alyssa vivas ashley barlond envh 472 herbal remedy derived from plant (ephedra sinica) chinese...
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What is ephedra?
Herbal remedy derived from plant (Ephedra sinica)
Chinese herb derivative in dietary supplements Acts as a stimulant
Constricts blood vessels Increases BP, HR, metabolism, body heat,
& expands bronchial tubes Different than ephedrine
Ephedra: plant Ephedrine: Main active ingredient,
similar to amphetamine Stimulate NS & heart
Common Uses…
Herbal remedy to treat respiratory problems (i.e. asthma, cold/flu symptoms)
Weight loss supplements Athletic enhancement Energy supplements Treatment of Hypotension Herbal street drug
alternative
Background
• 1990’s – first entered U.S. market
-FDA investigates adverse events• 1994 – DSHEA (Dietary Supplements Health & Education Act)• 1997 – FDA proposed ruling for banning: >8mg • - stricter labeling of low-dose ephedra supplements • 2001 – Minnesota Vikings player died (suspected)• 2003 – Studies confirm negative effects, consumer alert• 2003 – Orioles Pitcher Steve Bechler died• 2004 – FDA bans ephedra
Stopped retail sales, manufacture, and distribution
Ephedra considered “adulterated”
Ephedra manufacturers tried to lobby against it• 2005 – Utah judge tried to overturn ban• 2006 – Federal appeals court reaffirms FDA ban & overturns UT judge
After ban: dietary supplement companies replaced ephedra with other herbal
stimulants; marketed them as “ephedra-free”
FDA = no dose of ephedrine alkaloids safe!
Risk Assessment
1) Hazard Identification
2) Exposure Assessment
3) Dose-Response Assessment
4) Risk Characterization
Hazard Identification
To gain background, FDA uses data from:
Adverse event information FDA received 140 adverse event reports from 6/1/97 to
3/31/99 22 “attributable 33 “supportive” 72 “insufficient data” 8 “not evaluated”
Clinical studies & scientific reviews NIH RAND Corp. evaluated safety & efficacy
Hazard Identification (con’t)
Does ephedra really work?short-term weight lossincreased energy, endurance, and
strength
BUT There are serious side effects!
Hazard Identification (con’t)
Originally thought of as safe because it’s natural,but serious CV & CNS side effects (even in small doses):
HypertensionDizzinessNervousnessTremblingHeadache Insomnia
DehydrationVomitingIrregular heartbeatSeizuresHeart attackStroke
Hazard Identification (con’t)
Can cross blood-brain barrier and become potent CNS stimulator
More hazardous when combined with caffeineSynergistic effects
Can ultimately lead to death
Half-life: 3-6 hours Excreted largely unchanged in urine
Hazard Identification (con’t)
Past study found:Ephedra use related to stroke, heart
attack, sudden deathDon’t need to be pre-disposed to heart
problems to have severe side effectsToxic effects even with low dosesInduces cardiotoxic problems: lesions,
hemorrhage, necrosis, and degeneration.
Hazard Identification: Toxicology
Proposed Mechanism of Heart Toxicity
Ephedrine + Caffeine oral exposure
Quick Absorption (toxic levels develop within 1 hr)
“Fight-or-flight” hormones released
Blood vessels narrow (result in high BP)
Increase in heart rate
Chest pain; heart not getting enough O2-rich blood
Heart cell & tissue death
Hemorrhage
Sudden Death
Exposure Assessment
RouteIngestion (main method); injections (less common)
Excreted in breastmilk
EndpointHeart/Cardiovascular system
Amount Dietary supplements:Typical pills contain 10-50 mg per pill, x3
doses per day =30-150 mg/day
Exposure Assessment (con’t)
Duration3 doses/day
WhoAthletes (increased energy & stamina)Others:
Dieters (aids weight loss) People who use street drugs (herbal
alternative to drugs)People who use it as herbal remedy
(respiratory problems)
2003- Pitcher Steve Bechler died after taking ephedra.
Dose-Response Assessment
Before FDA ban…
NOAEL: 90 mg/day = 1.3 mg/kg*day
LOAEL: 150 mg/day = 2.1 mg/kg*day
But not enough supporting evidence was found as to how these values were calculated.
Given past studies about adverse effects associated with even low doses of ephedra, we think NOAEL & LOAEL are NOT valid.
Dose-Response Assessment (con’t)
Animal study: effects of ephedra + caffeine significantly increased cardiotoxicity (hemorrhage, necrosis, ventricle degeneration)
Our Risk Assessment
Using numbers from animal study…
NOAEL: 15 mg/kg*day = 0.015 mg/kg*day 1000
LOAEL: 30 mg/kg*day = 0.030 mg/kg*day 1000
Uncertainty Factors
Interspecies variability
10
Intraspecies variability
10
Database uncertainty 10
TOTAL 1000
Intake Calculation based on FDA limits
I = C * CR * EFD BW * ATI =(24 mg/day ) 70 kgI = 0.34 mg/kg*day
C (concentration): n/aCR (contact rate): 24 mg/dayBW (body weight): 70 kgI (intake): ??
Before, ban FDA recommended 24 mg maximum dose of ephedra per day. Based on this…
Our NOAEL/LOAEL values are lower!
Risk Characterization
Habit-forming
Can build up tolerance leads to higher doses for same effect
Based on precautionary assessment, risk is mild
Precautionary Assessment
Initial Parameter Score Comment
Community / Social Issues
Evaluate effects on the community and related social issues.
G G=Goal 3
1-a lot, 2-some, 3-little. Does this move forward the goal of human and environmental health?
N N=Need 3
1-a lot, 2-some, 3-little or not sure. Ask the question: Is it necessary? Do we really need this?
FF=Future Generations 1
1-little, 2-some, 3-high impact. Is there a potential impact on future generations of humans and other species?
D
D=Democratic, community based process 3
1-a lot of community involvement and consultation, 2-some, 3-little. Was the community consulted early and often in the process? Was the process democratic and inclusive.
A A=Alternatives 2
1-alternatives were carefully considered, 2-some consideration, 3-no consideration. Were alternatives considered?
Total 12/15 5-good, supportive of health and community
15-poor, not supportive of health or community
Not supportive of health or community
Precautionary Assessment
Exposure Issues Evaluate potential exposure issues.
E E=Exposure 30-none, 1-little, 2-some, 3-high. Do we have control over the exposure?
MM=Multiple exposures
10-none, 1-little, 2-some, 3-high. Is there exposure to other chemicals with similar hazard?
ChCh=Children exposed
30-none, 3-little, 5-some or high or don't know. Children are often more vulnerable. Are children being exposed.
CPCP=Consumer products
20-not in consumer products, 1-little, 2-some, 3- a lot or do not know. Is this compound in consumer products?
OO=Occupational exposure
00-no occupational exposure, 1-little, 2-some, 3- a lot or do not know. Is there occupational exposure?
FF=Food exposure
00-not in food supply, 1-little, 2-some, 3- a lot or do not know. Is the compound present in the food supply.
Total 9/20 0-no exposure, no problems20-significant exposure, serious concern
Mild exposure risk
Precautionary Assessment
Hazard / Toxicity Evaluate potential hazards.
H H=Hazard 10
1-low, 5-some, 10-high. Follow classical hazard evaluation, pick endpoint, exam relevant quality studies (cancer, reproductive, neurotoxicity, irreversible)
ISIS=Individual Sensitivity
21-little 2-some, 3-a lot. Determine if any individuals are more sensitive than health adult such as the very young or old.
ECEC=Ecological hazard
11-little 2-some, 3-a lot. Is it a hazard to other species or the environment?
V V=Volume 5 how much is produced (1=research only, 2=<1000 lbs, 3=<10,000, 4=<100,000, 5=>100,000 or do not know)
P P=Persistent 11-little persistence 2-some, 3-a lot of persistence or do not know. Is the compound presistent in the environment?
BB=Bioaccumulate
11-little 2-some, 3-a lot. Does it bioaccumulative in humans or animals or move up the food chain?
UCUC=Uncertainty
21-little 2-some, 3-a lot. How certain is the information?
Total
22/30
7-low hazard30-significant hazards or unknowns, serious concern
Medium-high hazard & toxicity
Precautionary Approach
Final Results
Community/Social Issues 12/15
Exposure Issues 9/20
Hazard/Toxicity 22/30
TOTAL: 43/65
Limitations of Risk Assessment
Lack of adequate data Animal studies No strong evidence that ephedra actually
enhances athletic performance Low dose extrapolation
Don’t really know the least dosage when side effects occur
Multiple chemical exposures Amount of caffeine taken with ephedra
varies & could have role in severity of side effects
Risk-Benefit Analysis
Feb 2004, FDA published final ruling that supplements with ephedrine alkaloids present unreasonable risk of illness or injury
Ex 1 : no significant differences in strength, endurance, power when taken as an athletic supplement
Ex 2: Weight loss associated with ephedra is only short-term and not sufficient enough to “cure” obesity. Severe heart and nervous system risks outweigh weight loss
July 2008 Final Rule: “… dietary supplements that contain ephedrine alkaloids are adulterated under section 402(f)(1)(A) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 342(f)(1)(A)). It is illegal to market an adulterated dietary supplement.”
FDA’s Lack of Power
Federal Food and Drug Administration (FDA): Main Task: Protect public from harmful
products
Ephedra considered dietary/herbal supplementNot a drug FDA cannot
regulate itFDA doesn’t regulate
manufacturer’s potentially false claims
Groups with Economic Interests
“Stakeholders“Dietary supplement manufacturers
Ex: Metabolife contributed millions to national politicans to sway their vote in favor of ephedraReceived 14,000+ adverse event reports from ephedra, but
not reported to FDA
Can make unproven health claimsNot required to report adverse reactions
Labels don’t list all ingredients, real dosage, adverse effects
Groups Claims/Scientific Uncertainty
“Asia MedLabs” (ephedra manufacturer) Made medical claims w/o
scientific evidence treats flu, fever, allergies
Manufacturers hired private consulting firm = scientific review claiming ephedra is safe
Manufacturers claimed: **Decreasing obesity
outweighs risks of ephedra
Insufficient evidence to support athletic-enhancing benefits of ephedra
Portrayal by Media
Manufacturers advertisements attract
consumers
Media introduced it to public w/
national headlines of Baltimore Orioles
death
Death: drew attention & thought to be key
factor in FDA’s push
National headlines = FDA warning
Media reinforcing FDA= ephedra dangerous
Stigma of WLS: Fear of WLS
Risk Management
In the hands of manufacturers w/: Dietary Supplement Health &
Education Act (DSHEA) Before market: Manufacturer evaluates
safety of WLS before reaches market On market:
FDA regulates unsafe WLS productsFTC regulates advertising
**DSHEA makes it harder for FDA to protect public
Barriers to consensus: WLS manufacturers have strong
lobbying against amending DSHEA Lack of evidence (except ephedra)
to prove DSHEA not adequately protecting public
What we think… FDA: 0.34 mg/kg*day Ours: 0.015 mg/kg*day
Ban should have happened long time ago
More stringent regulations during pre-manufacturing/ marketing of WLS Regulate like a drug = need to
tell consumers risks
Need to amend DSHEA
Promote healthy way to lose weight other than supplements