Herbals Flashcards
What is CAM?
A group of diverse medical and health care systems, practices, and products, that aren’t considered to be part of conventional medicine
What are herbal products?
Medicinal agents obtained from plants
Are herbal products considered dietary supplements?
Yes
Give me some examples of herbs
Flowering plants, shrubs, trees, moss, ferns, algae, seaweed, fungus, flowers, fruits, leaves, twigs, bark, roots, and seed.
Basically, fucking everything.
Decade when natural health had a rebirth
1960’s
Fuckin’ hippies, man
The Office of Alternative Medicine (NIH) was established in 1991 for this reason
Cost of healthcare was rising –> trying to make more options
The National Center for Complementary and Alternative Medicine (CAM NIH) was formed in 1998 for this reason
To research the efficacy of CAM options
As part of the Dietary Supplementand Health Education Act, the FDA created a “dietary supplement” category in 1994(under which herbal remedies fall). Tell me about this category of “medications”
Require no proof of efficacy or safety
Sets no quality control standards
They are exempt from pharmaceutical regulations
The products MAY claim an effect (boots immune system), but can’t claim a cure or treatment (treats colds)
Due to the lack of control of for efficacy, safety, or quality control in herbals, consumers do not know…
1) If active ingredients are even in the product
2) If ingredients are bioavailable
3) If the dosage is appropriate
4) If each bottle or even each pill has the same components
Give me an example of the poor quality control seen in herbal supplements
Amount of Ginseng and potency of Ginseng varies widely between manufacturers and even between batches.
The potency of Ginsenosides (active ingredient) varied WIDELY between manufacturers and batches
Labels were inaccurate
The ginseng was contaminated with other substances like scopolamine and heavy metals
Additives were not on the label (NSAIDs, steroids, sedatives, etc)
Why aren’t manufacturers compelled to do trials to prove efficacy?
1) They aren’t required to
2) They wouldn’t be able to recover the cost of proving that the herbal is safe
The claims of an herbal’s efficacy is mostly based on
anecdotal reports
Are toxicities for herbals listed?
No.
Toxicities are determined by clinical trials, which herbals do not undergo. Plus each pill/batch/manufacturer all have different ingredients and doses so it would be impossible to control
Classification system of herbal safety and toxicity
Class 1: Safe if used appropriately
Class 2: Restrictions unless otherwise directed
a) External use only
b) Do not use if pregnant
c) Do not use i f breastfeeding
Class 3: Only use under the supervision of an expert
Class 4: Insufficient data is available
__% of Americans use some sort of CAM
35%
__% of Americans presenting for surgery use herbal medications
23%
50% take multiple herbs
25% also take prescription drugs
__% of those using herbs don’t tell their doctor or anesthesia provider
70%
Need to ask them about it because often people don’t think of herbs as worth mentioning!
Profile of the typical herbal user
White, college educated females
40-60 years old
Patients undergoing neuro and OBGYN procedures
Ways in which herbal medications affect the perioperative period
1) Direct intrinsic effects
- Predictable SE like bleeding
2) Pharmacodynamic interactions
- Alteration of the action of other dugs
3) Pharmacokinetic interactions
- Altered absorption, distribution, metabolism, and elimination of other drugs
It is recommended that pts stop taking herbals ___ days before surgery
14
This is recommended by both the ASA and AANA, but is unrealistic because no one sees pts this far in advance of surgery
What is Kava Kava?
Polynesia plant
CNS depressant, sedative, and anxiolytic
(Sounds kinda of like a benzo!)
This med will prolong our anesthetic
Anesthesia concerns with Kava Kava
Potentiates the sedative effects of our anesthetics
Potential for addiction, tolerance, and W/D
SE: HA, dizziness, ataxia, sluggish reflexes, and GI discomfort
Long-term use can cause dry, scaly skin and yellow discoloration of skin and nails, photosensitivity, and hepatotoxicity***
Valerian
Sedative, mild anxiolytic, sleep aid
Potentiates the sedative effect of our anesthetics (avoid with opioids, benzos, and barbs)
SE: HA, excitability, ataxia, and GI discomfort
Can have W/D symptoms that are more severe than Kava Kava (delirium and cardiac abnormalities)
St. John’s Wort
“Prozac alternative” used to treat depression.
SE: Photosensitivity**, allergic reactions, HA, dizziness, restlessness, fatigue, GI upset, and has additive effects with anesthesia
St. John’s Wort is cannot be taken with these medications
MAOIs
Will lead to serotonin syndrome
St. John’s Wort induces the CYP450. It should be used with caution with these drugs:
Indinovir (HIV med), cyclosporines, digitalis, BBs, CCBs phenobarb, phenytoin, birth control, benzos, coumadin, alfentanil, lidocaine, steroids, and NSAIDs
Major SE with Ginko Biloba
Bleeding! Inhibits PAF and platelet aggregation. Will enhance the anticoagulant effect of other anticoagulants, especially those that inhibit platelet aggregation (coumadin, NSAIDs, and ASA)
It’s used to improve cognitive function and circulation.
Uses for Ginko
Improve cognitive function and circulation.
Use for Garlic
To treat HTN and high cholesterol
May also have anti-cancer properties.
Our main anesthesia concerns with Garlic
1) Bleeding
- Inhibits plt aggregation and causes fibrinolysis
- Bleeding risk enhanced when combined with other meds to inhibit plt aggregation (warfarin)
2) Hypotension
Ginseng use and SE
panax quinquefolius
“Pep Pill”
Used as a mood and energy booster! Also protects against stress and restores homeostasis.
SE: Hypoglycemia and bleeding (inhibition of plt aggregation)
Anesthesia concerns with Ginseng
1) They get too peppy! Transient nervousness, excitation, tachycardia, , HTN, epistaxis, HA, insomnia, allergies, fluid/electrolyte abnormalities
2) Hypoglycemia
3) Bleeding risk
- Avoid ASA and NSAIDs
- May decrease the effectiveness of warfarin
Saw Palmetto use and SE
Used to treat BPH
Also has anti-inflammatory effect via inhibition of COX (will also cause bleeding)
Ephedra use and SE
Has direct AND indirect sympathomimetic effects (just like ephedrine!) CNS stimulant (can cause seizures)
Used as weight loss aid. Also to increase energy and treat asthma.
What is the active ingredient of ephedra?
Ephedrine!
Anesthesia concerns with ephedra
All s/s of ephedrine: HTN, tachycardia, arrhythmias, vasoconstriction, and vasospasm
DANGERS: MI, myocarditis, stroke, agitation, shaking, anxiety, insomnia, psychosis, seizures, nervousness, and panic attacks
Those taking ephedra can develop ___ by depleting endogenous NE stores. This can result in hemodynamic instability.
Tachyphylaxis
Ephedra has a life-threatening interaction with
MAOIs
Echinacea is used for
It boosts the immune system! (Short-term)
Prophylaxis and treatment of infections (especially URIs)
Anesthesia concerns for Echinacea
1) Allergic reactions (boosts the immune system too much), especially in those with asthma, atophy, and allergic rhinitis
2) Prolonged use can overstimulate the immune system and actually cause immunosupression
- Avoid in those with systemic disorders (TB, MS, HIV, and other autoimmune diseases)
3) Hypoglycemia
4) Hepatotoxicity
Melatonin
1) Hormone that naturally controls the sleep-wake cycle
2) Used to treat insomnia, jet lag, etc
It readily crosses the BBB and increases the sedative effects of hypnotics/benzos (has actually been studied as a pre-op anxiolysis drug)
Melatonin may interact with these meds
Anticoagulants
Immunosuppressants
DM meds
BCP
If St. John’s Wort is taken with MAOIs, it can lead to this
Central Serotonin Syndrome
This herbal may decrease the effectiveness of warfarin
Ginseng
