Wk 14: Alternative Medications and Herbs Flashcards by Ashley Campbell

_________ and _________ medicine (_____) has implications for anesthesia providers because of specific complications associated with certain therapies often used as anesthesia adjuvants

complementary
alternative
CAM

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In 2007, ____ % of Americans used CAM therapies in the preceding year

38%

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Visits to CAM practitioners _____ those to American primary care physicians

exceed

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CAM is even more widely used in _______, where herbal medicines are prescribed more frequently than conventional drugs are

Europe

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Several commonly used herbal medications exhibit direct effects on the _________ and _______ sytems

cardiovascular
coagulation

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Some CAMs can interfere with conventional medications that are commonly given in the _________ period

postoperative

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The ___________ potential of CAM in the perioperative period is increasingly being described in the literature

therapeutic

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Scientific knowledge in this area is still _________ and often confusing for practitioners and patients

One recent study confirmed _____ knowledge of this subject among physicians

incomplete

poor

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Recommendations for clinicians are often based on small _______ trials, case reports, animal studies, predictions derived from known pharmacology, and expert opinion

clinical

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Many of the issues complicating the understanding of herbal medications derive from the fact that they are classified as _________ _________ under the Dietary Supplement Health and Education Act of 1994

dietary supplements

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The introduction of herbal medications does not require animal ______, ________ ________, or postmarketing __________

studies
clinical trials
surveillance

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Under current law, the burden is shifted to the ______ ______ ______ ____ _______ (____) to prove products unsafe before they can be withdrawn from the market

U.S. Food and Drug Administration
FDA

(Challenging for FDA to get off market if there are issues)

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Commercial herbal medicine preparations can have ________ pharmacologic effects resulting from
-___________ labeling
-___________ plants
-___________
-Variations in natural ________
-_____________ processing methods

unpredictable
-Inaccurate labeling
-Misidentified plants
-Adulterants
-Variations in natural potency
-Understandardized processing methods

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Two of the major problems confronting herbal medicine research involve ______ ________ and _______ _________

quality control
added adulterants

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Categories of complementary and alternative medicine (5)

1.Alternative medical systems (homeopathic medicine, naturopathic medicine)
2.Mind-body interventions (meditation, prayer)
3.Biologically based treatments (herbal medicines, dietary supplements)
4.Manipulative and body-based methods (chiropractic manipulation)
5.Energy therapies (acupuncture, reiki)

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The most commonly used CAM are

Natural products (17.7%)
Deep breathing exercises (12.7%)
Meditation (9.4%)
Chiropractic/Osteopathic
manipulation
Massage (8.3%)
Yoga (6.1%)

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Perioperative use of herbal medicines has been associated with _______ perioperative events

Surveys estimate that ____% to ____% of patients undergoing surgery use herbal medications

adverse

22
32

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Because approximately ___% of herbal medicine users take multiple herbs concomitantly and ___% of herbal medicine users take prescription drugs, adverse effects are difficult to predict and attribute

50
25

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Herbal medicines can affect the perioperative period through several classic mechanisms
-Direct effects (_______pharmacologic effects)
-Pharmacodynamic interactions (_________ of the action of conventional drugs at effector sites)
-Pharmacokinetic interaction (Alteration of the ______, ______, ______, and ________ of conventional drugs)

Intrinsic
Alteration
absorption, distribution, metabolism, and elimination

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_________ assessment should address the use of herbal medicines

One study found that ____% of anesthesia providers do not routinely ask about herbal medicine use

More than ___% of patients are not forthcoming about their herbal medicine use during routine preoperative assessment

Preoperative

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When a positive history of herbal medicine use is elicited, ___ in ____ patients is unable to properly identify the preparation being taken

1 in 5

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Asking patients to bring their herbal medicines and other ______ ________ with them at the time of the preoperative evaluation could be helpful

dietary supplements

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In general, herbal medicines should be discontinued _________

In clinical practice, patients who require nonelective surgery are often not evaluated until the day of surgery or are ________ with instructions to discontinue herbal medications preoperatively

In this situation, anesthesia can usually __________ safely at the discretion of the anesthesia provider, who should be familiar with commonly used herbal medicines

preoperatively

noncompliant

proceed

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Preoperative discontinuation of all herbal medicines might not ______ complications related to their use

eliminate

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Withdrawal of regular medications can increase ________ and ________ after surgery Alcoholics who abstain from drinking preoperatively may have _______ outcomes than those who continue drinking The danger of abstinence after long-term use may be similar with herbal medicines such as ________, which can produce acute withdrawal after long-term use

morbidity mortality poorer valerian

Most suggest that herbals be discontinued at least ____ ______ before surgery Some patients require nonelective surgery or are __________ with instructions to discontinue herbal medications preoperatively These factors and the extensive use of herbal medicines sometimes means that herbal medications are _____ until the time of surgery

2 weeks noncompliant taken

Echinacea A member of the daisy family, it is used for the prophylaxis and treatment of ______, ________, and _______ infections, particularly those of ________ _________ origin Its efficacy of the latter is _______

viral bacterial fungal upper respiratory doubtful

Echinacea The biological activity of Echinacea could be __________, ___________, or __________ depending on the portion of the plant and extraction method

immunostimulatory immunosuppressive antiinflammatory

Echinacea Patients who might require perioperative ___________, such as those awaiting organ transplantation, should be counseled to avoid Echinacea

immunosuppression

Echinacea significantly reduced plasma concentrations of _______, but did not significantly affect warfarin pharmacodynamics and ______ _________ in healthy subjects

S-warfarin platelet aggregation

Echinacea should be discontinued as far in advance of surgery as possible when compromises in _______ function or ______ _______ are anticipated In the absence of definitive information, patients with preexisting _______ dysfunction should be cautious in using Echinacea

hepatic blood flow liver

Echinacea pharmacologic effects Activation of cell-mediated ________

immunity

Echinacea perioperative concerns -______ reactions -Decreases effectiveness of __________ -Potential for ___________ with long-term use

Allergic immunosuppression immunosuppression

Echinacea discontinue before surgery

No data (DC as far in advance of surgery as possible)

Ephedra, known as ma huang in Chinese medicine, is a ______ native to central Asia It is used to promote ____ _____, increase _____, and treat respiratory conditions such as _____ and ______

shrub weight loss energy asthma and bronchitis

Ephedra contains alkaloids, including (5)

Ephedrine Pseudoephedrine Norephedrine Methylephedrine Norpseudoephedrine

Ephedra Commercial preparations can be standardized to a fixed _______ content *Publicity about _______ ________ to this herb prompted the FDA to bar its sale in 2004, but ephedra is still widely available via the Internet*

ephedrine adverse reactions

Ephedra Ephedra causes dose-dependent increases in _____ _______ _______ and ______ ________

arterial blood pressure heart rate

Ephedra *Ephedrine, the predominant active compound, is a __________ __________ that exhibits alpha-1, beta-1, and beta-2 activity directly at adrenergic receptors and indirectly by releasing endogenous _____________*

noncatecholamine sympathomimetic norepinephrine

Ephedra The sympathomimetic effects have been associated with more than 1070 reported adverse events, including fatal ______ and ______ ______ ______ complications

cardiac central nervous system

Ephedra Long-term use results in _______ from depletion of endogenous __________ stores and can contribute to perioperative hemodynamic instability In these situations, ______ -_______ sympathomimetics may be preferred as first-line therapy for intraoperative hypotension and bradycardia

tachyphylaxis catecholamine direct-acting

Ephedra Concomitant use of ephedra and _______ ________ inhibitors can result in life-threatening: (3)

monoamine oxidase hyperpyrexia hypertension coma

Ephedra pharmacologic effects Increases ______ and _______ through direct and indirect __________ effects

heart rate blood pressure sympathomimetic

Ephedra perioperative concerns Risk of __________ _________ and _______ from tachycardia and hypertension Ventricular ________ with halothane Long-term use depletes endogenous _________ and may cause intraoperative hemodynamic instability Life-threatening interaction with ______ inhibitors

myocardial ischemia stroke arrhythmias catecholamines MAO

Ephedra discontinue before surgery

24 h

_________is one of the most extensively researched medicinal plants

Garlic

Garlic has the potential to modify the risk for ____________ by reducing -________ blood pressure -________ formation -Serum ______ and ________ concentrations

atherosclerosis -Arterial -Thrombus -lipid and cholesterol

Garlic *Garlic's effects are primarily attributed to its _______-containing compouds, particularly _______ and its transformation products*

sulfur allicin

Garlic inhibits ________ aggregation in vivo in a ________-dependent fashion

platelet concentration

Garlic has interacted with ________, resulting in an increased _______ _______ ________

Warfarin international normalized ratio

Garlic The potential for _______ _______ of platelet function may warrant discontinuation of garlic at least ____ days before surgery Especially if postoperative ______ is a particular concern or other _________ are given

irreversible inhibition 7 bleeding anticoagulants

Garlic pharmacologic effects Inhibit ________ ________(may be irreversible Increases ________ Equivocal _________ activity

platelet aggregation fibrinolysis antihypertensive

Garlic perioperative concerns May increase risk of _______, especially when combined with other medications that inhibit ______ __________

bleeding platelet aggregation

Garlic discontinue before surgery

7 days

Ginger has a ______ range of reported health benefits for those with different ailments

wide

Ginger is an ________ and has been used to treat ________ _________ and prevent _______ after laparoscopy

antiemetic motion sickness nausea

The number of postoperative antiemetic medications was significantly reduced after aromatherapy with essential oil of ________

ginger

_________ supplementation has been shown to reduce the severity of acute __________-induced nausea in adult cancer patients

Ginger chemotherapy

Gingerols and related analogues inhibited _________ _____-induced platelet ______ release and aggregation, with a potency similar to that of aspirin This result may warrant the discontinuation of ginger at least ___ weeks before surgery

arachidonic acid serotonin 2

Ginger pharmacologic effects _____-________ Antiplatelet _________

Anti-emetic Antiplatelet aggregation

Ginger perioperative concerns May increase risk of ________

bleeding

Ginger discontinue before surgery _____ weeks prior to surgery

Ginkgo is derived from the leaf of Ginkgo biloba and has been used for -_______ disorders -________vascular disease -age-related _________ degeneration -___________ -___________ -___________ dysfunction -_________ sickness

cognitive peripheral macular vertigo tinnitus erectile altitude

Studies have suggested that ginkgo can stabilize or improve _______ performance in patients with _________ disease and multi-infarct _________

cognitive Alzheimer dementia

Ginkgo alters _________, acts as an _________, modulates ________ and receptor activity, and inhibits _________-activating factor

vasoregulation antioxidant neurotransmitter platelet

*Four cases of spontaneous _________ _________, one case of spontaneous __________, and one case of postoperative __________ after laparoscopic cholecystectomy have been described when ginkgo was being taken*

intracranial bleeding hyphema bleeding

Gingko should be discontinued at ____ hours to ___ weeks before surgery to avoid bleeding

36 2

Ginkgo pharmacologic effects Inhibits __________-activating factor

platelet

Gingko perioperative concerns May increase risk of ______, especially when combined with other medications that inhibit platelet _______

bleeding aggregation

Gingko discontinue before surgery

36 weeks

Ginseng has been labeled an "_______" because it reputedly protects the body against ________ and restores _________

adaptogen stress homeostasis

The many _________ and sometimes _________ effects of different ginsenosides give ginseng a broad but incompletely understood pharmacologic profile

heterogenous opposing

Ginseng The underlying mechanism is similar to that classically described for ______ hormones

steroid

Ginseng This herb _________ postprandial blood glucose in healthy patients and those with type 2 diabetes, and effect that can create unintended _________ in patients who have fasted before surgery

decreases hypoglycemia

Ginseng can alter _________ pathways

coagulation

*The antiplatelet activty of _________, a constituent of ginseng, may be __________ in humans*

panaxynol irreversible

Because warfarin is often used after orthopedic or vascular procedures, ginseng's significant decrease in warfarin __________ can affect perioperative management in many patients

anticoagulation

Because platelet inhibition by ginseng may be irreversible, ginseng use should be stopped at ___ days to ___ weeks before surgery

7 2

Ginseng pharmacologic effects _________ blood glucose __________ platelet aggregation (may be irreversible) __________PT/PTT in animals

lowers irreversible increased

Ginseng perioperative concerns -_______glycemia -May increase risk of __________ -May _______ anticoagulant effect of warfarin

Hypoglycemia bleeding decrease

Ginseng discontinue before surgery

7 days

Green tea Tea from the Camellia sinesis is one of the most ancient and ______ most widely consumed beverage in the world

second

Epigallocatechin-3-gallate (EGCG), athe most predominant ________ in green tea, is responsible for much of the biological activity mediated by green tea

catechin

The antiplatelet activity of green tea can result from the inhibition of ___________ _____ formation

thromboxane A2

Because green tea contains ________ _____, drinking green tea could _________ the anticoagulant effects of warfarin

vitamin K antagonize

Based on pharmacologic data and possible ___________ activity, green tea should be discontinued at least ____ days before surgery

antiplatelet 7

Green tea pharmacologic effects Inhibits ______ aggregation Inhibits _________ ____ formation

platelet Thromboxane A2

Green tea perioperative concerns -May increase risk of _______ -May ______ anticoagulant effect of warfarin

bleeding decrease

Green tea discontinue before surgery

7 days

Kava is derived from the ______ ____ of the pepper plants Piper methysticum

dried root

Kava has gained widespread popularity as an _________ and ________

anxiolytic sedative

Because of its _________ effects, kava was one of the first herbal medications expected to interact with ___________

psychomotor anesthetics

The kavalactones have dose-dependent effects on the ________ _________ system including: -___________ properties -_____________ properties -_________ anesthetic properties

central nervous -Antiepileptic -Neuroprotective -Local

Kava can act as a sedative-hypnotic by potentiating inhibitory neurotramsmission of ________ ______ (________)

y-aminobutyric acid (GABA)

Kava can influence ________ and __________ and ________ function

coagulation cardiovascular hepatic

*Continuous kava use can increase y-glutamyl transpeptidase levels, thus raising concern about __________*

hepatotoxicity

Kava inhibits _________ with the potential to decrease _______ blood flow and to interfere with ________ aggregation

cyclooxygenase renal platelet

Consumption of kava has potential ________ effects that could manifest in the perioperative period

cardiovascular

Although kava has been banned in Europe since 2002, it is available in North American and may countries in the _______ region

Pacific

Kava should be discontinued at least ___ hours before surgery

Kava pharmacologic effects ___________ ___________

Sedation Anxiolysis

Kava perioperative concerns -May increase ________ effect of anesthetics -Increase in _________ requirements with long-term use unstudied

sedative anesthetic

Kava discontinue before surgery

24 hours

Saw palmetto, which is used by more than 2 million men in the United States to treat symptoms associated with ______ ________ ________, is of questionable efficacy for this purpose

benign prostatic hypertrophy

Although the mechanism of action of saw palmetto is not known, _________ mechanisms have been proposed

multiple

Saw palmetto extract, like finasteride, inhibits ___-________ in vitro Results of studies have been ________

5alpha-reductase inconsistent

Other proposed mechanisms of saw palmetto are: -Inhibition of ______ and ______ receptors -Blocking of ______ receptor signal transduction -Interference with _______ proliferation, induction of ________ -Inhibition of ___-__________ receptors -Anti-__________ effects

estrogen and androgen prolactin fibroblast, apoptosis alpha1-adrenergic inflammatory

Saw Palmetto's _________ effects, specifically the inhibition of ________ and subsequent _______ dysfunction

antiiflammatory cycloocygenase platelet

Due to no __________ or clinical data for saw palmetto, specific recommendations for preoperative discontinuation cannot be made

pharmacokinetic

Saw palmetto pharmacologic effects -Inhibits ___-_________ -Inhibits_____________

5alpha-reductase cycloocygenase

Saw palmetto perioperative concerns May increase risk of ___________

bleeding

Saw palmetto discontinue before surgery

No data

St John's Wort __________ is the common name for Hypercum perforatum

St. John's Wart

*A multicenter clinical trial concluded that St. John's wort is not effective in the treatment of ______ __________*

major depression

St. John's wort exerts its effects by inhibiting reuptake of: (3)

Serotonin Norepinephrine Dopamine

Concomitant use of this herb with or without ________ reuptake inhibitors can create a syndrome of _______ _________ excess

serotonin central serotonin

Use of St. John's wort can significantly increase the __________ of many concomitantly administered drugs, some of which are vital to the perioperative care of certain patients

metabolism

St. John's wort *There is induction of the _______ _______ _______ isoform, with approximate doubling of its metabolic activity*

cytochrome P450 3A4

Interactions with substrate of the 3A4 isoform, including: (4)

Alfentanil Midazolam Lidocaine Calcium channel blockers

The cytochome P450 _____ isoform also may be induced The anticoagulant effect of warfarin, a substrate of the ____ isoform, was reduced in seven reported cases Other ____ substrates include the _________ ____-________ drugs

2C9 2C9 2C9 nonsteroidal anti-inflammatory

St. John's wort also affects _______pharmacokinetics

digoxin

St. John's Wort Pharmacokinetic data suggest that this herbal medication should be discontinued at least ___ days before surgery *Discontinuation is especially important in patients awaiting ______ ___________ or in those who might require oral ________ postoperatively* These patients should be advised to avoid taking St. John's Wort ___________

5 organ transplantation anticoagulation postoperatively

St. John Wort pharmacologic effects -Inhibits _____________ reuptake -________ inhibition unlikely

neurotransmitter MAO

St. John's Wort perioperative concerns Induction of cytochrome _____ enzymes; affects cyclosporine, warfarin, steroids, and protease inhibitors; may affect ___________, _________ __________ blockers, and many other drugs Decreased serum _______ levels Delayed ____________

P450 benzodiazepines, calcium channel blockers digoxin emergence

St. John's Wort discontinue before surgery

5 days

Valerian is an herb that is native to temperate regions of the ________, ________, and _________

Americas, Europe, and Asia

Valerian is used as a _________, particularly in the treatment of ________, and virtually all herbal sleep aids contain valerian

sedative insomnia

Valerian produces dose-dependent __________ and ___________ These effects are probably mediated through modulation of _____ neurotransmission and receptor function

sedation hypnosis GABA

In one patient, valerian withdrawal appeared to mimic acute _________ withdrawal characterized by ________, _______ complications after surgery Attenuation of the symptoms by administration of a _________

benzodiazepine delirium cardiac benzodiazepine

Based on these findings, valerian should potentiate the ________ effects of _________ and adjuvants that act at the _______ receptor, such as midazolam

sedative anesthetics GABA

*If such tapering is not feasible, anesthesia providers can advise patients to continue taking valerian until the day of ______*

surgery (don't want them to go through withdrawal)

Valerian pharmacologic effects ___________

sedation

Valerian perioperative concerns -May increase ________ effect of anesthetics -_________-like withdrawal -May increase _________ requirements with long-term use

sedative Benzodiazepine anesthetic

Valerian discontinue before surgery

No data

In a survey conducted in 2007, the top 10 herbal medicines also included __________, __________, and _________ There are no reports of ______ effects of perioperative risks for these herbs

soy isoflavones grape seed extract milk thistle adverse

Although boldo, Danshen, Dong quai, and papaya are encountered less frequently, it may be prudent to discontinue their use ___ weeks before surgery because they have shown ________ aggregation activity and herb-drug interactions

2 antiplatelet

Herbal medicines fall into the broader category of _________ supplements that also includes ______, _______, _______, _______, and _________ *Data on the safety of these agents in the perioperative period are ______*

dietary supplements vitamins minerals amino acids enzymes animal extracts scant

High-dose vitamin use, particularly of the ____-______ vitamins can be associated with acute and chronic __________

fat-soluble toxicity

*Drug interactions for coenzyme Q10, glucosamine, chondroitin, sulphate, and fish oil have been sufficiently documented to merit inclusion in this chapter*

Coenzyme Q10, or ubidecarenone, is a single-contituent __________ compound that is structurally related to _______ ____

antioxidant vitamin K

Coenzyme Q10 is widely promoted as an __________

antioxidant

Endogenous CoQ10 can interact with __________

warfarin

In 171 patients, coadministration of CoQ10 with _______ appeared to increase the risk of _________

warfarin bleeding

Based on the clinical information regarding drug interaction and reported prolonged _______ ____-________ (___ to ___ hours) after a single oral dose, *CoQ10 should be discontinued at least ___ weeks before surgery*

elimination half-time 38 to 92 2

________ and _____________ _______ are widely used for joint disorders by many patients undergoing orthopedic procedure

Glucosamine chondroitin sulfate

Glucosamine and chondroitin sulfate Standard therapies can alleviate the symptoms of _________ to some extent, but cannot prevent disease progression

osteoarthritis

Although their mode of action may be complex, glucosamine and chondroitin sulfate have been widely accepted as supplements in the management of _________ because they are the essential components of proteoglycan in normal _________

osteoarthritis cartilage

When a large-scale trial evaluated glucosamine and chondroitin sulfate alone or in combination, ______ was not reduced in a group of patients with _________ of the knee

pain osteoarthritis

Use of chondroitin sulfate alone is well tolerated without significant ______ drug interaction

adverse

One concern regarding the use of glucosamine is its potential to cause or worsen ________ in animal models

diabetes

In a report from the FDA MedWatch database, there were 20 cases of complications involving glucosamine or glucosamine-chondroitin sulfate use with _________ Coagulation was altered as manifested by ______ INR or _______ bleeding or bruising

warfarin increased increased

Considering the reported interaction between glucosamine-chondroitin and warfarin, these supplements *should be discontinued ___ weeks before surgery*, especially if warfarin will be given during the perioperative period

Intake of fish oil supplements containing ____-___ fatty acids reduces the influence of many chronic diseases that involve __________ processes including: -__________ diseases -__________ bowel disease -__________ -__________ arthritis -______________ illnesses

omega-3 inflammatory cardiovascular inflammatory cancer Rhematoid Neurodegenerative

In a recent study, however, omega-3 did not reduce the rate of ______ in patients with __________ risk factors

death cardiovascular

Omega-3 fatty acids can inhibit ______ aggregation and _______ bleeding risk

platelet increase

Extremely elevated ____ associated with warfarin in combination with omega-3 fatty acids was found in two cases -These reports suggest that fish oil be discontinued ___ weeks before surgery*, especially for patients taking large doses

INR 2

Other top 10 dietary supplements include: -Flaxseed oil -Fiber or psyllium -Cranberry -Melatonin -Methylsulfonylmethan (MSM) -Lutein *No special concerns have been published associated with _______ or other perioperative risks from the use of these supplements*

bleeding

Commonly used herbal medications can have ______ and ______ effects in the perioperative period Although there is *little _______ evidence for discontinuation timing*, emerging knowledge of the underlying biology of these medications and review of case reports suggest that herbal medications should be considered in the perioperative plan

direct indirect direct