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Adv Pharm 1 > Herbals > Flashcards

Herbals Flashcards

1
Q

When in doubt, when should you stop all herbals/supplements before surgery? (Blue box!)

A

2-3 weeks before surgery

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2
Q

What is the definition of supplements from the Dietary Supplement Health and Education Act (DSHEA of 1994)?

A

Vitamins, minerals, herbs or other botanicals, amino acids, or dietary supplements used to supplement the diet by increasing dietary intake, or concentrates, metabolites, constituents, extracts, or any combination of these ingredients.

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3
Q

What are the “facts” regarding supplements?

A

-Available without a prescription
-Legally not considered to be medications or drugs
-No proof of efficacy or safety required prior to marketing (FDA has to prove that it is harmful to have it removed)
-No FDA Approval required prior to sales

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4
Q

Are dietary supplements food?

A

They are regulated as food, but not used as food
-Often used like drugs
-Used in place of drugs
-Used in combination with drugs

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5
Q

What changed with the 2006 Dietary Supplement and Non-Prescription Drug Consumer Protection Act?

A

-Requires reporting by manufacturers, packers & distributors
-Submit to the FDA reports of serious adverse effects
-Goal: to identify trends to alert the public to potential safety issues

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6
Q

What did the FDA release in 2007?

A

The final Good Manufacturing Practice (GMP) standards
-For 13 years prior to this, the manufacturers governed themselves.

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7
Q

What are the problems related to oversight of supplements?

A
  • Lots of variation in product purity and potency due to the lack of manufacturing standards and FDA regulation
    -Now all manufacturers, small & large, should be in compliance with the 2007 regulations
    -Many of the ingredient suppliers are based overseas so unfortunately the FDA has very little oversight of the industry
    -Federal regulators are unable to adequately inspect manufacturing facilities in a timely or efficient manner
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8
Q

What are the issues related to reporting of adverse events associated with Herbals?

A

-Expect under-reporting
-Confusion: was it the primary ingredient or additives?
-Consumers do not routinely report, they don’t know how
-Inadequate testing for drug interactions (difficult and costly to achieve)
-Chemical analysis is rarely performed.

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9
Q

What are the common uses for Echinacea?

A

Supports immune system, may be effective in early colds. But, with long term use, it becomes an immune suppression.
Immune Modulation
Anti-Inflammatory
Antibacterial
Antifungal
Antiviral
Antioxidant

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10
Q

Echinacea should not be used for longer than ___ -___ days. (Blue Box!)

A

Should not be used for longer than 10-14 days.

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11
Q

What are the cautions for the use of Echinacea?

A

-Some evidence to support efficacy in the early treatment of colds
-Avoid in pts with immune deficiencies and autoimmune disorders!!
-Avoid when taking medications that have a disulfiram rxn (some preparations have a high alcohol content)

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12
Q

What are the common adverse rxns associated with Echinacea?

A

IV – flu like symptoms
PO – GI upset/rash
Immunosuppressing effects with long term use
Chronic use = hepatic failure

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13
Q

What are the common uses for Garlic?

A

-CV – reduces total cholesterol & triglycerides
-Antiplatelet effect
-Antihypertensive
-Cancer prevention

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14
Q

What are the cautions for the use of Garlic?

A

-Caution in pts taking anti-clotting meds (warfarin, ASA, ibuprofen, etc) as it also has anti-platelet effects
-Risk for bleeding rxn!!

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15
Q

What are the common adverse rxns associated with Garlic?

A

Nausea
Hypotension
Allergy
Bleeding
Breath/Body odor

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16
Q

What are the common uses for Ginkgo?

A

-CV: improves PVD
-Protective effect in dec oxidative stress in CABG pts through scavenging of free radicals
-May have antiplatelet effects (caution in those taking anti-coags)

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17
Q

What are the cautions for the use of Ginkgo?

A

-Caution in patients taking anticoagulants
-Enhances sedative effects of trazodone

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18
Q

What are the adverse rxns associated with Ginkgo?

A

-Seizures (toxicity)
-Nausea, GI upset
-HA, Bleeding
-Allergy, Anxiety
-Insomnia

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19
Q

What are the other uses of Ginkgo that do not have sufficient evidence at this time to support clinical use?

A

-Allergic & asthmatic bronchoconstriction
-Short term memory in healthy non-demented adults
-Erectile dysfunction
-Tinnitus & hearing loss
-Macular degeneration

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20
Q

What are the common uses of Ginseng?

A

-Immune Modulation (WBC stimulation)
-CNS - 🡹Ach, Serotonin, NE & Dopa
-Antioxidant effects
-Anti-Inflammatory effects
-Antistress activity
-Vasoregulatory effects
-Cardioprotective activity
-Improved glucose hemostasis
-Anticancer properties
-Anti-platelet activity

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21
Q

What does Ginseng claim to be?

A

An Adaptogen

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22
Q

What is an Adaptogen?

A

Helps the body return to normal after exposure to stressful stimuli

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23
Q

Why is it difficult to interpret the data from research of Ginseng?

A

Wide variety of Ginseng is used.
-Chinese: Panax Ginseng
-American: Panax Quinquefolium
-Siberian, Brazilian, etc.

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24
Q

For what uses does Ginseng have the strongest support?

A

Strongest support for use in cold prevention, lowering post-prandial glucose, and nonspecific CA prevention
-Intended use: Immune cell modulation.

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25
Q

What are the cautions associated with the use of Ginseng?

A

-Interactions with Psych Meds = irritability, sleeplessness & manic behavior
-Caution in patients taking anticoagulants
-Caution with immune suppressants

26
Q

What are the adverse effects associated with the use of High doses of Ginseng? (> 3g/d)

A

-Vaginal Bleeding/Mastalgia
-Insomnia/Nervousness
-HTN

2/2 Methylxanthines found in the plant

27
Q

What are the common uses for Milk Thistle?

A

-Liver Disease
-Chemotherapeutic Effects
-Lactation

28
Q

What are the cautions associated with the use of Milk Thistle?

A

-Effect on improving liver fxn or mortality from liver disease are poorly substantiated
-Clinical effect can neither be supported or ruled out
-IV: Silybin antidote for mushroom poisoning in Europe

29
Q

What are the adverse effects associated with the use of Milk Thistle?

A

-Laxative effect at high doses (>1500mg)
-No reported drug interactions

30
Q

What are the common uses for St. John’s Wort?

A

Antidepressant – inhibition of reuptake of serotonin, NE & Dopa

31
Q

What are the cautions associated with the use of St. John’s Wort?

A

-Evidence shows effective for depression
-No evidence for premenstrual dysphoric disorder, climacteric complaints, somatoform disorders or anxiety
-Being studied for antiviral and anticarcinogenic effects

32
Q

What are the adverse effects associated with the use of St. John’s Wort?

A

-Photosensitivity!
-CNS Effects: Hypomania & mania
-Autonomic arousal
-Use cautiously or avoid in pt’s taking antidepressants or stimulants
-May induce the CYP450 system!!!
-Sub-therapeutic levels of numerous drugs when taken in combo with SJW

33
Q

What drugs are at risk for having sub-therapeutic levels when taken in combo with St. John’s Wort?

A

-Digoxin
-Birth control meds
-Cyclosporine**
-HIV protease & nonnucleoside reverse transcriptase inhibitors
-Warfarin**
-Irinotecan
-Theophylline
-Anticonvulsants**

34
Q

What are the common uses for Saw Palmetto?

A

BPH

35
Q

What are the cautions associated with the use of Saw Palmetto?

A

-Evidence shows no significant improvement in most urologic symptoms
-Produce similar effects to Finasteride and Tamsulosin (one study lacking placebo controls)

36
Q

What are the adverse effects associated with Saw Palmetto?

A

-Incidence 1-3%
-ABD PN, nausea, diarrhea
-Fatigue, HA, decreased libido, rhinitis
-Rare: liver damage, pancreatitis, increased bleeding

-No drug interactions noted

37
Q

What is Coenzyme Q10?

A

Found in the mitochondria of organs
Potent antioxidant
Possible role in maintaining muscle function

38
Q

What are the common uses for Coenzyme Q10?

A

-HTN: small but significant reductions after 8-10 wks
-CHF: inc EF by 3.7%
-Ischemia: small reductions in the rate of reinfarction after an acute MI
-Statin-Induced Myopathy: more information is needed

39
Q

What are the adverse effects associated with the use of Coenzyme Q10?

A

-Little to no adverse effects in doses of 3000mg/day
-Diarrhea, nausea, heartburn, anorexia < 1%
-Similar structure to Vit K: decreases effects of warfarin

40
Q

What is Glucosamine?

A

-Found in human tissues
-Cartilage nutrient
-Needed for the production of articular cartilage
-Commercially derived from crabs & crustaceans

41
Q

What are the common uses for Glucosamine?

A

-OA: used to maintain and 🡹 the strength of existing cartilage
-Oral and intra-articular admin
-Early studies very + for improved mobility, ROM and strength
-Recent studies have mixed results and some (-)
-No benefit in mild-mod disease

42
Q

What are the adverse effects associated with the use of Glucosamine?

A

-Well tolerated
-Mild diarrhea and nausea occasionally reported
-Potential cross sensitivity with shellfish allergies
-May interfere with the INR in warfarin pts (inc risk for bruising and bleeding)

43
Q

What is Melatonin?

A

-Serotonin derivative produced by the pineal gland
-Regulates the sleep-wake cycle
-Natural release coincides with darkness
-Suppressed by daylight

44
Q

What are the common uses for Melatonin?

A

-Jet lag: subjective reduction in daytime fatigue,
Improved mood, quicker recovery times
Helpful when traveling >4 time zones

-Insomnia: improves sleep onset, duration and quality
🡹 REM sleep and morning alertness
Baseline endogenous levels not a factor

45
Q

What are the adverse effects associated with the use of Melatonin?

A

-Well tolerated
-Preferred over OTC sleep aids (Less of a foggy haze afterwards compared to other sleep meds (doesn’t use benadryl)
-Both inc and dec in BP have been seen
-BP should be monitored in pts on HTN meds
-Drowsiness, fatigue, HA, dizziness and irritability have been reported

46
Q

What is important to know regarding Melatonin and Reproduction?

A

-Female: Associated with midcycle suppression of luteinizing hormone surge and secretion
Potentially result inhibition of ovulation
Recommended not to use melatonin in women who are pregnant or attempting to conceive

-Male: Chronic use results in decreased sperm quality via aromatase inhibition in the testes

Recommended not to be used by couples trying to conceive

47
Q

What are the anesthetic implications associated with Echinacea?

A

-Activation of cell-mediated immunity
-Risk for Allergic Rxns
-Decreased effectiveness of immunosuppressive actions of corticosteroids and cyclosporine, potential for immunosuppression
-Inhibition of hepatic enzymes may precipitate toxicity of drugs metabolized by the liver (Phenytoin, rifampin, phenobarb)

48
Q

When should you d/c Echinacea prior to surgery?

A

No data; so 2-3 weeks prior

49
Q

What are the anesthetic implications with the use of Ephedra (Ma huang)?

A

-Increased HR and BP through direct & indirect sympathomimetic effects
-Risk of myocardial ischemia and stroke from tachycardia and HTN
-Ventricular arrhythmias with Halothane
-Long-term use depletes endogenous catechols and may cause intraop hemodynamic instability
-Control hypotension with direct vasoconstrictors like Phenylephrine
-Life-threatening interactions with MAOIs.

50
Q

When should you stop Ephedra (ma huang) before surgery?

A

At least 24 hrs before surgery

51
Q

What are the anesthetic implications associated with Garlic?

A

-Inhibition of plt aggregation (may be irreversible)
-Inc fibrinolysis
-Equivocal anti-hypertensive activity
-Potential to inc risk of bleeding, especially when combined with other meds that inhibit plt aggregation

52
Q

When should you stop taking garlic before surgery?

A

At least 7 days before

53
Q

What are the anesthetic implications with Gingko?

A

-Inhibition of platelet activating factor
-Potential to increase risk of bleeding, especially when combined with other medications that inhibit plt aggregation

54
Q

When should you stop taking Gingko before surgery?

A

At least 36 hours before

55
Q

What are the anesthetic implications with Ginseng?

A

-Lowers BG (hypoglycemia)
-Inhibition of plt aggregation (may be irreversible)
-Increased PT-PTT in animals
-Increased risk of bleeding
-Potential to decrease anti-coag effects of Warfarin

56
Q

When should you stop Ginseng before surgery?

A

At least 7 days before surgery

57
Q

What are the anesthetic implications with Kava?

A

-Sedation
-Anxiolysis
-Potential to increase sedative effects of anesthetics
-Potential for addiction, tolerance, and withdrawal after abstinence unstudied

58
Q

When should you stop taking Kava before surgery?

A

At least 24 hrs before surgery

59
Q

What are the anesthesia implications associated with St. John’s Wort?

A

-Inhibition of neurotransmitter reuptake
-Monoamine oxidase inhibition is unlikely
-Induction of CYP450
-Drug interactions: cyclosporine, warfarin, steroids, protease inhibitors, and possible benzos, CBs
-Decreased serum dig levels

60
Q

When should you stop taking St. John’s Wort before surgery?

A

At least 5 days before surgery

61
Q

What are the anesthesia implications with Valerian?

A

-Sedation
-Potential to increase sedative effects of anesthetics
-Benzo like acute withdrawal
-Potential to increase anesthetic requirements with long-term use

62
Q

When should you stop taking Valerian before surgery?

A

No data; so 2-3 weeks before

Adv Pharm 1 (28 decks)

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