Ephedra-Free Is Not Danger-Free

Clinically Relevant Herb-Drug Interactions: A 30-Year Historical Assessment

The Dietary Supplement Health and Education Act, a legislative measure ushering in a novel class of complementary healthcare products known as dietary supplements, will mark its 30th anniversary in October 2024. Over this 30-year period, dietary supplement usage evolved from a few hundred products made up mostly of vitamins, minerals, and select botanical extracts to more than 75,000 single- and multi-ingredient products that are now regular staples in the American healthcare system and used by half of all U.S. consumers. One of the fastest-growing segments of the dietary supplement market during this 3-decade interval has been those products formulated with botanical extracts. Coincident with the growing popularity of botanical dietary supplements (BDS) has been their concomitant ingestion with conventional prescription medications. BDS are complex mixtures of phytochemicals oftentimes exhibiting complex pharmacology. Formulated as concentrated phytochemical extracts, BDS are vehicles for a host of plant secondary metabolites rarely encountered in the typical diet. When taken with prescription drugs, BDS may give rise to clinically significant herb-drug interactions (HDI). Pharmacodynamic HDI describe interactions between phytochemicals and conventional medications at the drug receptor level, while pharmacokinetic HDI stem from phytochemical-mediated induction and/or inhibition of human drug metabolizing enzymes and/or transporters. This review summarizes BDS identified over the last 30 years that pose clinically relevant HDI and whose mechanisms are either pharmacodynamically or pharmacokinetically mediated.

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.

Blood Pressure and Heart Rate Effects Following a Single Dose of Bitter Orange

Background:

The ingredients of numerous “ephedra-free” dietary supplements used for weight loss include bitter orange, which contains sympathomimetic alkaloids such as synephrine. Due to the similarity in chemical structure to ephedrine and the potential sympathomimetic effects of synephrine, it is hypothesized that bitter orange may increase blood pressure (BP) and heart rate (HR).

Objective:

To determine the effects on BP and HR after a single dose of bitter orange in healthy adults.

Methods:

In a prospective, randomized, double-blind, placebo-controlled, crossover study, 15 young, healthy, adult subjects received either a single dose of Nature's Way Bitter Orange—a 900 mg dietary supplement extract standardized to 6% synephrine—or matching placebo, with a one week washout period. Systolic BP (SBP), diastolic BP (DBP), and HR were measured at baseline and every hour for 6 hours after administration.

Results:

SBP after bitter orange was significantly increased versus placebo at hours 1–5 (p < 0.0001); the peak difference was 7.3 ± 4.6 mm Hg. Although the baseline DBP was higher than after administration of both placebo and bitter orange, DBP after bitter orange was significantly increased versus placebo at hours 4 and 5 (p ≤ 0.02); the peak difference was 2.6 ± 3.8 mm Hg. HR was significantly increased after bitter orange versus placebo for hours 2–5 (p < 0.01); the peak difference was 4.2 ± 4.5 beats/min.

Conclusions:

SBP, DBP, and HR were higher for up to 5 hours after a single dose of bitter orange versus placebo in young, healthy adults.

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.

Assessment of herbal weight loss supplement counseling provided to patients by pharmacists and nonpharmacists in community settings

OBJECTIVE

To assess the extent of appropriate counseling provided to patients by pharmacists and nonpharmacists in retail settings regarding herbal dietary supplements for weight loss.

DESIGN

Descriptive, exploratory, nonexperimental study.

SETTING

Phoenix, AZ, metropolitan area, from June 2008 to January 2009.

PARTICIPANTS

Pharmacists and nonpharmacists (e.g., cashiers, sales clerks, pharmacy technicians) working in retail locations selling herbal dietary supplements (e.g., grocery stores, health food stores, pharmacies).

INTERVENTION

Investigators posing as patients sought herbal weight loss supplement product recommendations and counseling on potential safety, drug interaction, and adverse effect issues from pharmacists or nonpharmacists.

MAIN OUTCOME MEASURES

Level of knowledge regarding safety and efficacy of herbal dietary supplements for weight loss.

RESULTS

52 sites were visited, and 27 unique product recommendations were given. In general, counseling provided to investigators/patients by pharmacists versus nonpharmacists varied significantly (P < 0.05) except when participants were asked about expected weight loss (P = 0.39) or use of herbal supplements during pregnancy (P = 0.07) and breast-feeding (P = 0.48). Pharmacists were more reluctant to recommend herbal products for weight loss than nonpharmacists and tended to question the safety and/or efficacy of these products or refer the patient to an alternate health care provider.

CONCLUSION

The counseling that investigators/patients received regarding herbal products for weight loss in various retail settings from both pharmacists and non-pharmacists varied greatly. Efforts are needed from the medical and herbal communities to ensure that patients are adequately informed about herbal products at the point of purchase.

Developmental toxicity of Citrus aurantium in rats

BACKGROUND

Ephedra was commonly used in herbal products marketed for weight loss until safety concerns forced its removal from products. Even before the ban, manufacturers had begun to replace ephedra with other compounds, including Citrus aurantium, or bitter orange. The major component in the bitter orange extract is synephrine which is chemically similar to ephedrine. The purpose of this study was to determine if relatively pure synephrine or synephrine present as a constituent of a bitter orange extract produced developmental toxicity in rats.

METHOD

Sprague-Dawley rats were dosed daily by gavage with one of several different doses of synephrine from one of two different extracts. Caffeine was added to some doses. Animals were sacrificed on GD 21, and fetuses were examined for the presence of various developmental toxic endpoints.

RESULTS AND CONCLUSION

At doses up to 100 mg synephrine/kg body weight, there were no adverse effects on embryolethality, fetal weight, or incidences of gross, visceral, or skeletal abnormalities. There was a decrease in maternal weight at 50 mg synephrine/kg body weight when given as the 6% synephrine extract with 25 mg caffeine/kg body weight; there was also a decrease in maternal weight in the caffeine only group. This decrease in body weight may have been due to decreased food consumption which was also observed in these two groups. Overall, doses of up to 100 mg synephrine/kg body weight did not produce developmental toxicity in Sprague-Dawley rats.

Dietary supplements and military operations: caution is advised

We describe the case of a 32-year-old soldier who presented with acute organic psychosis during an operational tour to Iraq. This was precipitated by excessive consumption of caffeine coupled with additional use of oral nutritional stimulants. Her biochemical profile was compounded by the additional use of exogenous creatine. We present a brief overview of the issue of exercise supplementation and highlight some of the potential problems and clinical issues surrounding their use. This has important implications for both serving soldiers and the wider medical community.

The acute effects of the thermogenic supplement Meltdown on energy expenditure, fat oxidation, and hemodynamic responses in young, healthy males

The purpose of this study was to evaluate the effects of a thermogenic supplement, Meltdown, on energy expenditure, fat oxidation, and hemodynamics before and after maximal treadmill exercise. In a double-blind, randomized, placebo-controlled, cross-over design, 12 male participants underwent two testing sessions after consuming either the Meltdown or placebo supplement. While in a fasted state, participants rested for one hour, orally ingested either Meltdown or placebo and rested for another hour, performed a maximal treadmill exercise test, and then rested for another hour. Throughout the testing protocol, resting energy expenditure (REE) and respiratory exchange ratio (RER) were assessed. In addition, heart rate (HR) and blood pressure (BP) were assessed before and after exercise. Meltdown increased REE significantly more than placebo at 45 min (1.44 ± 0.25 vs. 1.28 ± 0.23 kcal/min; p = 0.003), 60 min (1.49 ± 0.28 vs. 1.30 ± 0.22 kcal/min; p = 0.025), and 120 min (1.51 ± 0.26 vs. 1.33 ± 0.27 kcals/min; p = 0.014) post-ingestion. Meltdown significantly decreased RER at 30 min (0.84 ± 0.03 vs. 0.91 ± 0.04; p = 0.022) and 45 min post-ingestion (0.82 ± 0.04 vs. 0.89 ± 0.05; p = 0.042), and immediately post-exercise (0.83 ± 0.05 vs. 0.90 ± 0.07; p = 0.009). Furthermore, over the course of the evaluation period, area under the curve assessment demonstrated that REE was significantly increased with Meltdown compared to placebo (992.5 ± 133.1 vs. 895.1 ± 296.1 kcals; p = 0.043), while RER was significantly less than placebo (5.55 ± 0.61 vs. 5.89 ± 0.44; p = 0.002) following ingestion. HR and BP were not significantly affected prior to exercise with either supplement (p > 0.05) and the exercise-induced increases for HR and BP decreased into recovery and were not different between supplements (p > 0.05). These data suggest that Meltdown enhances REE and fat oxidation more than placebo for several hours after ingestion in fully rested and post-exercise states without any adverse hemodynamic responses associated with maximal exercise.

Fast high-performance liquid chromatography analysis of phenethylamine alkaloids in Citrus natural products on a pentafluorophenylpropyl stationary phase

In this study, the chromatographic performance of a pentafluorophenylpropyl (PFPP) stationary phase was evaluated for the rapid separation of phenethylamine alkaloids (i.e. (+/-)-octopamine, (+/-)-synephrine, tyramine, N-methyltyramine and hordenine) in Citrus aurantium plant material (fruits and peel), various Citrus species, extracts and dietary supplements claiming to contain C. aurantium. The problems of phenethylamine alkaloid separation, such as peak tailing, low retention and low resolution, were successfully solved with this stationary phase. The parameters used for the method optimization included the mobile phase counter ion concentration and column temperature. A Discovery HS F5 column (150 mm x 4.6 mm i.d., 5 microm) was used, with an isocratic mobile phase composed of 10 mM ammonium acetate in 90:10 ACN-H(2)O (v/v), at a flow rate of 1.0 mL/min. The column temperature was set at 20 degrees C. The photodiode array detector monitored the eluent at 225 nm. The total analysis time was 10 min. The validation parameters, such as linearity, sensitivity, accuracy, precision and specificity, were found to be highly satisfactory. With a simple sample preparation procedure, different matrices were successfully analyzed for their alkaloid content. The results indicated that the products on sale, labeled as dietary supplements, vary widely in the quantitative composition of the active constituents: the amount of (+/-)-synephrine, the major alkaloid, in such products ranged from 0.65 to 27.41 mg/g. The other compounds were either not detected or were present at low levels. The developed method can be considered suitable for the quality control of Citrus plant material and commercial products.

Chromatographic and electrophoretic methods for the analysis of phenethylamine [corrected] alkaloids in Citrus aurantium

Citrus aurantium (bitter orange) is a plant belonging to the family Rutaceae, whose fruit extracts have been used recently for the treatment of obesity. The most important biologically active constituents of the C. aurantium fruits are phenethylamine alkaloids (i.e. octopamine, synephrine, tyramine, N-methyltyramine and hordenine). Synephrine is a primary synthesis compound with pharmacological activities such as vasoconstriction, elevation of blood pressure and relaxation of bronchial muscle. Synephrine is present in the peel and the edible part of Citrus fruit. Of the adrenergic amines of natural origin, synephrine has been found to be the main constituent of C. aurantium fruits and extracts; the other alkaloids are either absent or present in only low concentrations. It is known that synephrine and the other amines found in C. aurantium have adverse effects on the cardiovascular system, owing to adrenergic stimulation. In light of the great commercial proliferation of C. aurantium herbal medicines in recent years, this review provides an overview of various extraction, separation and detection techniques employed for the qualitative and quantitative determination of the alkaloids in C. aurantium and related species. The application of chromatographic and electrophoretic methods for the separation and determination of these active components in C. aurantium plant material and derivatives are described. Since synephrine is a chiral compound, enantioselective chromatographic and electrophoretic techniques for the analysis of synephrine enantiomers in natural products are presented. Furthermore, examples of identification of these active compounds in complex matrices by hyphenated methods, such as gas chromatography-mass spectrometry and high-performance liquid chromatography-mass spectrometry, are described. The advantages and limitations of these separation and identification methods are assessed and discussed.

A rapid and simple procedure for the determination of synephrine in dietary supplements by gas chromatography-mass spectrometry

A simple and rapid procedure based on gas chromatography-mass spectrometry (GC-MS) is described for determination of synephrine, active principle of Citrus aurantium plant, in solid and liquid dietary supplements. After the addition of 3,4-methylenedioxypropylamphetamine as internal standard (I.S.), a liquid-liquid extraction procedure in alkaline conditions with chloroform/isopropanol (9:1, v/v) was applied to the samples prior to analysis. Chromatography was performed on a fused capillary column and synephrine and I.S., derivatized with pentafluoropropionic anhydride, were determined in the selected-ion-monitoring (SIM) mode. The method was validated in the range 0.1-50 microg/mg or microg/mL synephrine. Mean recovery ranged between 89.3% and 90.5% in both solid and liquid dietary supplements. The quantification limit was 0.1 microg/mg or microg/ml. The method was applied to analysis of various dietary supplements promoted for aiding weight control containing, among other constituents such as ephedrine alkaloids and methylxanthines, Citrus aurantium. Amount of synephrine present in such products ranged from 3.1 microg/mg solid product to 480.2 microg/mL liquid product.

Use of complementary medicine and dietary supplements among U.S. adolescents

PURPOSE

Use of complementary and alternative medicine (CAM) is increasing, but some dietary supplements have potentially negative side effects. This study examines CAM and dietary supplement use among a national sample of adolescents.

METHODS

A total of 1280 adolescents 14-19 years old completed an online survey in 2002 about lifetime and past-30-day use of all CAM modalities, and specifically about use of herbal medicines and dietary supplements. We e-mailed invitations to 12,353 members of Harris Interactive's national Youth Query panel, and filled age/gender quotas sample targets. Data were then weighted to reflect the U.S. adolescent population by gender, race/ethnicity, urbanicity, region, parents' education, propensity to be online, and likelihood of nonresponse. Chi-square and logistic regression analyses were done using SPSS.

RESULTS

Seventy-nine percent of adolescents had used CAM in their lifetime, 48.5% in the previous month; 46.2% had used dietary supplements in their lifetime, 29.1% in the previous month; 9.3% reported concurrent use of supplements and prescription medication in the previous month. Factors associated with CAM and supplement use included being female, positive attitudes towards CAM, and being age 16-17 years (rather than in younger or older age groups). Commonly used supplements included ginseng, zinc, echinacea, ginkgo, weight loss supplements, and creatine.

CONCLUSIONS

Many adolescents use CAM and dietary supplements, including a significant number concurrent with prescription medications. Commonly used supplements (weight loss supplements and creatine) are closely linked to attempts to change body shape. Health care providers should be aware of CAM and supplement use by adolescents.

Citrus aurantium and synephrine alkaloids in the treatment of overweight and obesity: an update

Obesity is a major health problem facing the developed and developing world. Efforts by individuals, health professionals, educators, and policy makers to combat the escalating trend of growing obesity prevalence have been multifaceted and mixed in outcome. Various dietary supplements have been marketed to reduce obesity. These products have been suggested to accomplish this by decreasing energy intake and energy absorption, and/or increasing metabolic rate. Ephedra, one such supplement, was banned from sale in the US market because of concerns about adverse events. Another substance, Citrus aurantium, which contains several compounds including synephrine alkaloids, has been suggested as a safe alternative. This review examines the evidence for safety and efficacy of C. aurantium and synephrine alkaloids as examined in animal studies, clinical weight loss trials, acute physiologic studies and case reports. Although at least three reviews of C. aurantium have been published, our review expands upon these by: (i) distinguishing and evaluating the efficacy of C. aurantium and related compounds; (ii) including results from previously unreviewed research; (iii) incorporating recent case reports that serve to highlight, in an anecdotal way, potential adverse events related to the use of C. aurantium and related compounds; and (iv) offering recommendations to guide the design of future trials to evaluate the safety and efficacy of C. aurantium. While some evidence is promising, we conclude that larger and more rigorous clinical trials are necessary to draw adequate conclusions regarding the safety and efficacy of C. aurantium and synephrine alkaloids for promoting weight loss.

Citrus aurantium used for weight loss by an adolescent with anorexia nervosa

A 16-year-old woman with an eating disorder admitted to taking a Citrus aurantium-containing dietary supplement for weight loss purposes. Its adrenergic agonist properties may have masked bradycardia and hypotension while exacerbating her weight loss.

Enantioselective LC analysis of synephrine in natural products on a protein-based chiral stationary phase

An enantioselective LC method with photodiode array detection (PAD) was developed for the enantioseparation of (+/-)-synephrine from C. aurantium L. var. amara fruits and phytotherapic derivatives by using a protein-based chiral stationary phase with cellobiohydrolase as the chiral selector (Chiral-CBH). Analyses were carried out on a Chiral-CBH column (100x4.0 mm i.d., 5 microm), with a mobile phase consisting of 2-propanol (5%, w/w) in sodium phosphate buffer (pH 6.0; 10 mM) and disodium EDTA (50 microM). The flow rate was 0.8 mL/min. Detection was set at 225 nm. To identify the order of elution, the racemate was resolved by the preparation of suitable diastereoisomeric salts with antipodes of appropriate organic acids. Isolation of synephrine from C. aurantium fruits and phytoproducts was performed by solid-phase extraction (SPE) with a strong cation-exchange phase. The method developed was validated and was found to be linear in the 0.40-40.14 microg/mL range (r2=1.000, P<0.0001) for both synephrine enantiomers. The limit of detection (LOD) for each enantiomer was 0.04 microg/mL. The limit of quantification (LOQ) for each enantiomer was 0.13 microg/mL. Intra-day precision (calculated as %R.S.D.) ranged from 0.03 to 0.24% for (-)-synephrine and from 0.03 to 0.35% for (+)-synephrine. Inter-day precision (calculated as %R.S.D.) ranged from 0.07 to 1.45% for (-)-synephrine and from 0.06 to 1.26% for (+)-synephrine. Intra- and inter-day accuracies (calculated as %recovery) were in the ranges of 97.4-100.6 and 98.0-101.6% for (-)-synephrine, and in the ranges 97.0-101.5 and 98.1-102.8% for (+)-synephrine. The results of the application of the method to the analysis of C. aurantium samples showed that (-)-synephrine was the main component. (+)-Synephrine was not detected in C. aurantium fruits and was present in low concentration in the phytoproducts.

Ischemic stroke associated with use of an ephedra-free dietary supplement containing synephrine

In response to concerns regarding the safety of ephedra-containing dietary supplements, manufacturers have marketed "ephedra-free" products. Many of these contain synephrine, a sympathomimetic amine from the plant Citrus aurantium. Synephrine is structurally similar to ephedrine and has vasoconstrictor properties. We describe a 38-year-old patient with ischemic stroke associated with an ephedra-free dietary supplement containing synephrine and caffeine. The patient presented with memory loss and unsteady gait after taking 1 or 2 capsules per day of a dietary supplement (Stacker 2 Ephedra-Free) for 1 week. He had no notable medical history or major atherosclerotic risk factors and took no other medications. Physical examination showed a mildly ataxic gait and substantial Impairment of both concentration and memory. Computed tomography and magnetic resonance Imaging of the brain showed subacute infarctions in the left thalamus and left cerebellum in the distribution of the vertebrobasilar circulation. Other causes of ischemic stroke were evaluated, and findings were unremarkable; a vasospastic origin was considered most likely. The patient was discharged with nearly complete resolution of symptoms. Synephrine, a sympathomimetic amine related to ephedrine, may be associated with Ischemic stroke. Consumers and clinicians need to be Informed about the potential risks of ephedra-free products.

Adverse reaction to an adrenergic herbal extract (Citrus aurantium)

We report the case of a 52 year old woman that had an adverse reaction after taking a dry herbal extract of an unripe fruit of Citrus aurantium L. var. amara, as dietary supplement for weight loosing. The fruit is also known as zhi shi (in traditional Chinese Medicine) or bitter orange in other parts of the world.

Exercise-induced syncope associated with QT prolongation and ephedra-free Xenadrine

The Food and Drug Administration recently banned the sale of ephedra alkaloids because of their association with arrhythmic sudden death, myocardial infarction, and stroke. This has resulted in the emergence of formulations marketed for weight loss and performance enhancement that are "ephedra free" but contain other sympathomimetic substances, the safety of which has not been established. We report a case of exercise-induced syncope in a healthy 22-year-old woman that occurred 1 hour after she took the second dose of Xenadrine EFX, an ephedra-free weight-loss supplement. Electrocardiography revealed prolongation of the QT interval (corrected QT, 516 milliseconds); this resolved in 24 hours. Results of echocardiography and exercise stress testing were normal. Nine months of monitoring with an implanted loop recorder revealed no arrhythmias in the absence of Xenadrine EFX. Although this product contains a number of compounds whose pharmacologic effect is poorly characterized, notable quantities of phenylephrine are present, and the proarrhythmic potential of this compound in the setting of exercise is discussed.

Possible Association of Acute Lateral-Wall Myocardial Infarction and Bitter Orange Supplement

OBJECTIVE

To report a possible incidence of acute lateral-wall myocardial infarction (MI) coinciding with the use of a Citrus aurantium L. (bitter orange)—containing dietary supplement in a patient with undetected coronary vascular disease.

CASE SUMMARY

A 55-year-old white woman presented to the emergency department with symptoms of dull aching shoulder and chest pain. A review of medications during cardiac rehabilitation revealed the patient had ingested a multicomponent dietary supplement for weight loss containing 300 mg of bitter orange (Edita's Skinny Pill) for the past year. Although the patient's past medical history did not include hypertension, coronary disease, or hyperlipidemia, an arteriogram revealed a lesion in the left main coronary artery. She did have a smoking history. She was diagnosed with acute lateral-wall MI and hospitalized for 4 days.

DISCUSSION

Consumers generally consider dietary supplements safe. However, some supplements taken for weight loss contain ingredients that have been associated with cardiovascular events. Although consumers are becoming more aware of the serious adverse effects secondary to products containing ingredients such as Ma huang and ephedra, reports involving other ingredients are increasing. Bitter orange or synephrine, found in bitter orange, has been associated with adverse cardiovascular reactions. Based on the Naranjo probability scale, C. aurantium is possibly associated with this cardiovascular event.

CONCLUSIONS

The use of C. aurantium—containing supplements may present as a risk for cardiovascular toxicity; however, additional studies/case reports are needed to validate this conclusion.

Caffeine and Ephedrine

Preparations containing caffeine and ephedrine have become increasingly popular among sportspersons in recent years as a means to enhance athletic performance. This is due to a slowly accumulating body of evidence suggesting that combination of the two drugs may be more efficacious than each one alone. Caffeine is a compound with documented ergogenicity in various exercise modalities, while ephedrine and related alkaloids have not been shown, as yet, to result in any significant performance improvements. Caffeine-ephedrine mixtures, however, have been reported in several instances to confer a greater ergogenic benefit than either drug by itself. Although data are limited and heterogeneous in nature to allow for reaching consensus, the increase in performance is a rather uniform finding as it has been observed during submaximal steady-state aerobic exercise, short- and long-distance running, maximal and supramaximal anaerobic cycling, as well as weight lifting. From the metabolic point of view, combined ingestion of caffeine and ephedrine has been observed to increase blood glucose and lactate concentrations during exercise, wheareas qualitatively similar effects on lipid fuels (free fatty acids and glycerol) are less pronounced. In parallel, epinephrine and dopamine concentrations are significantly increased, wheareas the effects on norepinephrine are less clear. With respect to pulmonary gas exchange during short-term intense exercise, no physiologically significant effects have been reported following ingestion of caffeine, ephedrine or their combination. Yet, during longer and/or more demanding efforts, some sporadic enhancements have indeed been shown. On the other hand, a relatively consistent cardiovascular manifestation of the latter preparation is an increase in heart rate, in addition to that caused by exercise alone. Finally, evidence to date strongly suggests that caffeine and ephedrine combined are quite effective in decreasing the rating of perceived exertion and this seems to be independent of the type of activity being performed. In general, our knowledge and understanding of the physiological, metabolic and performance-enhancing effects of caffeine-ephedrine mixtures are still in their infancy. Research in this field is probably hampered by sound ethical concerns that preclude administration of potentially hazardous substances to human volunteers. In contrast, while it is certainly true that caffeine and especially ephedrine have been associated with several acute adverse effects on health, athletes do not seem to be concerned with these, as long as they perceive that their performance will improve. In light of the fact that caffeine and ephedra alkaloids, but not ephedrine itself, have been removed from the list of banned substances, their use in sports can be expected to rise considerably in the foreseeable future. Caffeine-ephedra mixtures may thus become one of most popular ergogenic aids in the years to come and while they may indeed prove to be one of the most effective ones, and probably one of the few legal ones, whether they also turn out to be one of the most dangerous ones awaits to be witnessed.