Ran into this link from another forum, it does raises some interesting questions and probably few answers for you DXMers..
http://www.jefferson.edu/anesthesiology/research/herbmed.cfm
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K. Mathai Kurien, M.D
Jefferson Medical College
Thomas Jefferson University
In 1997 adults in the US spent an estimated 3.5 billion dollars on herbal medicines. Of concern is the fact that 70% of patients do not reveal their use of herbal agents to treating physicians, considering these agents natural supplements rather than medicines. Hence the patient presenting for surgery may pose a considerable challenge to the anesthesia provider in terms of unexpected complications during the perioperative period.
Herbals: supplements or medicines?
The manufacture and sale of herbal products are not held to the same standards and regulations that the FDA maintains for the pharmaceutical industry. This was due to the Food, Drug and Cosmetic Act of 1938 and the Kefauver- Harris Drug Amendment of 1962, which classified herbals as food supplements. The reality of the market place however is that herbals are being used not for their nutritional value but for their drug like effects. Safety and health practices continued to be of concern and in 1998 the FDA published regulations stating that “dietary supplements that expressly or implicitly claim to diagnose, treat, prevent or cure a disease continue to be regarded as drugs and have to meet the safety and effectiveness standards for drugs under the Food, Drugs and Cosmetics Act”. In response herbal manufacturers now add the disclaimer that their product “ is not intended to diagnose, cure, treat or prevent any disease” Thus as long as specific medical diagnoses are avoided, any advertising claim however outrageous is permitted.
The effects of specific nutrients:
Echinacea (E.angustifolia, E. pallida, E. purpurea)
It is effective in reducing symptoms of URI if taken very early in the course of the illness for 10 days. It is however ineffective in the prevention of cold/UTI.
Clinical Aspects: The commonest side effects are an unpleasant taste and tachyphylaxis. The immunostimulatory effects of Echinacea may antagonize the immunosuppressive actions of cyclosporine and steroids. Flavanoids from Echinacea inhibit hepatic cytochrome P-450 3A4 enzyme thus increasing levels of Phenytoin, Rifampin and Phenobarbital.
Ephedra (Ephedra sinica)
It is effective in the short term treatment of asthma and bronchospasm but ineffective as a single agent for weight loss. Ephedra contains ephedrine, pseudoephedrine and phenylpropanolamine. It has positive chronotropic, inotropic and bronchodilator actions. It increases metabolic rate because of which it is used as a slimming aid. Adverse effects of this drug include hypertension, tachycardia, cardiomyopathies, myocardial infarction, strokes and death.
Clinical Aspects: Perioperative hypertension is possible with this drug causing myocardial ischemia or stroke. It can also interact with volatile general anesthetics and digoxin to cause cardiac arrhythmias. With prolonged use peripheral catecholamines stores are depleted causing intraoperative hypotension responsive to a direct vasoconstrictor rather than ephedrine. Use with MAO inhibitors can result in a hypertensive crisis while the effectiveness of decadron is reduced due to increased clearance.
Feverfew (Tanacetum parthenium)
Feverfew is effective in the prevention of migraine and the US Headache Consortium 2000 guidelines suggest feverfew as a second line preventive treatment. Chrysanthenyl acetate is one of the active ingredients in feverfew and by blocking vascular muscle contraction prevents the onset of a migraine. Adverse effects include apthous ulcers, loss of taste and a rebound headache on abrupt discontinuation.
Clinical Aspects: Due to its anti-platelet actions there is an increased risk of bleeding when used with heparin, NSAID’s, aspirin, and Vitamin E. To date there has been no known complication with regional anesthesia including central blockade and feverfew use.
Garlic (Allium sativum)
The drug is possibly effective in moderate reduction in cholesterol. Contrary to the statins there is no sustained reduction at six months. It has modest antihypertensive actions due to smooth muscle relaxation secondary to the production of NO. Garlic powder 900 mgs per day retards atherosclerotic progression by the prevention of endothelial cell depletion of glutathione, which reduces oxidative stress. Several epidemiological studies have shown a reduction in colorectal, stomach and prostate cancer risk but not lung or breast cancer. Blood sugar reduction in diabetics is known but not significant. Garlic also reduces platelet activity by inhibition of epinephrine induced aggregation and increases the bleeding time. Further it enhances the anticoagulant effect of warfarin reflected as an increase in the INR. There is one case of a spontaneous epidural hematoma in an 87 year man related to excess garlic ingestion. Garlic also inhibits cytochrome P450 2D6 enzyme increasing blood levels of Fentanyl, Demerol, Methadone, Zofran, and Ultram by a modest 6-10%.
Clinical Aspects: Since garlic can augment the effects of warfarin, heparin and aspirin and can independently increase the bleeding time, it should be stopped two weeks prior to surgery and serious thought should be given before central blockade within that period.
Ginger (Zingiber officinale)
Ginger is effective in the treatment of dyspepsia and vertigo and is superior to dimenhydrinate and metoclopramide in the treatment of motion sickness. Ginger is also effective in the treatment of post operative nausea and vomiting particularly in the absence of opiates. It is a potent inhibitor of Thromboxane synthetase enzyme, which can inhibit platelet activity and increase bleeding time.
Clinical Aspects: Concomitant use of ginger and other anticoagulants should be avoided. Occasionally the hypertensive and positive inotropy effects of the drug interfere with intraoperative blood pressure control.
Gingko (Gingko biloba.
Gingko is effective in Alzheimer’s, vascular and mixed dementias .In higher doses it improves claudication pain. It improves the neuropsychological symptoms of premenstrual syndrome and is also effective in the treatment of acute mountain sickness. Of concern are two case reports of subdural bleeds and one subarachnoid bleed associated with gingko. The FDA is also aware of 7 cases of seizures related to gingko use.
Clinical aspects: Concomitant use of gingko and other anti-coagulants/anti platelet drugs should be avoided. It should be used with caution in patients with a history of seizures or on anti-seizure medication. Blood sugars should be monitored frequently in diabetics as gingko improves beta cell function as well as increasing insulin clearance thus complicating blood sugar management.
Ginseng (Panax ginseng)
It is used as a general tonic, as an adaptogenic to improve resistance to stress, anti-aging, and energy booster and to improve stamina by athletes. Its adaptogenic properties stem from its action on the Hypothalamic- Pituitary-Adrenal axis causing an increase in cortisol levels. It has an inhibitory action on platelet aggregation. On the contrary it reduces the effectiveness of warfarin and decreases the INR. It also causes a reduction in fasting blood sugars and HbA1c levels in non-insulin dependant diabetics. There is some evidence that fresh white and red ginseng reduces the incidence of stomach,lung, liver and ovarian cancer.
Clinical Aspects: Ginseng should be avoided in patients along with drugs such as heparin, aspirin and NSAID’s. A coagulation profile prior to central blockade is wise as the ginseng can increase the PTT and the TT. Due to its hypoglycemic effect blood sugars should be checked during the intraoperative period. Use with MAO inhibitors can precipitate mania. The variability in actions on the cardiovascular system dictate that one should be prepared for both hypo and hypertension in the perioperative period.
Cayenne (Capsicum annuum, C. frutescens)
It is used to stimulate digestion and to treat colic, cramps and sea sickness. Pepper spray is used in self-defense. Topically it is widely used for pain relief in shingles, post mastectomy pain and in diabetic and HIV related neuropathy. This is secondary to the release and subsequent depletion of Substance P from nerve endings. As do many herbals, cayenne does have an anti-platelet action as well as an anti-fibrinolytic effect. The drug also has a sympathomimetic action and can interact with MAO inhibitors and cocaine to cause dangerous stimulatory effects.
Clinical Aspects: Care should be exercised with concomitant use of other anti-coagulants and anti-platelet drugs. In addition severe hypertensive effects can be seen with cocaine and MAO inhibitors.
St Johns Wort
It is used for depression, anxiety and obsessive-compulsive states. It is as effective as low dose tricyclics and SSRI’s in the treatment of mild to moderate depression. However there is no evidence of its efficacy in obsessive disorders. The drug blocks the therapeutic effects of many medications including oral contraceptives and warfarin. Patients taking MAO inhibitors may develop symptoms of a serotoninergic syndrome exhibited by changes in mental status, agitation, hyper-reflexia, shivering, tremor, in coordination and progress to death.
Clinical Aspects: The anesthesia provider should review additional medications the patient may be taking. Concomitant use with photosensitization drugs ( piroxicam, tetracycline), MAO inhibitors, sympathomimetic amines or SSRI drugs is to be undertaken with caution. Oral contraceptive efficacy is affected and appropriate action needs to be taken.
Conclusion
Clearly all herbs are not safe. In the last 20 years there have been over 100 deaths due to herbal use. With their present categorization as food supplements, strict scrutiny is lacking. Anesthesiologists should have a detailed knowledge of the common herbals and asking about their use in the pre-operation evaluation should be routine. The ASA suggests that all herbal medications should be discontinued 2-3 weeks prior to an elective surgical procedure and patients must be educated about the serious drug-herb interactions that may occur if they fail to observe our recommendation. Further reading and sources of information ASA pamphlet: Considerations for Anesthesiologists: What you should know about your Patients’ use of Herbal Medicines (1999) – ASA@ 520 N.Northeast Highway, Park Ridge, Illinois 60068-2573, www.asahq.org.
Gruenwald J et al
DR for Herbal Medicines, 1st edition. Montvale, New Jersey: Medical Economics Co ; 1998. P> Handbook of Medicinal Herbs by James Duke: CRC Press, Boca Raton, Fla.,
Gillis CN. Medicinal Plants rediscovered. Seminars in Anesthesia, Perioperative Medicine and Pain.1998; 17(4): 319-330.
Natural Medicines comprehensive database accessed at www.naturaldatabase.com. This is available as a web and a book version.
---------
http://www.jefferson.edu/anesthesiology/research/herbmed.cfm
------
K. Mathai Kurien, M.D
Jefferson Medical College
Thomas Jefferson University
In 1997 adults in the US spent an estimated 3.5 billion dollars on herbal medicines. Of concern is the fact that 70% of patients do not reveal their use of herbal agents to treating physicians, considering these agents natural supplements rather than medicines. Hence the patient presenting for surgery may pose a considerable challenge to the anesthesia provider in terms of unexpected complications during the perioperative period.
Herbals: supplements or medicines?
The manufacture and sale of herbal products are not held to the same standards and regulations that the FDA maintains for the pharmaceutical industry. This was due to the Food, Drug and Cosmetic Act of 1938 and the Kefauver- Harris Drug Amendment of 1962, which classified herbals as food supplements. The reality of the market place however is that herbals are being used not for their nutritional value but for their drug like effects. Safety and health practices continued to be of concern and in 1998 the FDA published regulations stating that “dietary supplements that expressly or implicitly claim to diagnose, treat, prevent or cure a disease continue to be regarded as drugs and have to meet the safety and effectiveness standards for drugs under the Food, Drugs and Cosmetics Act”. In response herbal manufacturers now add the disclaimer that their product “ is not intended to diagnose, cure, treat or prevent any disease” Thus as long as specific medical diagnoses are avoided, any advertising claim however outrageous is permitted.
The effects of specific nutrients:
Echinacea (E.angustifolia, E. pallida, E. purpurea)
It is effective in reducing symptoms of URI if taken very early in the course of the illness for 10 days. It is however ineffective in the prevention of cold/UTI.
Clinical Aspects: The commonest side effects are an unpleasant taste and tachyphylaxis. The immunostimulatory effects of Echinacea may antagonize the immunosuppressive actions of cyclosporine and steroids. Flavanoids from Echinacea inhibit hepatic cytochrome P-450 3A4 enzyme thus increasing levels of Phenytoin, Rifampin and Phenobarbital.
Ephedra (Ephedra sinica)
It is effective in the short term treatment of asthma and bronchospasm but ineffective as a single agent for weight loss. Ephedra contains ephedrine, pseudoephedrine and phenylpropanolamine. It has positive chronotropic, inotropic and bronchodilator actions. It increases metabolic rate because of which it is used as a slimming aid. Adverse effects of this drug include hypertension, tachycardia, cardiomyopathies, myocardial infarction, strokes and death.
Clinical Aspects: Perioperative hypertension is possible with this drug causing myocardial ischemia or stroke. It can also interact with volatile general anesthetics and digoxin to cause cardiac arrhythmias. With prolonged use peripheral catecholamines stores are depleted causing intraoperative hypotension responsive to a direct vasoconstrictor rather than ephedrine. Use with MAO inhibitors can result in a hypertensive crisis while the effectiveness of decadron is reduced due to increased clearance.
Feverfew (Tanacetum parthenium)
Feverfew is effective in the prevention of migraine and the US Headache Consortium 2000 guidelines suggest feverfew as a second line preventive treatment. Chrysanthenyl acetate is one of the active ingredients in feverfew and by blocking vascular muscle contraction prevents the onset of a migraine. Adverse effects include apthous ulcers, loss of taste and a rebound headache on abrupt discontinuation.
Clinical Aspects: Due to its anti-platelet actions there is an increased risk of bleeding when used with heparin, NSAID’s, aspirin, and Vitamin E. To date there has been no known complication with regional anesthesia including central blockade and feverfew use.
Garlic (Allium sativum)
The drug is possibly effective in moderate reduction in cholesterol. Contrary to the statins there is no sustained reduction at six months. It has modest antihypertensive actions due to smooth muscle relaxation secondary to the production of NO. Garlic powder 900 mgs per day retards atherosclerotic progression by the prevention of endothelial cell depletion of glutathione, which reduces oxidative stress. Several epidemiological studies have shown a reduction in colorectal, stomach and prostate cancer risk but not lung or breast cancer. Blood sugar reduction in diabetics is known but not significant. Garlic also reduces platelet activity by inhibition of epinephrine induced aggregation and increases the bleeding time. Further it enhances the anticoagulant effect of warfarin reflected as an increase in the INR. There is one case of a spontaneous epidural hematoma in an 87 year man related to excess garlic ingestion. Garlic also inhibits cytochrome P450 2D6 enzyme increasing blood levels of Fentanyl, Demerol, Methadone, Zofran, and Ultram by a modest 6-10%.
Clinical Aspects: Since garlic can augment the effects of warfarin, heparin and aspirin and can independently increase the bleeding time, it should be stopped two weeks prior to surgery and serious thought should be given before central blockade within that period.
Ginger (Zingiber officinale)
Ginger is effective in the treatment of dyspepsia and vertigo and is superior to dimenhydrinate and metoclopramide in the treatment of motion sickness. Ginger is also effective in the treatment of post operative nausea and vomiting particularly in the absence of opiates. It is a potent inhibitor of Thromboxane synthetase enzyme, which can inhibit platelet activity and increase bleeding time.
Clinical Aspects: Concomitant use of ginger and other anticoagulants should be avoided. Occasionally the hypertensive and positive inotropy effects of the drug interfere with intraoperative blood pressure control.
Gingko (Gingko biloba.
Gingko is effective in Alzheimer’s, vascular and mixed dementias .In higher doses it improves claudication pain. It improves the neuropsychological symptoms of premenstrual syndrome and is also effective in the treatment of acute mountain sickness. Of concern are two case reports of subdural bleeds and one subarachnoid bleed associated with gingko. The FDA is also aware of 7 cases of seizures related to gingko use.
Clinical aspects: Concomitant use of gingko and other anti-coagulants/anti platelet drugs should be avoided. It should be used with caution in patients with a history of seizures or on anti-seizure medication. Blood sugars should be monitored frequently in diabetics as gingko improves beta cell function as well as increasing insulin clearance thus complicating blood sugar management.
Ginseng (Panax ginseng)
It is used as a general tonic, as an adaptogenic to improve resistance to stress, anti-aging, and energy booster and to improve stamina by athletes. Its adaptogenic properties stem from its action on the Hypothalamic- Pituitary-Adrenal axis causing an increase in cortisol levels. It has an inhibitory action on platelet aggregation. On the contrary it reduces the effectiveness of warfarin and decreases the INR. It also causes a reduction in fasting blood sugars and HbA1c levels in non-insulin dependant diabetics. There is some evidence that fresh white and red ginseng reduces the incidence of stomach,lung, liver and ovarian cancer.
Clinical Aspects: Ginseng should be avoided in patients along with drugs such as heparin, aspirin and NSAID’s. A coagulation profile prior to central blockade is wise as the ginseng can increase the PTT and the TT. Due to its hypoglycemic effect blood sugars should be checked during the intraoperative period. Use with MAO inhibitors can precipitate mania. The variability in actions on the cardiovascular system dictate that one should be prepared for both hypo and hypertension in the perioperative period.
Cayenne (Capsicum annuum, C. frutescens)
It is used to stimulate digestion and to treat colic, cramps and sea sickness. Pepper spray is used in self-defense. Topically it is widely used for pain relief in shingles, post mastectomy pain and in diabetic and HIV related neuropathy. This is secondary to the release and subsequent depletion of Substance P from nerve endings. As do many herbals, cayenne does have an anti-platelet action as well as an anti-fibrinolytic effect. The drug also has a sympathomimetic action and can interact with MAO inhibitors and cocaine to cause dangerous stimulatory effects.
Clinical Aspects: Care should be exercised with concomitant use of other anti-coagulants and anti-platelet drugs. In addition severe hypertensive effects can be seen with cocaine and MAO inhibitors.
St Johns Wort
It is used for depression, anxiety and obsessive-compulsive states. It is as effective as low dose tricyclics and SSRI’s in the treatment of mild to moderate depression. However there is no evidence of its efficacy in obsessive disorders. The drug blocks the therapeutic effects of many medications including oral contraceptives and warfarin. Patients taking MAO inhibitors may develop symptoms of a serotoninergic syndrome exhibited by changes in mental status, agitation, hyper-reflexia, shivering, tremor, in coordination and progress to death.
Clinical Aspects: The anesthesia provider should review additional medications the patient may be taking. Concomitant use with photosensitization drugs ( piroxicam, tetracycline), MAO inhibitors, sympathomimetic amines or SSRI drugs is to be undertaken with caution. Oral contraceptive efficacy is affected and appropriate action needs to be taken.
Conclusion
Clearly all herbs are not safe. In the last 20 years there have been over 100 deaths due to herbal use. With their present categorization as food supplements, strict scrutiny is lacking. Anesthesiologists should have a detailed knowledge of the common herbals and asking about their use in the pre-operation evaluation should be routine. The ASA suggests that all herbal medications should be discontinued 2-3 weeks prior to an elective surgical procedure and patients must be educated about the serious drug-herb interactions that may occur if they fail to observe our recommendation. Further reading and sources of information ASA pamphlet: Considerations for Anesthesiologists: What you should know about your Patients’ use of Herbal Medicines (1999) – ASA@ 520 N.Northeast Highway, Park Ridge, Illinois 60068-2573, www.asahq.org.
Gruenwald J et al
DR for Herbal Medicines, 1st edition. Montvale, New Jersey: Medical Economics Co ; 1998. P> Handbook of Medicinal Herbs by James Duke: CRC Press, Boca Raton, Fla.,Gillis CN. Medicinal Plants rediscovered. Seminars in Anesthesia, Perioperative Medicine and Pain.1998; 17(4): 319-330.
Natural Medicines comprehensive database accessed at www.naturaldatabase.com. This is available as a web and a book version.
---------
![:\](https://bluelight.org/xf/BL_Images/Orig_Emoji/wrygrin.gif "wry grin :\")
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. Cimetidine to potentiate you take like 400mgs 15 minutes before dosing right? I just want to make sure. And whats rantidine Bwitaiacumen??? People help me out. 
