Week 7 Herbals and Opioids Flashcards
T/F individuals with little education and low socioeconomic status commonly use supplements
False, most individuals who use supplements have a higher income and education
What plant was morphine isolated from?
opium
What plant was digitalis derived from?
purple fox glove
What plant was atropine derived from?
Belladonna
How many individuals use herbal medications?
1:3 or 5 adults
There has been a recent increase in the use of:
CBD oils
Why are supplements referred to as “dietary supplements” and not medications?
the lack of testing and regulation by the FDA
What percent of supplements are actually tested?
1%
When should supplements be discontinued prior to surgery?
at least two weeks
What percent of patients actually disclose the use of herbals?
30%
What herbal supplement can cause hypertension?
Ephedra
What herbal supplement most commonly causes coagulopathies?
Gingko
What are the indirect health effects of using herbal supplements?
contaminants such as mercury, arsenic, lead, heavy metals
variation in potency
decreased concentration of conventional medications
Does herbal medicine induce or inhibit CYP450 enzyme?
BOTH/EITHER
What causes patients to refrain from disclosing herbal usage?
not medicine
“all natural”
fear of reaction
fear of healthcare bias
Herbal medicine is very common in which two cultures?
native american
asian
What is belladona used for?
anticholinergic
What is cocaine derived from?
Erythozylon coca- local anesthetic
What cause chondrodendon cause?
NMB
What is foxglove used for?
antiarrythmic effects
What is ephedrine used for?
CNS stimulant
What is datura metel used for?
Scopolamine alternative/ Anti-emetic
What are the effects of Dong quai on platlets?
decreases activation
what is the indication for Dong Quai?
migraines, anemia, hypertension, menstrual cramping
Dong Quai is made of an herb used for:
anticoagulation/coumadin derivative
Dong quai can also cause:
antithrombotic, antiarrythmic, phototoxic, and carcenogenic effects
What is echinachea used for?
Treats viral, bacterial, and fungal URIs by modulating cytokine signaling and stimulation of macrophages and NK cewlls
What are the effects of echinachea on wound healing?
Treats chronic wounds and arthritis
What does echinachea work well with?
decreases Chemo drug side effects
What are the adverse effects of echinachea?
unpleasent taste, GI upset, headache, dizziness
Why is echinachea contraindicated in a renal transplant patient?
it can cause acute rejection
Patients with SLE, HIV, cancer, and rheumatoid arthritis should not take:
echinachea
Does echinachea inhibit or induce CYP450 activity?
inhibits
greater than eight weeks of echinachea use can cause
immunosupression
Why was ephedra banned?
many deaths occured after using it
What are other names for ephedra?
herbal ecstasy, natural ecstasy, cloud 9, ultimate xyphoria
What does ephedra cause?
weight loss, increased energy, bronchodialation, treats URI
What is ephredra typically used to treat?
asthma and bronchitis
now: aphrodisiac, increases energy, decreases appetite
Prolonged use of ephedra can cause
Catecholamine depleted state: hemodynamic instability and tachyphylaxis
Adverse effects of ephedra:
palpatations, HTN, hyperthermia, seizures, stroke, MI, cardiomyopathy, vasoconstriction
How does ephedra cause stroke and mi?
Vasoconstriction can lead to coronary and cerebral artery vasospasm
Long term ephedra use in combination with halothane can cause:
myocardial hypersensitivity
What can occur with ephedra use in combination with an MAOI?
life threatening hypertension, hyperpyrexia, and coma
What is feverfew used for?
fever, migraines, and menstrual irregularities
What is a contraindication for feverfew usage?
chamomile, ragweed, and yarrow allergies
Can feverfew be taken by an individual also taking warfarin?
no, it inhibits platelet activity
What is an indication for ginger usage?
motion sickness, n/v, arthitis
What are adverse effects of ginger?
inhibits platelet aggregation
large quantities: CNS depression, potentiation of CCB
Why is garlic beneficial?
treats infection, tumor, diabetes, hypertension, hyperlipidemia, and atherosclerosis
What is the compound in garlic that is beneficial?
cystiene, allicin inhibits biosynthesis of cholesterol
What are adverse effects of garlic?
nausea, inhibits platelet aggregation, reduces blood sugar
What is the most expensive, popular herb?
ginseng
What is ginseng used for?
stimulant, tonic, diuretic, immunomodulation, mood elevation, increased vitality, hypoglycemia
What is the active part of ginseng?
ginsenoside- a glycosylated steroid
What is the MOA of ginseng?
augments adrenal steroidogenesis
increased IgG and IgM production
increased interferon production
enhanced NK and cell mediated
What is the major ginseng drug interaction?
phenelzine- causes tremulousness and mania
Others: warfarin, heparin, ASA, NSAIDs
cause in taking ginseng for individuals
with HTN, heart disease, or using stimulants
What is the indication for Gingko biloba?
neuroprotective: treats alzheimers, memory loss, and multi infarct dementia
Peripheral vascular disease- decreases blood viscosity
What is the MOA of gingko?
increases cholinergic transmission in the brain via anticholinesterase
also possibly a free radical scavenger
How does gingko effect bleeding?
increases, by inhibiting platelet aggregation
What are the side effects of gingko?
Gi upset, headache, bleeding
What two drugs interact with gingko?
NSAIDs, and anticoagulants
What are different terms for Kava?
tonga, intoxicating pepper, root of petter plant
What is Kava for?
anxiolytic, sedative, sleep enhancer, anticonvulsant
What is the MOA of kava?
inhibits Na and Ca channels to decrease SVR
How does long term kava use affect anesthetic dose?
increases dose requirement
What are adverse effects of kava?
increase effects of ETOH, barbiturates, and other drugs
can prolong anesthetic agents
kava dermopathy- scaly cutaneous lesions
What is papain?
a digestive aid; treats infammatory disorders, hemorrhoids, worms, diarrhea, tumors, and URI
Papain is contraindicated with what drug?
warfarin
Why do people take saw palmetto?
BPH, diuretic, urinary antiseptic
interacts with Barbiturates
What drug class does saw palmetto interact with?
barbiturates
What is the MOA of saw palmetto?
inhibits estrogen receptors
prevents testosterone conversion
blocks prolactin
alpha1 antagonism
anti inflammatory effects
What is St. john’s wort used for?
depression and anxiety
What is the MOA of St. john wort?
inhibits serotonin reuptake
weakly inhibits monoamine oxidase A and B
inhibits norepi and dopamine reuptake
What are the adverse effects of st john wort?
gi upset, dizziness, confusion, headache, photosensitivity
What drugs should not be given with St johns wort?
tricyclic antidepressants, MAOIs, cyclosporin, and digoxin - messes up the levels
How does St. Johns wort affect anesthesia?
can delay emergence
What is valerian root?
herb used for anxiolytic, restlessness, and sleep aids
Most all herbal sleep aids contain:
Valerian root
What is the MOA of valerian?
is mediated by modulation of GABA
Valerian root has prolonged effects when taken with:
Thiopental and pentobarbital
Adverse effects of valerian root include:
Gi upset, headache, tremor, cardiac disturbances
Can potentiate effects of benzos
T/F valerian root can be abruptly stopped the night before surgery
False, due to the fact that cessation can cause benzo like withdrawal symptoms, patient may need to do a taper to stop prior to surgery
How does valerian root affect anesthesia?
delays emergence
What is the indication for turmeric (curcumin longa)?
antioxidant and anti-inflammatory
possibly thrombolytic, anti-carcinogenic
What is the indication for an individual to take turmeric after experiencing a CVA?
It has neuroprotective properties
What herbal supplement can lower amyloid protein depositions?
Turmeric
What type of drug interacts with turmeric?
antacid medications such as PPIs and H2A
What is Garcinia cambogia?
tropical fruit rind used as herbal medicine
What is garcinia used for?
weight loss, diabetes, hyperlipidemia
What is a major adverse reaction to garcinia?
heptotoxicity
What two supplements can cause hypertension?
ephedra and licorice
What 3 supplements DO NOT increase bleeding risk?
increase clotting: ephedra, garcinia
no effect: St. John’s wort
What supplements are hepatotoxic?
Echinacea, ephedra, saw palmetto, garcinia
immunosuppressive vs immunostimulating
echinacea (long term use suppresses)
echinacea, garlic, st john wort, ginseng, garcinia
Which supplements are immunostimulating?
echinacea, garlic, st john wort, ginseng, garcinia
Which supplements induce CYP450?
garlic, st john wort, ginseng, and garcinia
Which supplements inhibit MAO?
ephedra, st john wort
What supplements can cause hypotension?
gingko, ginger, kava
What two supplements can cause arrythmias?
ginger, garcinia
What supplements can cause sedation?
ginger, st johns wort, saw palmetto, valerian, kava
Which 5 supplements can cause delayed emergence?
St. John wort, Valerian root, Kava, ginger, saw palmetto
What is an example of a chemically modified opiate?
oxycodone
What is an example of a fully synthetic opioid?
fentanyl
What are the opioid receptors?
Mu, delta, kappa
What type of receptors are Mu receptors?
G-couples protein receptors
What two factors lead to the development of an addiction?
genetic and environmental
What is the “pleasure-repeat” pathway?
Mesdimbic pathway
What are the effects of cAMP and mu receptors?
Activated Mu receptors bind to and decrease cAMP
What two body systems experience withdrawal symptoms?
GI and Brain
What type of receptors are inactivated by opioids: chemoreceptors or baroreceptors?
chemoreceptors
What is the noncompetitive receptor antagonist used to treat opioid overdoses?
naloxone
What are the effects of opiates on volatile anesthetics?
decreases MAC
T/F: opioids always cause amnesia but not always unconciousness
False: they cause unconsciousness but not always amnesia
What are two off label uses for opioids?
cough suppressant, antidiarrheal
What is the difference between M1 and M2 receptors?
M1 is primarily responsible for analgesia, while M2 is responsible for respiratory depression, bradycardia, and dependance
What does the kappa receptor do?
inhibits neurotransmission
Why doesnt merperidine cause bradycardia?
it has an atropine like additive
What are the two histamine releasing drugs that cause itching?
merperidine and morphine
What can occur when mixing opioids with MAOIs?
seretonin toxicity
What are s/s of seretonin toxicity?
fever, diapheresis, shivering, myoclonus, agitation, confusion, coma
What is the #1 drug used to reverse opioid overdose?
naloxone: nonselective, works on all three receptors
What are side effects of naloxone?
n/v, htn, tachy, dysrhythmias, pulmonary edema
What is the dosage of naloxone?
1-4mcg/kg, redose 60-90mins
What drug treats shivering?
merperodine
What is fentanyl used for during induction?
to blunt sympathetic response to intubation
What is unique about remifentanyl?
prevents movement without the use of a NMB when used as a gtt
How early before the end of the case should sufentanyl be turned off?
30 minutes
What is methadone composed of?
L methadone: opioid, R methadone: NMDA, longest half life of any opioid
What are the effects of cannabis on the nervous system?
inhibits PNS, induces SNS
What malignant arrhythmias can cannabinoids cause?
VTach, VFib, brugada pattern
sinus arrest in chronic use
What are the effects of cannabis on thermoregulation?
decreases thermoregulation which can result in severe postoperative shivering
How does cannabis effect bleeding tendencies?
increases bleeding by decreasing platelets and increasing clotting time
What is the most common vascular side effect with cannabis use?
ischemic stroke
How do steroids work in multimodal anesthesia?
reduces local inflammation triggered by afferent stimulation of the parasympathetic nervous system
