Ephedra is a genus of plants one species of which is known as Ma Huang (Ephedra sinica), which has been used in traditional Chinese medicine for centuries as a stimulant and antiasthmatic agent, and was recently introduced into use in the United States and Europe as a weight loss agent and aid in body building. Ma Huang and Ephedra species containing ephedrine alkaloids have been linked to multiple potentially severe side effects, including clinically apparent liver injury and has been banned from sale in the United States and elsewhere.


Ephedra is prepared from the aerial parts of plants belonging to the genus Ephedra, family Ephedraceae. The 45 species of Ephedra are found worldwide, but Ephedra sinica is used predominantly and is native to China where it was first used therapeutically. Ephedra sinica is an herbaceous perennial with a strong pine odor and astringent taste which accounts for its Chinese name – Ma Huang – which can be translated as “yellow astringent” or “yellow hemp.” Ma Huang is purported to increase mental acuity and to improve sexual performance, increase circulation, and decrease weight through an increase in sympathetic nervous system activity and thermogenesis. It is also used for allergies, allergic rhinitis, colds, flu, fever, chills, nasal congestion, bronchospasm and asthma. The active ingredient of Ma Huang appears to be ephedrine and other related sympathomimetic alkaloids, which probably account for its therapeutic efficacy as well as its adverse effects. Not all Ephedra species contain ephedrine alkaloids, particularly those native to the United States. Ephedrine was a component of many herbal weight loss and body building products (such as those sold under the names Ma Huang and Hydroxycut). The typical dose was 1.5 to 9 grams of the decocted herb daily or as herbal tea prepared by boiling dried green stems in water. Side effects were not uncommon and included nervousness, anxiety, palpitations, tachycardia, gastrointestinal upset, nausea, diarrhea, headache, and dizziness. Ephedrine has also been implicated in an increased risk for myocardial infarction, stroke and sudden death and was banned from sale in the United States in April 2004.


Despite its apparent safe use for centuries in Chinese traditional medicine, Ma Huang was linked to many serious and potential fatal side effects since its widescale use in Western countries for weight loss. The major reported serious adverse events were cardiovascular, including hypertension, palpitations, myocardial infarction, seizures, transient ischemic attacks, cerebrovascular accidents and sudden death. Ephedra preparations have also been implicated in more than a dozen instances of clinically apparent, acute liver injury. The time to onset ranged from a few weeks to more than 6 months, but averaged 12 weeks, presenting with symptoms of fatigue, nausea and abdominal discomfort followed by jaundice. The serum enzyme elevations were typically hepatocellular and the clinical syndrome resembled acute viral hepatitis. Immunoallergic features (rash, fever and eosinophilia) were uncommon as were autoantibodies. Recovery occurred within 1 to 6 months of stopping the ephedra preparation, but instances with acute liver failure and death or need for emergency liver transplantation have been reported. As with most herbal products, it is difficult to say whether the liver injury is due to ephedra itself as opposed to a contaminant or another undisclosed hepatotoxin in the herbal supplement. While cases of ephedra-associated liver injury are now rare in the United States, they continue to be reported from Asia, largely as a result of use of traditional Asian and Chinese medicines.

Mechanism of Injury

Ephedra sinica extracts contain multiple compounds including the sympathomimetic alkaloids ephedrine, pseudoephedrine, methylephedrine and norephedrine. The cardiovascular side effects and complications of ephedra use have been attributed to these sympathomimetic constituents. The liver injury has been attributed to ephedrine as well, but other constituents may be responsible for this idiosyncratic liver injury.

Outcome and Management

The severity of liver injury due to ephedrine ranges from mild, asymptomatic elevations in serum enzymes to clinically apparent acute liver injury and to acute liver failure. Chronic use of Ma Huang has been linked to a chronic hepatitis-like syndrome, but recovery was prompt when ephedra was stopped. There have been no instances of vanishing bile duct syndrome attributed to ephedra. Recurrence of liver injury is typical when ephedra is restarted, and rechallenge should be avoided. There is no apparent cross sensitivity to liver injury between Ma Huang and other weight loss agents or herbal preparations, but ephedrine was previously found in many commercial herbal preparations.

Other Names: Belcho, Chinese ephedra, Desert herb, Ephedrine, Heral ecstasy, Joint fir, Mongolian ephedra, Pakistani ephedra, Popotillo, Sea grade, Teamster’s tea, Yellow astringent, Yellow horse.

Drug Class: Herbal and Dietary Supplements


Case 1. Acute hepatitis due to Ma Huang.

[Modified from: Nadir A, Agrawal S, King PD, Marshall JB. Acute hepatitis associated with the use of a Chinese herbal product, ma-huang. Am J Gastroenterol 1996; 91: 1436-8. PubMed Citation]

A 33 year old woman developed nausea and abdominal discomfort a few days after starting Ma Huang for weight loss. She continued taking the product for another 3 weeks when she noted jaundice and sought medical attention. She had no history of liver disease, alcohol abuse or risk factors for viral hepatitis and liver tests were known to be normal two years earlier. She was taking no other medications. Initially, she did not reveal that she was taking an herbal product. On examination, she was jaundiced and had hepatic tenderness but no fever, rash or signs of chronic liver disease. Laboratory tests showed raised serum bilirubin (4.5 mg/dL) and prominent elevations in serum aminotransferase levels (ALT 832 U/L, AST 376 U/L), with minimal increase in alkaline phosphatase (178 U/L). Tests for hepatitis A, B and C and a monospot were negative. Autoantibodies were present in moderate titers with ANA 1:160 and SMA 1:80. Ultrasound and computerized tomography of the liver were normal. She was initially thought to have viral hepatitis and sent home. She restarted Ma Huang but quickly felt worse, stopped and returned to the hospital where liver tests were found to be worse (Table). A liver biopsy showed changes of acute hepatitis with occasional eosinophils and plasma cells suggestive of drug induced liver disease. She stopped taking Ma Huang and when seen four months later, all liver tests were again normal.

Key Points

Laboratory Values


A typical case of an acute hepatitis due to Ma Huang. The time to onset was difficult to assess, because she reported having nausea and abdominal discomfort “soon after” starting Ma Huang, but the time to jaundice was about 4 weeks. The clinical presentation was similar to acute viral hepatitis, which was the initial diagnosis, because the patient did not admit to using an herbal product (and this was the first published report of Ma Huang related acute liver injury). The finding of autoantibodies might suggest an autoimmune drug induced hepatitis. Immunoglobulin levels and serial ANA titers were not provided, but the liver histology did not suggest autoimmune hepatitis. Moderate levels of autoantibodies are not infrequent in cases of acute liver injury due to Ma Huang, but autoimmune features (hyperglobulinemia, prolonged course, response to corticosteroids) are not found.



Ephedra – Generic


Herbal and Dietary Supplements


Fact Sheet at National Center for Complementary and Integrative Health, NIH

Fact Sheet at Office of Dietary Supplements, NIH



References updated: 10 February 2018

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