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Many drugs can cause increased stimulation when used with ephedra or ephedrine. Examples include caffeine and theophylline. When combined with ephedra, these drugs may lead to difficulty sleeping, nervousness, or stomach upset. The combination of ephedrine and caffeine may be fatal. Many products contain both ephedrine and caffeine and should be used with caution, if at all.
Combined ingestion of caffeine and ephedrine has been observed to increase blood glucose and lactate concentrations. Ephedrine and dopamine concentrations are significantly increased. A case report exists of ephedra use associated with the onset of psychosis and autonomic hyperactivity after administration of risperidone.
If ephedra is taken with monoamine oxidase inhibitor (MAOI) antidepressants, such as isocarboxazid (Marplan®), phenelzine (Nardil®), and tranylcypromine (Parnate®), severe side effects may develop, including dangerously high blood pressure, muscle damage, fever, and irregular heart rate. Other antidepressants and medications for psychiatric disorders (phenothiazines, tricyclics, selective serotonin reuptake inhibitors [SSRIs]) may reduce the effects of ephedra and cause low blood pressure and rapid heartbeat.
Because ephedra affects blood pressure and heart rate, it may alter the effectiveness of medications given to control blood pressure or heart rhythm, including digoxin, alpha-blockers, beta-blockers, diuretics, calcium-channel blockers, or angiotensin converting enzyme (ACE) inhibitors. The side effects of ephedra may be worsened by guanethidine, ergot alkaloids (bromocriptine, dihydroergotamine, ergotamine), oxytocin (Ptosin®), diuretics, morphine, and anesthetic drugs (halothane, cyclopropane, propofol).
Ephedra may lower blood sugar levels, although ephedra-caffeine combinations may increase blood sugar. Caution is advised when using medications that may also alter blood sugar. Patients taking drugs for diabetes by mouth or insulin should be monitored closely by a qualified healthcare provider. Medication adjustments may be necessary.
Ephedra may reduce the effects of steroids such as dexamethasone. Ephedra may increase serum levels of thyroid hormones and may alter thyroid hormone treatments. Medications that alter the acidity of urine may reduce the effectiveness of ephedra.
Effects of cholesterol-lowering medications may be altered by ephedra, although this has not been proven.
Phenylpropanolamine, previously removed from the U.S. market, may lead to additive effects if taken with ephedra. Caution is advised with other agents takes for weight loss.
Ephedra may also interact with alcohol, general anesthetics and drugs taken for gout. Ephedra products should be stopped 24 hours prior to surgery.
The stimulant effects of ephedra may be increased when combined with herbs and supplements that have stimulant properties or with supplements that contain caffeine, such as guarana, cola nut, bitter orange, and yerba mate. Commercially available products may contain combinations of ephedrine and caffeine or guarana. Ephedra may alter thyroid hormones and should be used cautiously with other herbs or supplements that affect thyroid hormones, such as bladderwrack (seaweed, kelp).
Ephedra may decrease the effectiveness of cardiac glycosides (supplements taken for heart failure and irregular heart beat).
Ephedra may raise blood pressure and may increase the blood pressure-raising effects of herbs such as American ginseng.
Ephedra may lower blood sugar levels. Caution is advised when using herbs or supplements that may also lower blood sugar. Blood glucose levels may require monitoring, and doses may need adjustment.
Ephedra may increase the diuretic effects of herbs such as artichoke. Ephedra may also interact with urine acidifiers/alkalinizers.
Combining ephedra with herbs that have possible monoamine oxidase inhibitor (MAOI) antidepressant activity such as St. John's wort may cause severe side effects, including dangerously high blood pressure, muscle breakdown, fever, and irregular heartbeats. Ephedra may also interact with other antidepressant herbs such as those that have selective serotonin reuptake inhibitor (SSRI) activity.
Effects of cholesterol-lowering herbs and supplements may be altered by ephedra, although this has not been proven.
Ephedra may also interact with herbs taken for gout or with hormonal activity.
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