Ephedrine Withdrawal Causes Severe Psychiatric Symptoms:

A Case Report

Gene Makela, Pharm.D., BCPP

Kelly Slear

Marcella Hoyland

Kelly SlearMarcella Hoyland

Pharmaceutical Investigations course, West Virginia University

School of Pharmacy

The Case 64-year-old woman long history of depression abruptly increased symptoms of depression

and suicidal ideation with a plan to shoot herself with a gun

difficulty sleeping very low energy decreased appetite, energy, and concentration language and memory intact

The Case judgment and insight poor some signs of paranoia: during the interview she

reported “my family wants to get rid of me” auditory hallucinations had returned recently: she

heard voices of her great aunt and uncle telling her she was worthless, no good, and she should have died when she was born

major depressive disorder with psychotic features was diagnosed

Beck Depression Inventory (BDI) 63

Medications on Admission

mirtazepine 30mg daily olanzapine 20mg daily levothyroxine 0.88mg daily conjugated estrogen 0.625mg daily calcium carbonate 600mg twice daily compliant with therapy, had been stable

Pharmacist Intervention

pharmacist faculty member with student conducted detailed medication history with following findings: patient was taking eight Xenadrine capsules

daily as a weight loss product for the past three to four months

she reported that she took this product until two days before admission to the hospital

at that time, on the advice of her daughter, she abruptly discontinued the Xenadrine

Components of Xenedrine®

• Pantothenic acid 20mg

• Bitter orange - standardized to 2.5mg synephrine (similar to phenylephrine)

• Ma Huang (ephedra) - standardized to 10mg ephedrine

• Guarana extract (100mg caffeine)

• Ginger root 25mg

• White willow bark (15mg salicin)

• L-tyrosine, L-carnitine, Magnesium phosphate, Deanol (choline precursor).

• Note: normal dose is 2 capsules daily **

Bitter Orange

Citrus aurantium Adrenergic amines

Synephrine and octopamine (structurally similar to epinephrine)

Hordenine Tyramine Methyltyramine

Background Common adverse effects of ephedrine reported to FDA by

consumers included elevated blood pressure, tachycardia, muscle injury, psychosis, and memory loss

FDA mandates rule in 1997 requiring manufactures of supplements containing ephedrine that products be labeled with information about risks and dangers

FDA requires stronger labeling cautions in 2003: “ephedrine has a significant risk of illness or injury to the consumer”

FDA creates new Adverse Event Reporting System (CAERS) in 2003 to enable both health care providers and consumers to more easily report adverse events from dietary supplements

In February, 2004, the FDA acts to ban ephedra-containing products

Resolution mirtazepine dosage increased to 45mg at bedtime over the next several days depression symptoms

and psychosis cleared without further intervention BDI 54 after 2 days

on the day of discharge, seven days after admission, the patient reported feeling much better

no suicidal thoughts or auditory hallucinations hopeful about the future

discharge diagnoses included major depressive disorder, recurrent, improving, Xenadrine abuse, and Xenadrine withdrawal, resolving

Whatever happened toEphedrine Products?

2008 internet search… Ephedra products still available many new products marketed using

bitter orange as a substitute for MaHuang

Advertisement for ephBURN25

“this product is made from the old ephedra like the old lipodrene – smell the pills you’ll agree”

one capsule: MaHuang extract 8% Dark (25mg) Caffeine 200mg Other ingredients Dose: 1 capsule twice daily

http://www.worldclassnutrition.com/eph1.html

Is Ephedrine Legal?

May be you ask yourself how we are still selling ephedrine after the ephedra ban on A ugust 21,2006. The answer is very simple.

Ephedrine HCL is not Ephedra. Ephedra for weight loss has been banned. Ephedrine HCL is thedrug with ephedrine and it is used as a bronchodilator.

Although ephedra diet pills are banned, it is legal to sell remaining stocks of ephedra dietpills.

We bought remaining inventory from our d istributors. Ephedra Products are highly effectiveweight loss supplements and have helped millions slim down to achieve their goals with propernutrition plan and using recommended dosage. We have a select amount and they will be gon eshortly as they are heavily demanded.

http://www.buyvasoproephedrine.com/is-ephedrine-legal.html

Xenadrine RFA-1 is a registered trademark of Cytodyne Technologies Superdrine RX-10 is aregistered trademark of American Generic Labs, LLC

http://www.worldclassnutrition.com/superdrine.html

Considerations abrupt discontinuation of a stimulant taken for a long

period of time may lead to depressive symptomatology In this unique case, however, a depressed patient stable

on medications was thrown into severe depression with psychosis and suicidality as a result of the abrupt withdrawal of a non-prescription dietary supplement used for weight loss

despite combined antidepressant (mirtazepine) and antipsychotic (olanzapine) treatment, discontinuation of a non-prescription weight loss product was sufficient to acutely de-stabilize this patient’s condition

Results / Conclusions

abrupt discontinuation of non-prescription stimulant medication may cause severe depressive symptomatology, even in a patient whose depression had been adequately controlled with prescription medication

detailed medication history important in clarifying cause of hospitalization, helpful in defining the appropriate course of treatment.

What Would Have Happened if: There was no pharmacist intervention?…

possible: delayed or incorrect diagnosis higher doses of prescribed medication…

potential adverse effects addition of other medication to stabilize patient

…potential drug interactions prolonged hospitalization

To Take Home

Psychiatric pharmacists can facilitate accurate diagnoses by conducting medication histories… Resultant pharmacotherapeutic approaches may

minimize length of stay for patients**

Current availability of ephedrine…need for awareness

Questions ???