Lecture 1: Herbal Medications & Anesthesia JL Flashcards
Complementary & Alternative Medicine
CAM Therapy
A broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs other than those intrinsic to the politically dominant health system of a particular society or culture.
CAM Therapies: Use
Adult = X%
Children = X%
Adult – 38.3%
Children – 11.8%
CAM Therapies: Most Common ? - 17.7% ? - 12.7% ? - 9.4% ? - 8.6% ? - 8.3%
Natural products - 17.7% Deep breathing – 12.7% Meditation – 9.4% Chiropractic -8.6% Massage -8.3%
CAM Therapies = __ billion/yr
Herbals = __ billion/yr
80
8-10
Herbal medicine
- Plants, seeds, berries, roots, bark, and flowers***
- Used long before recorded history
- Traditional Chinese Medicine
- Ayurveda
Bark of the Willow Tree ?
Papaver Somniferous ?
Penicillium ?
Bark of the Willow Tree - aspirin
Papaver Somniferous - opium
Penicillium – antibiotics
19th & 20th Centuries……
21st Century…….
19th & 20th Centuries……
• Scientists figured out the active compounds from plants
• Chemists manufactured them in the lab
21st Century…….
• Genomic era
• Automated assays enabling mass screening of compounds
• Gene manipulation
• Mixing or re-arranging of terminal groups
FDA Dietary Supplement Health and Education Act (1994)
- Defines and regulates dietary supplements
- A dietary supplement must contain one or more dietary ingredients including vitamins, minerals, herbs, amino acids, dietary substance, metabolite, constituent, extract, or combination of above.
- Must be labeled as dietary supplement
- Cannot be approved or authorized for investigation as new drug, antibiotic, or biologic unless labeled before investigation
Labeled as dietary supplement =
dont have to do anything
Dietary Supplements: • Manufacturers are not required to prove ? • Not required to report ? • Manufactured before 1994 = ? • After 1994 = ?
- Manufacturers are not required to prove efficacy, safety, or quality of their products.
- Not required to report any post-marketing adverse events to central agency.
- Manufactured before 1994 = Grandfathered in
- After 1994 = Reasonable evidence of their safety or reasonable expectations of their safety must be reviewed not approved.
FDA Good Manufacturing Practices (2007):
- Tries to regulate production and manufacturing
- NO real oversight
- Variations in quality, harvesting, storage conditions, processing, purity, and efficacy of herbal
- Herbal medications are not what they seem.
- (2013) New York Times Article - 1/3 had outright substitutions - St. John’s Wort Product contained… ..- Rice - Alexandria senna (laxative)
National Institute of Health:
Office of Alternative Medicine (1988)
• Study and evaluation of complementary and alternative medicine practices to disseminate the results.
National Institute of Health:
National Center for Complementary & Alternative Medicine (1992)
- Define, through rigorous scientific investigation, the usefulness and safety of complementary and integrative health interventions and the role in improving health and health care.
- To produce scientific evidence to inform decision making by the public, health care professionals, and policy makers.
AANA/ASA Pre op Recommendations (for all) =
Discontinue 2 weeks before surgery (testing answer)….see slides for Hopkins clinical/practice recommendations!
Echinacea: Chemistry (just review)
- Not a single compound
* Volatile oils, alkamides, polyalkenes, & caffeic acid derivatives
Echinacea: Pharmacology & Clinical Effects
- Anti-inflammatory
- Cancer
- Immune modulation
- URI Treatment
- Recurrent URI preventions
Echinacea: Adverse Effects
- Allergic reactions (1 case of anaphylaxis)
- Caution in patients with liver dysfunction
- Caution in antipsychotic and antidepressants
- Poor wound healing
- Decrease the effectiveness of exogenous steroids
Ephedra: Chemistry (just review)
• Alkaloids ephedrine, pseudoephedrine & methylephedrine
Ephedra: Pharmacology & Clinical Effects
- Has both direct and indirect effects on α and β adrenergic receptors
- CNS Stimulant
- Weight loss supplement
- Treatment of asthma
Ephedra: Adverse Effects
- CV: palpitation, tachycardia, hypertension, & cardiomyopathy (chronic use)
- Fatal arrhythmias & MI
- Hemodynamic instability intraop
- CNS: Seizure, stroke, psychosis
- Other: Hepatitis
Ginseng: Chemistry (just review)
- Ginsenosides (steroidal saponins)
* Like steroids
Ginseng: Pharmacology & Clinical Effects
- Memory enhancement
- Physical enhancement
- Lower blood sugar
- Alter coagulation pathway/inhibits platelet aggregation
- Immunomodulation
- Aphrodisiac
Ginseng: Adverse Effects
- Increased bleeding
- Inhibit platelet (irreversible)
- Hypoglycemia
- Interacts adversely with monoamine oxidase inhibitors
Ginger: Chemistry
• Shogaol, gingerol, and galanolactone (just review)
- • Antagonizes serotonin (5HT3 receptors) = ?
- • Inhibits prostaglandin = inhibit vasodilation, platelet aggregation and inflammation
- • Inhibits thromboxane synthetase = inhibits clot formation
Ginger: Pharmacology & Clinical Application
- GI discomfort
- Anti-inflammatory
- Nausea/motion
- Respiratory problems
- Sore throat
- Increased bleeding time
Ginger: Adverse Effects
- Increased bleeding
- Hyperglycemia
- Pregnancy – possibly safe?
- Large doses may alter fetal sex hormones
Garlic: Chemistry
Sulfur containing compounds – alliin or ajoene
• Potent antibiotic properties
• HMG-CoA reductase
Cysteine
• Alters arachidonic acid metabolism
Garlic: Pharmacology & Clinical Application
- Decrease blood pressure
- Decrease atherosclerosis (Decrease lipids/cholesterol)
- Inhibits platelet aggregation
- Anti-tussive/expectorant
Garlic :Adverse Effects
- Bleeding – 1 case report of spontaneous epidural hematoma
- Smell-bad breath
- GI upset (N/V/D)
Kava: Chemistry
• Kavalactones (May potentiate GABA) -> increased inhibition of NTs = higher affinity to receptors….sedation!
Kava: Pharmacology & Clinical Applications
- Anxiolytic
- Sedative…… Addiction/tolerance
- Antiepileptic
- Neuroprotective
Kava: Adverse Effects
- Addiction/tolerance
- Withdrawal
- Inhibits cytochrome P450 and 2E1
- Glutathione depletion – acetaminophen induced cytotoxicity
Valerian: Chemistry
Sesquiterpines
• Modulation of GABA neurotransmitters
• Inhibit GABA breakdown or re-uptake = longer effect
Valerian: Pharmacology & Clinical Applications
- Insomnia
- Sedation
- Anxiety
Valerian
• Adverse Effects
- Stopping after long term use may result in withdrawal
- Interactions with alcohol and sedatives
- Hepatotoxicity with long term use
- *Abuse
Ginkgo biloba: Chemistry
Flavonids, terpenoids, & organic acids
• Free radical scavenger
• Modulation of neurotransmitters
• Inhibits platelet activating factor
Ginkgo biloba: Pharmacology & Clinical Applications
- Dementia – Alzheimer’s
- Age related macular degeneration
- Peripheral vascular disease
- Vertigo
Ginkgo biloba: Adverse reactions
- Spontaneous intracranial bleeding
- Postoperative bleeding risk
- Nausea/vomiting
- Stomach pain
- Interactions with SSRI or MAOI’s
St. John’s Wort (Hypericum perforatum): Chemistry (just review)
Hypericin and hyperforin
• Inhibits re-uptake of serotonin, norepinephrine, and dopamine
St. John’s Wort (Hypericum perforatum): Pharmacology & Clinical Applications
- Mild to moderate depression
- Insomnia
- OCD
- ADHD
St. John’s Wort (Hypericum perforatum): Adverse Reactions
Induces cytochrome P450 enzymes (3A4 & 2C9) = LIVER
• Alfenta, midazolam, lidocaine, CCB, serotonin receptor antagonists
• Warfarin and NSAIDS
• Cyclosporin (49% reduction)
Serotonin syndrome
Fatigue
Sedation
Hoodia gordonii: Chemistry
- Molecule P57 – neuroactive steroid
- Has effect on hypothalamus (May look like glucose and trick brain into thinking your full)
- Multiple companies have tried to bring to market without success
Hoodia gordonii: Pharmacology & Clinical Application
Appetite suppressant
• Used in Africa for thousands of years
Hoodia gordonii: Adverse Reactions
- Nausea & vomiting
- Dizziness
- Increased blood pressure and heart rate
- Altered skin sensations
- Abuse potential
Feverfew: Chemistry
Parthedolide
• Inhibits Nf-KB –> anti-inflammatory
• Inhibits prostaglandin synthetase
Feverfew: Pharmacology & Clinical Application
- Prevent migraines
- Reducing headache symptoms (pain & sensitivity to light)
- Rheumatoid arthritis
Feverfew: Adverse Reactions
- Nausea, vomiting, & diarrhea
- Nervousness & dizziness
- ***Pregnancy - potential abortifacient, d/t increase blood flow
- ***Induce liver enzymes – altering drug metabolism
- ***Increase risk of bleeding (Especially if already on platelet altering medications)
Summary: Herbal Products FDA NIH AANA/ASA
Herbal Products
• Commonly used
• Always ask about use
FDA
• Dietary Supplement Health and Education Act (1994)
• Good Manufacturing Practices (2007)
• “Relative” efficacy & safety
NIH
• Study efficacy of products
AANA/ASA
• Both recommend holding medications for up to two weeks
• No specific guidelines…..
Bleeding
- Ginseng
- Ginger
- Garlic
- Ginkgo
- Feverfew
Sedation (gaba)
- Kava
- Valerian
- St. John’s Wort
Sympathetic stimulation (dietary)
- Ephedra
* Hoodia?
Liver
- Echinacea
- St. John’s Wort
- Feverfew
Pregnancy
- Feverfew
* Ginger?
