Herbals Flashcards
Echinacea: uses, actions, pharmacokinetics
member of the daisy family
use: prophylaxis and treatment of viral, bacterial and fungal infections (specifically URI)
actions: immunostimulatory, immunosuppressive or anti inflammatory
pharmacokinetics: limited, stop as far in advance as possible, consider hepatic function and compromise to blood flow related to surgery type
Echinacea: concerns
immunosuppressive
-contraindicated in pts with systemic autoimmune disorders (TB, leukosis, MS, HIV, SLE, etc)
worsen metabolic control in diabetic patients - hypoglycemia
hepatotoxicity
Ephedra: details, uses, pharmacokinetics
ma huang
contains alkaloids - ephedrine, pseudoephedrine, norephedrine, norpseudoephedrine
banned in 2004, but available on internet
uses: promotes weight loss, increase energy, treats respiratory conditions
pharmacokinetics:
- elimination half life: 5.2 hours
- 70-80% excreted unchanged in urine
- stop AT LEAST 24 hrs prior
Ephedra: concerns
- sympathomimetic effects - fatal cardiac and CNS complications
- release of endogenous norepi
- acts on adrenergic receptors - cardiovascular function - hypersensitivity myocarditis
- hemodynamic instability
- MAOIs-interaction life threatening (increase circulating norepi —> hypertensive crisis)
- kidney stones
Garlic: details, use, actions
extensively researched
use: reduce BP, thrombus formation, serum lipid and cholesterol, may have anticancer properties
actions: sulfur containing compounds (allicin)
- promotes phagocytosis and stimulates T cell production —->preventing infection
- decreases LDL production and lowers cholesterol
- anti thrombotic properties
Garlic: concerns
- inhibits platelet aggregation
- interaction with warfarin (INR) tend to see increased INR
- decrease systemic and pulmonary vascular resistance (animals) –> hypotension
Garlic: pharmacokinetics
insufficient data
stop 7 days prior
risk for bleeding, anticoagulant, neuraxial techniques (consider risk/benefit analysis)
Ginger: details, use
Use: arthritis, sprains, muscular aches, pain, sore throat, antiemetic
Ginger: concerns
concerns:
1. inhibit arachidonic acid - induced human platelet serotonin release and aggregation
2. increased INR and epistaxis
potency similar to that of aspirin with antiplatelet activity
may warrant d/c at least 2 wks prior to sx
Gingko: details, use, actions
use: cognitive disorders, PVD, macular degeneration, vertigo, tinnitus, erectile dysfunction, altitude sickness, cognitive performance (alzheimers or dementia)
actions: terpenoids and flavonoids
Gingko: concerns
- alters vasoregulation
- modulates neurotransmitter and receptor activity
- inhibits platelet activating factor
- potential drug interactions with warfarin, MAOIs, amlodipine, prochlorperazine
Gingko: pharmacokinetics
E1/2 life: 3-10 hours
stop 2 wks prior
Ginseng: details, actions
actions: protects against stress and restores homeostasis
Ginseng: concerns
- hypoglycemia –> also consider NPO status for sx
- alters coag pathways - inhibit platelet aggregation, prolong thrombin time and APTT
- warfarin interference
- side effects: transient nervousness, excitation, tachycardia, insomnia, headache, HTN, epistaxis, water/electrolyte disturbances
Ginseng: pharmacokinetics
stop 48 hours to 2 weeks prior
platelet inhibition may be irreversible so maybe want to consider stopping 2 weeks prior
Green tea: use
use: improve brain function, fat loss, protection against CA, lowering risk of heart disease
Green tea: concerns
- antiplatelet activity (inhibit thromboxin a2?/prolong bleeding)
- antagonize warfarin (vitamin K)
Green tea: pharmacokinetics
half life: 1.9-4.6 hrs/2.2 -3.4 hrs
stop 7 days prior
Kava: actions
anxiolytic and sedative effects
Kava: concerns
- CNS - antiepileptic, neuroprotective, LA properties
- sedative hypnotic (potentiate GABA)
- increased barb sleep time
- abuse potential
- hepatotoxicity
- kava dermopathy
- inhibition of platelet aggregation
- CV effects
Kava: pharmacokinetics
peak plasma: 1.8 hours
E1/2 life: 9 hours
renal and fecal elimination
d/c 24 hours prior (consider that it will effective sedatives)
earlier if potential to compromise hepatic function
Saw Palmetto: details, use, actions
Use: BPH
Actions:
- inhibition of estrogen and androgen receptors
- binding of autonomic recptors
- blocking prolactin receptor signal transduction
- interference with fibroblast proliferation
- induction of apoptosis
- inhibition of alpha 1 adrenergic receptors
- anti inflammatory effects
Saw Palmetto: concerns
- bleeding/coagulopathy
- inhibition of COX
- platelet dysfunction
Saw Palmetto: pharmacokinetics
No clinical data
No specific recs to stop
St Johns Wart: use, actions
Use: mental health, clinical depression (Major)
Actions: inhibits reuptake of serotonin, norepi, dopamine
syndrome of central serotonin excess?
St Johns Wart: concerns
- increase metabolism of many drugs –> indinavir sulfate (HIV med), ethinylestradiol (birth control), cyclosporine as well as alfentanil, midazolam, lidocaine, ca channel blockers, 5HT
- decreased anticoagulant effect of warfarin, NSAIDs
- changes digoxin pharmacokinetics
St Johns Wart: pharmacokinetics
Stop 5 days prior and avoid post op
important in transplant/those requiring anticoagulation
Valerian: use, actions
Use: sedative, treatment for insomnia
Actions: dose dependent sedation/hypnosis (GABA)
Valerian: concerns
- Withdrawal (with abrupt d/c)
- cardiac complications
- attenuation of symptoms with benzos
- potentiate sedative effects of anesthetics
Valerian: pharmacokinetics
not studied
withdrawal - dose gradually decreased
close supervision over several weeks if possible (if unable to do so, consider having patient take up until day of surgery)
consider benzos for withdrawal symptoms
Coenzyme Q: details, use, actions
dietary supplement
antioxidant compound - structurally related to Vit K
Use: cancer
Actions: counteract apoptotic events (DNA fragmentation, cyctochrome C release, membrane potential depolarization)
Coenzyme Q: concerns, when to stop
Concerns:
- warfarin –> decrease effects
- increase risk of bleeding
conflicting evidence
stop 2 weeks prior
Glucosamine and Chondroitin: details, use
dietary supplement
Use: joint disorders, management of OA
Glucosamine and Chondroitin: concerns
- worsen diabetes (animal)
2. warfarin
Glucosamine and Chondroitin: pharmacokinetics, when to stop
90% absorbed (oral)
extensive first pass metabolism
peak plasma - 4 hours
stop 2 weeks prior
Fish oil: details, use
dietary supplement
Use: reduce incidence of chronic dx involving inflammatory processes, CV dx, bowel dx, RA, neurodegenerative illnesses
Fish oil: concerns, when to stop
Concerns
- inhibit platelet aggregation
- warfarin
stop 2 weeks prior
prolonged sedative effects of anesthetic agents
kava - anxiolytic and sedative effects
valerian - potentiate sedative effects of anesthetics
increased risk of bleeding
garlic - inhibits platelet aggregation
ginger - increased INR, potency similar to aspirin
ginkgo - inhibits platelet activating factor
ginseng - alters coag pathways, prolongs PT/PTT (platelet inhibition may be irreversible)
green tea - antiplatelet
Kava - inhibition of platelet aggregation
saw palmetto - bleeding, inhibition of COX, platelet dysfunction
coenzyme Q - increased risk of bleeding? (unclear)
glucosamine/chondroitin - increased risk of bruising and bleeding (with warfarin)
fish oil - inhibit platelet aggregation (warfarin int also)
coagulopathy
green tea - antiplatelet activity/antagonizes warfarin
saw palmetto - coagulopathy, platelet dysfunction
CV instability
ephedra - sympathomimetic effects garlic - hypotension ginseng - tachycardia, HTN kava - CV effects valerian - cardiac complications?
hypoglycemia
echinacea
ginseng
hepatotoxicity
echinacea
kava
interactions with other meds
ephedra - MAOIs
garlic - warfarin - tend to see increase INR
ginkgo - warfarin, MAOIs, amlodipine, prochlorperazine
ginseng - warfarin interference
green tea - antagonizes warfarin
kava - sedatives, barbs, LA
st johns wart - increase metabolism of many drugs
–induction of CYP450 3A4 - indinavir, ethinylestradiol, cyclosporine, alfentanil, midazolam, lidocaine, CCB, 5HT
–CYP450 2C9 - decreased anticoag effect of warfarin, NSAIDs
–digoxin
coenzyme Q - warfarin (decrease effects, structurally similar to vitamin K) (unclear effect)
glucosamine/chondroitin - warfarin (increases effects)
fish oil - warfarin (may see increased INR, especially with larger doses)
Withdrawal symptoms if stopped abruptly
valerian - benzos for withdrawal symptoms
stop at least 24 hours prior
ephedra
kava - potential enhancement of sedative (earlier if potential to compromise hepatic function)
stop 7 days prior
garlic
green tea
stop at least 2 weeks before surgery
ginger ginkgo ginseng - 48 hrs - 2 wks coenzyme Q glucosamine/chondroitin fish oil
If they can’t taper, advise them to take up until day of surgery.
valerian
