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[Definitie:] "An ergogenic aid is any substance or phenomenon that enhances performance."
(Wilmore and Costill) 
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1 2 - 0 3 - 2 0 0 5 Severe hepatotoxicity associated with the use of weight loss dietsupplements containing ma huang or usnic acid
Guy Neff, Rajender Reddy, Francisco Durazo, Douglas Meyer, Ricardo Marrero, Neil Kaplowitz
In evaluating the recent experiences at four transplant centers, we were impressed with the presentation of a surprising number of patients with acute hepatitis or acute liver failure with no other cause than the association with the use of herbal products for weight loss. Therefore, we decided to report this series of cases of hepatic injury due to herbal weight loss remedies, which require hospitalization in order to alert the medical community to this association. We retrospectively reviewed the records of 12 patients, who had hepatotoxicity thought to be related to the ingestion of herbal weight loss compounds from various ingredients, including ma huang and usnic acid. Data recorded on each patient include duration of therapy, time to presentation from last ingestion, and the determination of the contribution of other possible underlying diseases or medical conditions.
Table 1 contains patient demographics, laboratory data and patient outcomes. All patients had complete testing for hepatitis serology, autoimmune markers and ceruloplasmin. These were all negative in every case. Each patient denied the use of illicit drugs, concomitant herbal products or acetaminophen containing products. Abdominal sonography and physical findings were not suggestive of chronic liver disease in any of the patients. All urine drug and toxicology screens were negative. One of the more common herbal ingredients in weight loss products is ma huang, a potent herb that is present in many agents including Xenadrine, Excelerator, BetaLin, Thermo Diet Stack, Super Diet Max, Hydroxycut, Metabolife and Herbalife. Used to increase energy or lose weight, ma huang containing products on the market will use one of the following lists of names: ma huang, herbal ecstasy, mahuang, mahuanggen and ma huang root.
A recent study found that patients that took Lipokinetix supplements developed hepatotoxicity and in some cases developed fulminant hepatic failure. Usnic acid has been shown to kill hepatocytes and a recent report describes acute liver failure requiring liver transplantation in a patient who took pure usnic acid.
The association between ma huang ingestion without other medications and the onset of fulminant hepatic failure strongly suggests that these herbal products caused the acute liver failure requiring liver transplantation in three cases.
The time interval of approximately 6 weeks or more between the use of the drugs containing ephedra, and the absence of hypersensitivity manifestations, suggest an idiosyncratic mechanism for liver injury. Whether the drug or an intermediate metabolite is involved in hepatotoxicity is unclear as ma huang appears metabolized through the liver and its half life may be prolonged with individuals suffering from hepatic failure.
In our 10 cases of ephedra alkaloid use, the development of severe hepatic dysfunction and even features of fulminant hepatic failure followed the ingestion of this product. Either death or transplantation with complications, evolved in three of the nine cases.
Seven patients had a severe course of hepatitis, yet recovered spontaneously and without any residual effects. The pre ma huang ingestion laboratory values were not available in any of the patients; however, none suffered from any comorbid diseases. The potential role of prior liver disease, particularly marked fibrosis, as a result of obesity cannot be excluded. Despite growing concerns within the medical community, the distribution of herbal remedies, including ephedra free products remains uncontrolled and unsupervised.
Even though the FDA recently restricted the use of ma huang agents there remains many other herbal agents that have been reported to cause hepatotoxicity with a few listed as follows; jin bu huan, chelidonium majus, chaparral, chaso and onshido. Consumers should be aware that the FDA has been unable to regulate these products and that potential dangers can lead to organ failure, transplantation or death.
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