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Eight herbal medications pose potential dangers in surgical patients

OB/GYN News, April 1, 2003 by Mitchel L. Zoler

BIG SKY, MONT. -- Eight herbal medications each may have a significant impact on patients undergoing surgery.

Results from a 1997 survey indicated that 12% of people in the United States used herbal medications, and recent survey results from people who were undergoing surgery indicated that in this group the fraction may be as high as 22% or 32%.

Eight herbal medications can be singled out because, as a group, they account for more than half of the single-herb preparations sold in the United States, even though more than 1,500 different preparations are on the U.S. market, Dr. Eric J. Bieber said at a meeting on gynecology gynecologic oncology and reproductive endocrinology.

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Although herbal preparations are widely used by patients who undergo surgery in hospitals or as outpatients, it's been estimated that more than 70% of patients fail to disclose their use of herbal medicine during routine preoperative assessments. As a result, physicians need to specifically elicit and document a patient's history of using herbal medications, said Dr. Bieber, chairman of the division of ob.gyn. at the Geisinger Health System in Danville, Pa.

Dr. Bieber, who coedited the "Textbook of Complementary and Alternative Medicine" (Boca Raton: Parthenon, 2002), summarized some of the relevant effects that each of these eight commonly used herbal medications have in surgical patients:

* Echinacea. This agent is immunostimulatory with short-term use, so it should be avoided by patients who need perioperative immunosuppression. When used for more than 8 weeks, echinacea has the potential to cause immunosuppression, which in theory can lead to postsurgical complications, including impaired wound healing and opportunistic infections. Echinacea use also has been associated with allergic reactions, so it should be used with caution by patients with asthma, atopy or allergic rhinitis. The herb should be used with caution by patients with liver dysfunction because of concerns that it can cause hepatotoxicity. The potential for hepatotoxicity is another reason to stop use far in advance of scheduled surgery.

* Ephedra. This herb causes dose-dependent increases in heart rate and blood pressure. It also causes vasoconstriction and, in some cases, vasospasm of coronary and cerebral arteries that may lead to myocardial infarction and thrombotic stroke. Patients who use ephedra and are later anesthetized with halothane may be at risk of developing ventricular arrhythmias. Ephedra can also affect cardiovascular function by causing hypersensitivity myocarditis. Long-term use can cause tachyphylaxis by depleting catecholamine stores, which can contribute to perioperative bradycardia instability. Concurrent use of ephedra and monoamine oxidase inhibitors can result in life-threatening hyperpyrexia, hypertension, and coma. Ephedra should be discontinued at least 24 hours before surgery.

* Garlic. Garlic inhibits platelet aggregation, and also has the potential to lower blood pressure, although this effect is weak. The potential that garlic holds for irreversibly inhibiting platelet aggregation may warrant stopping garlic use at least 7 days before surgery especially if postoperative bleeding is a particular concern or if other platelet inhibitors are used.

* Ginkgo. Ginkgo appears to alter vasoregulation, act as an antioxidant, modulate neurotransmitter and receptor activity, and inhibit platelet-activating factor (PAP). The effect on PAP raises the greatest concern for the perioperative period because this may alter platelet function and lead to bleeding. Use should be discontinued at least 36 hours before surgery.

* Ginseng. This herb has a broad and incompletely understood pharmacologic profile. It lowers postprandial blood glucose, which may create hypoglycemia in patients who have fasted before surgery It also inhibits platelet aggregation in vitro, but this effect has not been confirmed in humans. Ginseng has been reported to interfere with the anticoagulation effect of warfarin. Because its effect on platelets may be irreversible, it should be discontinued at least 7 days before surgery.

* Kava. Kava interacts with anesthetics and has several effects on the central nervous system, including antiepileptic, neuroprotective, and (locally) anesthetic. It also may act as.a sedative and hypnotic, and should be discontinued at least 24 hours before surgery.

* St. John's wort. This agent inhibits serotonin, norepinephrine, and dopamine re-uptake. St. John's wort can also significantly increase the metabolism of many concomitantly administered drugs, some of which are used for perioperative care, including cyclosporine, midazolam, and lidocaine. It also may decrease the anticoagulant effect of warfarin. St. John's wort should be discontinued at least 5 days before surgery he said at the meeting, sponsored by the University of Chicago.

* Valerian. Valerian produces dose-dependent sedation and hypnosis and can potentiate the sedative effects of anesthetics and adjuvants such as midazolam. Discontinue with caution in patients who are long-term users and may have a physical dependence; stopping could result in a benzodiazepine-like withdrawal. In these patients, tapered discontinuation over several weeks with close medical supervision is recommended. If this isn't possible, the patient may take valerian up until the day of surgery If withdrawal symptoms develop postoperatively, treat with benzodiazepines.

Health Care Industry

Eight herbal medications pose potential dangers in surgical patients

OB/GYN News, April 1, 2003 by Mitchel L. Zoler

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