Herbals

Question 1

Current regulation stems from

Answer 1

1994 FDA created supplement category

Requires no proof of efficacy or safety

No quality controls

Exempt from pharm. regulations

Question 2

Can supplements claim to cure anything?

Answer 2

No, but they may claim specific effects, such as “boosts immunity”

Question 3

Lack of regulation leads to

Answer 3

Unknowns regarding-
Active ingredients
Bioavailability
Proper dosage
Consistency
Contaminants

Question 4

Why do manufacturers not conduct safety studies

Answer 4

Not required to

Expensive and unlikely to recoup the costs

Question 5

Does the FDA issue warnings about potential problems with supplements?

Answer 5

No, in the past they did, but too numerous to continue to do so

Question 6

What is the industry group that offers safety recommendations regarding supplements

Answer 6

American Herbal Product Association

Question 7

What are the safety classes used by the AHPA

Answer 7

Class 1- safe when used appropriately

Class 2- External use only, not to be used when nursing/pregnant

Class 3- Only to be used under the supervision on an expert

Class 4- Insufficient data

Question 8

How large is the supplement market

Answer 8

$63 billion in 2003

35% of the population takes some form

Question 9

What percentage of patients continue to use herbals prior to surgery

Answer 9

About 23%

Half of those take multiple products and a quarter also take Rx drugs

Question 10

What percentage of pts do not report supplement use to anesthesia providers

Answer 10

70%

Question 11

Profile of common herbal users

Answer 11

Female, 40-60
White
College education
Neuro/OB/GYN procedures

Question 12

Most commonly used herbals in the US

Answer 12

Echinacea
Gingko
St.John's wort
Garlic
Ginseng
Saw palmetto
Ephedra
Valerian
Kava

Question 13

How do herbals affect periop course

Answer 13

Direct effects

Dynamic interactions (alters effects of other meds)

Kinetic interactions (altered metabolism/elimination of other drugs)

Question 14

Specific anesthesia concerns

Answer 14

Prolong effects of anesthetic agents
Increased bleeding risk
Hypo/hypertension
Hypoglycemia
Hepatotoxicity

Question 15

What are the current recommendations regarding herbals and surgery

Answer 15

Discontinue 14 days prior to surg

Question 16

Kava kava

Answer 16

CNS depressant, sedative, anxiolytic

Additive to anesthetics

Potential withdraw/addiction potential

SE: HA, dizziness, sluggishness, GI upset

Long term use may cause scaly skin, yellowing of skin/nails, photosensitivity, and hepatotoxicity

Question 17

Valerian

Answer 17

Sedative, anxiolytic, sleep aid

Increase sedative effects of anesthetics, avoid with barbs, opioids, and benzos

SE: HA, excitability, ataxia, GI upset

Can develop withdrawal- delirium, CV instability

Question 18

St. John’s wort

Answer 18

Used for depression

SE: allergic reactions, HA, dizziness, restlessness, fatigue, GI upset, photosensitivity, additive effects with anesthesia

Caution with MAOIs (serotonin syndrome)

Induces CYP450 (Indinavir, cyclosporine, dig, CCBs, BBs, phenobarb, phenytoin, birth control, benzos, coumadin, alfentanil, lidocaine, steroids, NSAIDs

Question 19

Gingko

Answer 19

Used for cognitive function and to improve circulation

SE: HA, dizziness, GI upset, dermal sensitivity

Can increase risk of bleeding, especially with other platelet inhibitors, coumadin, ASA/NSAIDS

Question 20

Garlic

Answer 20

Inhibits platelets, increases fibrinolysis, treats HTN/Cholesterol. May have anticancer properties.

Concerns- increased risk of bleeding, especially with platelet inhibitors and warfarin

Can create hypotension

Question 21

Ginseng

Answer 21

Lowers blood glucose, inhibits platelets, used to enhance mood/energy and protect against stress

Concerns- nervousness, excitation, tachycardia, inability to concentrate, insomnia, HA, HTN, epistaxis, allergies, water/e-lyte imbalances.

Hypoglycemia

Increased bleeding risk with anticoagulants. Avoid with ASA/NSAIDS.

May DECREASE effectiveness of warfarin

Question 22

Saw palmetto

Answer 22

Used for BPH

May have anti inflammatory properties (Inhibits COX, platelets)–> may increase bleeding

Question 23

Ephedra

Answer 23

Direct and indirect sympathomimetic, CNS stimulant. Its basically ephedrine.

Used for weight loss, increased energy, asthma

Concerns- HTN, tachycardia, arrhythmias, vasospasm, MI, myocarditis, stroke, agitation, anxiety, psychosis, panic attacks

Can develop tachyphylaxis

Life threatening interactions with MAOIs

Banned in 2003, but still available in Utah, also online

Question 24

Echinacea

Answer 24

Short-term immune stimulation. Used for prophylaxis, infections, esp URIs

Concerns- allergic reactions (in asthma, atopy, rhinitis), decreased effectiveness of immunosuppressants, may lead to overstimulation (avoid in tuberculosis, leukosis, MS, HIV, DM, other autoimmune disorders)

Worsens control in diabetic pts- hypoglycemia

Hepatotoxic

Question 25

Melatonin

Answer 25

Hormone that controls sleep-wake cycle

Used for insomnia, jet lag, shift work sleep aid

Readily crosses BBB, increases sedative effects of benzos. Has been studied as a pre op anxiolytic drug.

May interact with anticoags, immunosuppressants, DM meds, BCP

Question 26

Pre-op assessment

Answer 26

Specifically address herbals
List agents used, dose, frequency, duration
Source, potential side effects
D/C prior to surg, especially for coags, CNS, and blood glucose altering agents
Check appropriate labs if not stopped