundant in the unripe fruit. Synephrine, octopamine, tyramine, and other alkaloids have been repeatedly identified and quantified in Citrus members of the Rutaceae family or in their extracts incorporated in dietary supplements for weight management. However, there are only scarce reports on their lipolytic action. This study aimed at comparing the acute lipolytic activity of synephrine, octopamine, tyramine, and N-methyltyramine in rat and human adipocytes. Maximal response to the prototypical β-adrenergic agonist isoprenaline was taken as reference in both species. In rat, octopamine was slightly more active than synephrine while tyramine and N-methyl tyramine did not stimulate-and even inhibited-lipolysis. In human adipocytes, none of these amines stimulated lipolysis when tested up to 10 μg/ml. At higher doses (≥100 μg/ml), tyramine and N-methyl tyramine induced only 20% of the maximal lipolysis and exhibited antilipolytic properties. Synephrine and octopamine were partially stimulatory at high doses. Since synephrine is more abundant than octopamine in C. aurantium, it should be the main responsible for the putative lipolytic action of the extracts claimed to mitigate obesity. Noteworthy, their common isopropyl derivative, isopropylnorsynephrine (also named isopropyloctopamine or betaphrine), was clearly lipolytic: active at 1 μg/ml and reproducing more than 60% of isoprenaline maximal effect in human adipocytes. This compound, not detected in C. aurantium, and which has few reported adverse effects to date, might be useful for in vivo triglyceride breakdown.

(R,R)-Disynephrine ether bis-(hydrogen sulfate)

THE ASYMMETRIC UNIT OF THE TITLE COMPOUND [SYSTEMATIC NAME: (R,R)-2,4-bis-(4-hydroxy-phen-yl)-N,N'-dimethyl-3-oxapentane-1,5-diammonium bis-(hydrogen sulfate)], C(18)H(26)N(2)O(3) (2+)·2HSO(4) (-), contains one half-cation and one hydrogen sulfate anion. The cation has crystallographically imposed twofold symmetry with the rotation axis passing through the central ether O atom. Hydrogen bonds between the hydr-oxy group and amine H atoms of the cation to two hydrogen sulfate anions link the three ions in a ring motif. A three-dimensional network is accomplished by additional O-H⋯O hydrogen bonds between the anions and by N-H⋯O hydrogen bonds between the cations. Disorder with equally occupied sites affects the H-atom position in the anion.