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

Rhabdomyolysis secondary to a weight-loss prescription

We present a case of a case of a man in his 70s on multiple medications (including treatment of ischemic heart disease and diabetes who developed significant rhabdomyolysis, complicated by acute kidney injury (AKI) and encephalopathy, while using a compounded medication for weight loss. The patient was admitted to the intensive care unit and progressed favourably after haemodialysis and supportive care. Information regarding the ingestion of weight-loss drugs was unknown at the time of admission and was only discovered after resolution of encephalopathy, raising the possibility of toxin-associated rhabdomyolysis. This case emphasises the need for a thorough clinical history and scrutiny of the safety of weight-loss prescriptions, including preparations that comprise a combination of drugs and supplements that may adversely interact with chronic medications, especially in polymedicated patients.

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.

Citrus aurantium L. and synephrine improve brown adipose tissue function in adolescent mice programmed by early postnatal overfeeding

Introduction and aims

Obesity is a multifactorial condition with high health risk, associated with important chronic disorders such as diabetes, dyslipidemia, and cardiovascular dysfunction. Citrus aurantium L. (C. aurantium) is a medicinal plant, and its active component, synephrine, a β-3 adrenergic agonist, can be used for weight loss. We investigated the effects of C. aurantium and synephrine in obese adolescent mice programmed by early postnatal overfeeding.

Methods

Three days after birth, male Swiss mice were divided into a small litter (SL) group (3 pups) and a normal litter (NL) group (9 pups). At 30 days old, SL and NL mice were treated with C. aurantium standardized to 6% synephrine, C. aurantium with 30% synephrine, isolated synephrine, or vehicle for 19 days.

Results

The SL group had a higher body weight than the NL group. Heart rate and blood pressure were not elevated. The SL group had hyperleptinemia and central obesity that were normalized by C. aurantium and synephrine. In brown adipose tissue, the SL group showed a higher lipid droplet sectional area, less nuclei, a reduction in thermogenesis markers related to thermogenesis (UCP-1, PRDM16, PGC-1α and PPARg), and mitochondrial disfunction. C. aurantium and synephrine treatment normalized these parameters.

Conclusion

Our data indicates that the treatment with C. aurantium and synephrine could be a promising alternative for the control of some obesity dysfunction, such as improvement of brown adipose tissue dysfunction and leptinemia.

The Serious Side of Supplements: An Ischemic Stroke in a Healthy 38-year-old Female

The incidence of ischemic stroke in the young is on the rise. With young stroke victims, providers must consider both typical risk factors and other rare causes. We present a case of a healthy, 38-year-old female military dependent who presented with an ischemic right posterior central gyrus stroke in the setting of a patent foramen ovale and supplement diindolylmethane use. This case serves as a reminder of the hazards associated with supplement use and the importance of a thorough investigation of etiology in medical cases of ischemic stroke in the young.

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.

Ephedrae Herba: A Review of Its Phytochemistry, Pharmacology, Clinical Application, and Alkaloid Toxicity

Ephedrae Herba (Ephedra), known as "MaHuang" in China, is the dried straw stem that is associated with the lung and urinary bladder meridians. At present, more than 60 species of Ephedra plants have been identified, which contain more than 100 compounds, including alkaloids, flavonoids, tannins, sugars, and organic phenolic acids. This herb has long been used to treat asthma, liver disease, skin disease, and other diseases, and has shown unique efficacy in the treatment of COVID-19 infection. Because alkaloids are the main components causing toxicity, the safety of Ephedra must be considered. However, the nonalkaloid components of Ephedra can be effectively used to replace ephedrine extracts to treat some diseases, and reasonable use can ensure the safety of Ephedra. We reviewed the phytochemistry, pharmacology, clinical application, and alkaloid toxicity of Ephedra, and describe prospects for its future development to facilitate the development of Ephedra.

Review of Case Reports on Adverse Events Related to Pre-workout Supplements Containing Synephrine

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.

Natural Sympathomimetic Drugs: From Pharmacology to Toxicology

Sympathomimetic agents are a group of chemical compounds that are able to activate the sympathetic nervous system either directly via adrenergic receptors or indirectly by increasing endogenous catecholamine levels or mimicking their intracellular signaling pathways. Compounds from this group, both used therapeutically or abused, comprise endogenous catecholamines (such as adrenaline and noradrenaline), synthetic amines (e.g., isoproterenol and dobutamine), trace amines (e.g., tyramine, tryptamine, histamine and octopamine), illicit drugs (e.g., ephedrine, cathinone, and cocaine), or even caffeine and synephrine. In addition to the effects triggered by stimulation of the sympathetic system, the discovery of trace amine associated receptors (TAARs) in humans brought new insights about their sympathomimetic pharmacology and toxicology. Although synthetic sympathomimetic agents are mostly seen as toxic, natural sympathomimetic agents are considered more complacently in the terms of safety in the vision of the lay public. Here, we aim to discuss the pharmacological and mainly toxicological aspects related to sympathomimetic natural agents, in particular of trace amines, compounds derived from plants like ephedra and khat, and finally cocaine. The main purpose of this review is to give a scientific and updated view of those agents and serve as a reminder on the safety issues of natural sympathomimetic agents most used in the community.

Comparing effectiveness of fat burners and thermogenic supplements to diet and exercise for weight loss and cardiometabolic health: Systematic review and meta-analysis

BACKGROUND

Those who are overfat face an onslaught of advice for losing weight, including using dietary supplements that purport to have fat burning capabilities to achieve a reduced body mass, fat mass and improvement in cardiometabolic health in combination with exercise or diet and exercise regimens.

AIM

To examine long-term effectiveness of supplements for both weight loss and improvements in cardiometabolic health for these individuals.

METHODS

A PRISMA methods of systematic review was conducted from August 2018 through January 2019 using Medline, PubChem, PubMed, EBOSCO CINHAL and SPORTDiscus, and Google Scholar yielding 23,441 returns of which 21 studies (duration greater than 8 weeks with participant populations of BMI greater than 24.9) were included for meta-analysis. Meta-analysis examined pooled effect size and 95% confidence interval for: body mass, fat mass, fat-free mass, total cholesterol, high-density lipoproteins, low-density lipoproteins, resting metabolic rate. Intra-study effect sizes were compared with previously reported results for diet or diet and exercise in a 2x2 chi-square analysis for the number of studies that induced effects greater than or less than the effect size.

RESULTS

There is a general trend to show effectiveness (effect size greater than 0.00) for obtaining beneficial changes from use of thermogenic dietary supplements, yet the 95% confidence interval for effect size crossed 0.00 (indicating no benefit). Chi-square comparison to exercise, or combination of diet and exercise, indicates that responses induced from weight-loss supplements were less effective than what is obtained from utilizing exercise, or diet and exercise, without additional weight-loss supplements.

CONCLUSION

There appears to be limited benefit that may be derived from the inclusion of thermogenic dietary supplements to reduce body mass and improve cardiometabolic health for individuals who are overfat.

A Review of the Ephedra genus: Distribution, Ecology, Ethnobotany, Phytochemistry and Pharmacological Properties

Ephedra is one of the largest genera of the Ephedraceae family, which is distributed in arid and semiarid regions of the world. In the traditional medicine from several countries some species from the genus are commonly used to treat asthma, cold, flu, chills, fever, headache, nasal congestion, and cough. The chemical constituents of Ephedra species have been of research interest for decades due to their contents of ephedrine-type alkaloids and its pharmacological properties. Other chemical constituents such as phenolic and amino acid derivatives also have resulted attractive and have provided evidence-based supporting of the ethnomedical uses of the Ephedra species. In recent years, research has been expanded to explore the endophytic fungal diversity associated to Ephedra species, as well as, the chemical constituents derived from these fungi and their pharmacological bioprospecting. Two additional aspects that illustrate the chemical diversity of Ephedra genus are the chemotaxonomy approaches and the use of ephedrine-type alkaloids as building blocks in organic synthesis. American Ephedra species, especially those that exist in Mexico, are considered to lack ephedrine type alkaloids. In this sense, the phytochemical study of Mexican Ephedra species is a promising area of research to corroborate their ephedrine-type alkaloids content and, in turn, discover new chemical compounds with potential biological activity. Therefore, the present review represents a key compilation of all the relevant information for the Ephedra genus, in particular the American species, the species distribution, their ecological interactions, its ethnobotany, its phytochemistry and their pharmacological activities and toxicities, in order to promote clear directions for future research.

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.

Phytochemistry and pharmacology of genus Ephedra

The genus Ephedra of the Ephedraceae family contains more than 60 species of nonflowering seed plants distributed throughout Asia, America, Europe, and North Africa. These Ephedra species have medicinal, ecological, and economic value. This review aims to summarize the chemical constituents and pharmacological activities of the Ephedra species to unveil opportunities for future research. Comprehensive information on the Ephedra species was collected by electronic search (e.g., GoogleScholar, Pubmed, SciFinder, and Web of Science) and phytochemical books. The chemical compounds isolated from the Ephedra species include alkaloids, flavonoids, tannins, polysaccharides, and others. The in vitro and in vivo pharmacological studies on the crude extracts, fractions and few isolated compounds of Ephedra species showed anti-inflammatory, anticancer, antibacterial, antioxidant, hepatoprotective, anti-obesity, antiviral, and diuretic activities. After chemical and pharmacological profiling, current research is focused on the antibacterial and antifungal effects of the phenolic acid compounds, the immunosuppressive activity of the polysaccharides, and the antitumor activity of flavonoids.

An Overview on Citrus aurantium L.: Its Functions as Food Ingredient and Therapeutic Agent

Citrus aurantium L. (Rutaceae), commonly known as bitter orange, possesses multiple therapeutic potentials. These biological credentials include anticancer, antianxiety, antiobesity, antibacterial, antioxidant, pesticidal, and antidiabetic activities. The essential oil of C. aurantium was reported to display marked pharmacological effects and great variation in chemical composition depending on growing locations but mostly contained limonene, linalool, and β-myrcene. Phytochemically, C. aurantium is rich in p-synephrine, an alkaloid, and many health-giving secondary metabolites such as flavonoids. Animal studies have demonstrated a low affinity of p-synephrine for adrenergic receptors and an even lower affinity in human models. The present review focuses on the different biological activities of the C. aurantium in animal and human models in the form of extract and its pure secondary metabolites. Finally, it is concluded that both the extract and isolated compounds have no unwanted effects in human at therapeutic doses and, therefore, can confidently be used in various dietary formulations.

Integrative Medicine and Cardiovascular Disorders

Integrative medicine (IM) has developed an increasingly significant role in health care worldwide, including cardiovascular diseases (CVD). This review describes the commonly used IM in CVD, with particular attention placed with dietary supplements and mind-body therapies. More rigorous research continues to be needed to determine the mechanisms and efficacy of IM cardiovascular morbidity and mortality. Health care providers will need to develop skills in open communication and nonjudgmental dialogue around IM use in discussing treatment plans with their patients.

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.

Gender differences in biochemical markers and oxidative stress of rats after 28 days oral exposure to a mixture used for weight loss containing p-synephrine, ephedrine, salicin, and caffeine

ABSTRACT The association of p-synephrine, ephedrine, salicin, and caffeine in dietary supplements and weight loss products is very common worldwide, even though ephedrine has been prohibited in many countries. The aim of this study was to evaluate a 28-day oral exposure toxicity profile of p-synephrine, ephedrine, salicin, and caffeine mixture (10:4:6:80 w/w respectively) in male and female Wistar rats. Body weight and signs of toxicity, morbidity, and mortality were observed daily. After 28 days, animals were euthanized and blood collected for hematological, biochemical, and oxidative stress evaluation. No clinical signs of toxicity, significant weight loss or deaths occurred, nor were there any significant alterations in hematological parameters. Biochemical and oxidative stress biomarkers showed lipid peroxidation, and hepatic and renal damage (p < 0.05; ANOVA/Bonferroni) in male rats (100 and 150 mg/kg) and a reduction (p < 0.05; ANOVA/Bonferroni) in glutathione (GSH) levels in all male groups. Female groups displayed no indications of oxidative stress or biochemical alterations. The different toxicity profile displayed by male and female rats suggests a hormonal influence on mixture effects. Results demonstrated that the tested mixture can alter oxidative status and promote renal and hepatic damages.

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.

Hypertension in an Adolescent Secondary to Performance-Enhancement Supplement Use

Objective: To describe the effects of performance-enhancing supplements and caffeine on the blood pressure (BP) of an adolescent male. Case Summary: An adolescent male presented to his primary care provider for a preseason athletic physical. On physical exam, his BP was 162/90, exceeding the 99th percentile for his age. It had been elevated during the previous 2 yearly physicals. He was referred to the Pediatric Preventive Cardiology Clinic for follow-up. Illegal substance use and renal trauma were ruled out. During the evaluation, the patient acknowledged using energy drinks and performance-enhancing supplements, the majority of which were caffeine-based. His intention was to continue the use of supplements, so lisinopril was initiated. On follow-up, however, the patient reported supplement discontinuation, intermittent medication adherence, and lower home-based BP readings. He was subsequently lost to follow-up. An objective causality assessment revealed that the adverse drug event was probable. Discussion: When working with adolescent patients, it is particularly important to conduct an in-depth interview reflecting lifestyle choices. Use of performance-enhancing supplements and caffeine for adolescent athletes has been well reported in the literature. Adolescent use of supplements may be driven by misguided beliefs and lack of knowledge about potentially detrimental health effects, such as altered heart rate and elevated BP. Little evidence-based research is available to provide treatment guidance for clinicians regarding potential effects. Conclusions: A thorough patient history, including specific questions probing for any recent or chronic use of nutritional supplements, including energy drinks, will help identify substances that may contribute to BP variations. Even mild BP elevations in adolescents should lead clinicians to further investigate supplement use and include specific questions on any product use within the past 24 hours, several days, or longer. Adolescents may not consider the potential for adverse health effects when ingesting performance-enhancing supplements or energy drinks.

Iatrogenic venous thrombosis secondary to supplemental medicine toxicity

OBJECTIVE

We described a case of cerebral venous sinus thrombosis in a patient taking multiple supplements as part of a naturopathic anti-aging regimen.

METHODS

Case report.

RESULTS

The patient presented with a thalamic infarct associated with a thrombus in the vein of Galen. He reported no previous history of endocrinopathy and no known hypercoagulability risk factors. He was treated with therapeutic anticoagulation resulting in improvement. Diagnostic workup revealed hyperthyroidism and gonadotrophic deficiency attributed to significant supplement medicine usage.

CONCLUSION

This case highlights a potential risk of dietary supplements. Use of these supplements may be a risk factor for idiopathic cerebral venous thrombosis.

Citrus aurantium and Rhodiola rosea in combination reduce visceral white adipose tissue and increase hypothalamic norepinephrine in a rat model of diet-induced obesity

Extracts from the immature fruit of Citrus aurantium are often used for weight loss but are reported to produce adverse cardiovascular effects. Root extracts of Rhodiola rosea have notable antistress properties. The hypothesis of these studies was that C aurantium (6% synephrine) and R rosea (3% rosavins, 1% salidroside) in combination would improve diet-induced obesity alterations in adult male Sprague-Dawley rats. In normal-weight animals fed standard chow, acute administration of C aurantium (1-10 mg/kg) or R rosea (2-20 mg/kg) alone did not reduce deprivation-induced food intake, but C aurantium (5.6 mg/kg) + R rosea (20 mg/kg) produced a 10.5% feeding suppression. Animals maintained (13 weeks) on a high-fat diet (60% fat) were exposed to 10-day treatments of C aurantium (5.6 mg/kg) or R rosea (20 mg/kg) alone or in combination. Additional groups received vehicle (2% ethanol) or were pair fed to the C aurantium + R rosea group. Although high-fat diet intake and weight loss were not influenced, C aurantium + R rosea had a 30% decrease in visceral fat weight compared with the other treatments. Only the C aurantium group had an increased heart rate (+7%) compared with vehicle. In addition, C aurantium + R rosea administration resulted in an elevation (+15%) in hypothalamic norepinephrine and an elevation (+150%) in frontal cortex dopamine compared with the pair-fed group. These initial findings suggest that treatments of C aurantium + R rosea have actions on central monoamine pathways and have the potential to be beneficial for the treatment of obesity.

Synephrine-containing dietary supplement precipitating apical ballooning syndrome in a young female

Apical ballooning syndrome (ABS) is a unique reversible cardiomyopathy that is frequently precipitated by emotional or physical stress. In addition, the few drugs reported to precipitate ABS were either illegal or strictly controlled for medical use. This paper reports a case of ABS precipitated by a dietary supplement. Our case accentuates the potential risk of dietary supplements containing synephrine, which is uncontrolled and available to the general public. Therefore, the Korea Food and Drug Administration should regulate these dietary supplements, and warn healthcare workers and the general public of the potential hazards of the indiscriminate abuse of dietary supplements.

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.

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.

Fast CE analysis of adrenergic amines in different parts of Citrus aurantium fruit and dietary supplements

A CE method has been developed for the simultaneous analysis of the adrenergic amines synephrine, octopamine and tyramine in Citrus aurantium (bitter orange) fruit extracts and in dietary supplements. The analytes were separated on a fused silica capillary (50 microm id, 40.0 cm effective length, 48.5 cm total length) using a BGE composed of phosphate buffer (pH 2.5, 50 mM) and applying a 30 kV potential. The samples were injected hydrodynamically at 50 mbar for 25 s. The use of photodiode array detection (lambda=195 nm) allowed the quantification of the analytes and the control of peak purity. The method has been fully validated, obtaining satisfactory values of precision and extraction yield. The analytes are extracted with water from the dried whole fruits or fruit parts (endocarp, mesocarp and exocarp) or from the commercial formulations and directly injected into the CE apparatus. The results obtained were satisfactory in terms of precision (RSD < 5.7%) and accuracy (recovery > 89%). Thus, the method has demonstrated to be suitable for the qualitative and quantitative determination of synephrine, octopamine and tyramine in C. aurantium extracts, for dietary supplement quality control and for food adulteration identification.

Use of herbal products and potential interactions in patients with cardiovascular diseases

More than 15 million people in the U.S. consume herbal remedies or high-dose vitamins. The number of visits to providers of complementary and alternative medicine exceeds those to primary care physicians, for annual out-of-pocket costs of $30 billion. Use of herbal products forms the bulk of treatments, particularly by elderly people who also consume multiple prescription medications for comorbid conditions, which increases the risk of adverse herb-drug-disease interactions. Despite the paucity of scientific evidence supporting the safety or efficacy of herbal products, their widespread promotion in the popular media and the unsubstantiated health care claims about their efficacy drive consumer demand. In this review, we highlight commonly used herbs and their interactions with cardiovascular drugs. We also discuss health-related issues of herbal products and suggest ways to improve their safety to better protect the public from untoward effects.

Ephedra-Induced Gastric Mucosal Injury

In this case report we detail the difficult case of a 74-year-old male patient who was transferred to our cardiac intensive care unit in severe shock with an acute abdomen. His abdomen was emergently explored revealing isolated gastric necrosis and ischemia. A subtotal gastrectomy was performed and the patient was discharged from the hospital 34 days after surgery. Postoperatively we learned that for the preceding 2 weeks the patient had doubled the dose of Forcalide syrup which he had been taking for his reactive airway disease for many years. Formal testing of this fluid revealed a concentrated sugar-based solution with a high concentration of both Ephedra and potassium chloride. Final pathology of the resected stomach demonstrated patent vessels to the stomach with extensive microvascular thrombosis and full-thickness gastric necrosis. On final summation of this case we concluded that the Ephedra in the patient's Forcalide syrup caused the microvascular necrosis seen in the stomach and should be added to the list of potential adverse reactions seen with the ingestion of ephedrine.

Ischemic stroke associated with cough and cold preparation containing methylephedrine and supplement containing Chinese herbal drugs

Methylephedrine is generally harmless and is contained in many cough and cold preparations. Likewise, Chinese herbal drugs are considered to be effective and to have few side effects. A 32-year-old woman experienced ischemic stroke attributed to concomitant administration of a cough and cold preparation containing methylephedrine and a supplement containing Chinese herbal drugs. Computed tomography and magnetic resonance imaging of the brain showed acute infarctions bilaterally in the cerebellum. Conventional angiography and magnetic resonance angiography showed transient stenosis of the left vertebral artery. These findings suggested vasospasm or dissection, presumably related to hypertension and/or angiitis or vasoconstriction of large cerebral arteries leading to local thrombosis as a result of stasis and sympathomimetic-induced platelet activation. Combining methylephedrine and Chinese herbal drugs might carry a risk of stroke.

Life threatening intracerebral hemorrhage with isometheptene mucate, dichlorophenazine and acetaminophen combination therapy

A 45 year old female with no stroke risk factors suffered a massive intracerebral hemorrhage (ICH) after ingesting Midrin--a combination of isometheptene mucate, dichlorophenazine and acetaminophen. Neuroimaging revealed no evidence of structural disease or underlying vasculopathy. This is the first reported case of isometheptene induced ICH in the absence of underlying cerebrovascular disease. Physicians must be aware of the potential for this complication, and inquire about the use of isometheptene in unexplained cerebral hemorrhages. Neurological communities in countries with nonprescription isometheptene should discourage unsupervised or excessive use of the drug.

Presence of p-synephrine in teas commercialized in Porto Alegre (RS/Brazil)

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.

Malignant hypertension and acute aortic dissection associated with caffeine-based ephedra-free dietary supplements: a case report

The use of weight loss dietary supplements is prevalent in the United States, and over the past decade, there has been tremendous growth of the use of these products. It is well documented that ephedra-based products are associated with various cardiovascular adverse effects. With new restrictions placed on such products, companies are now manufacturing caffeine-based ephedra-free herbal supplements. We present the case of 36-year old, previously healthy female who developed malignant hypertension and aortic dissection while taking various caffeine-based dietary supplements. Given the lack of research studies in regards to their safety and efficacy, judicious care should be taken with the use of dietary supplements, including those designated as ephedra-free.

Malignant hypertension and acute aortic dissection associated with caffeine-based ephedra-free dietary supplements: a case report

The use of weight loss dietary supplements is prevalent in the United States, and over the past decade, there has been tremendous growth of the use of these products. It is well documented that ephedra-based products are associated with various cardiovascular adverse effects. With new restrictions placed on such products, companies are now manufacturing caffeine-based ephedra-free herbal supplements. We present the case of 36-year old, previously healthy female who developed malignant hypertension and aortic dissection while taking various caffeine-based dietary supplements. Given the lack of research studies in regards to their safety and efficacy, judicious care should be taken with the use of dietary supplements, including those designated as ephedra-free.

Subchronic toxicity of Citrus aurantium L. (Rutaceae) extract and p-synephrine in mice

Extracts of Citrus aurantium L. (Rutaceae) unripe fruits have gained popularity for the treatment of obesity. Due to the wide use of C. aurantium/p-synephrine-containing products, this research was undertaken to evaluate its subchronic toxicity in mice and their actions in oxidative stress biomarkers. Groups of 9-10 mice received for 28 consecutive days a commercial C. aurantium dried extract (containing 7.5% p-synephrine) 400, 2000 or 4000 mg/kg and p-synephrine 30 or 300 mg/kg by oral gavage. There was a reduction in body weight gain of animals treated with both doses of p-synephrine. Organs relative weight, biochemical and hematological parameters were not altered in all treated mice. There was an increase in reduced glutathione (GSH) concentration in groups treated with C. aurantium 4000 mg/kg and p-synephrine 30 and 300 mg/kg. In glutathione peroxidase (GPx), there were an inhibition of the activity in C. aurantium 400 and 2000 mg/kg and p-synephrine 30 and 300 mg/kg treated animals, respectively, and was no alteration in malondialdehyde (MDA) levels. Thus, the results indicate a low subchronic toxicity of the tested materials in mice and a possible alteration in the oxidative metabolism. However, further tests are required to better elucidate the effects of these compounds in the antioxidant system.

Concentrations of p-synephrine in fruits and leaves of Citrus species (Rutaceae) and the acute toxicity testing of Citrus aurantium extract and p-synephrine

Dietary supplements containing bitter orange unripe fruit extract/p-synephrine are consumed worldwide for lose weight. This study were conducted to determine the concentration of p-synephrine in unripe fruits and leaves from Citrus aurantium Lin, C. sinensis Osbeck, C. deliciosa Ten, C. limon Burm and C. limonia Osbeck, collected in Southern Brazil, and to evaluate the acute toxicity of C. aurantium extract and p-synephrine. A high performance liquid chromatographic method with diode array detector (HPLC-DAD) was optimized and validated for determination of p-synephrine. The results indicate that all of analyzed samples present p-synephrine in amounts that range from 0.012% to 0.099% in the unripe fruits and 0.029 to 0.438% in the leaves. Acute oral administration of C. aurantium extracts (2.5% p-synephrine, 300-5,000 mg/kg) in mice produced reduction of locomotor activity, p-synephrine (150-2,000 mg/kg) produced piloerection, gasping, salivation, exophtalmia and reduction in locomotor activity, which was confirmed in spontaneous locomotor activity test. All the effects were reversible and persisted for 3-4h. The toxic effects observed seem to be related with adrenergic stimulation and should alert for possible side effects of p-synephrine and C. aurantium.