Herbal Medicines in the Perioperative Period The ABCs

Herbal Medicines in the Perioperative Period—The ABC’s Asking Before Cutting Victor S. Sierpina, MD Associate Professor Principal Investigator, CAM Education Project Grant UTMB, Family Medicine Department Learning Objectives  Know to make routine inquiry into patient use of herbs and supplements prior to surgery  Identify most commonly used OTC products likely to create problems with surgery and/or anesthesia Appreciate that herbal products have individualized pharmacokinetics relevant to clinical usage and practice  Evidence Based Curriculum in Alternative Therapies    UTMB received in 2000, a 5 year grant for $1.5 million to develop a “core curriculum” in AT Will focus on evidence and critical thinking, improved communication, life-long learning skills regarding use of alternative therapies Target audiences: medical, nursing, allied health students, house staff, faculty, community preceptors, and CME ABC: ASK BEFORE YOU CUT (or pass gas)    During medication history is easiest, most logical time to inquire Patients may not think of herbs and other OTC’s as medication “Are you using any herbs, supplements, or other therapies in addition to your medication?” What to do when they say, “Yes”     Record and document Inform yourself of significance (see resources) Determine risk Advise patient as an advocate and “informed intermediary” UTMB’s Alternative and Integrative Health Care Program Website http://atc.utmb.edu /altmed Points to Remember    FDA neither establishes nor regularly enforces any standards of quality for herbs Herbs are technically unapproved drugs, in an OTC limbo Best advice: obtain a standardized extract marketed by a reputable firm Herbal Quality     Proper identification and plant taxonomy Different lots, genetic variation Time of harvesting, proper part of plant Environmental and soil conditions Herbal Standardization     Determining active constituents is a biochemical challenge Echinacea--caffeic acids, alkylamides, “marker compounds,” interspecies variation Ginseng--ginsenosides, 30 different types St. John’s Wort--hypericin or hyperforin as active ingredient. To which do you standardize? Herbs are Drugs     Though not classified so legally Have pharmacological potency and individualized pharmacokinetics Have a mixture of ingredients, some active, some “inactive” which yield effects Think about them as drugs and you will have less difficulty in this area as a physician CNS Effects  St. John’s Wort--SSRI’s, general anesthetics, benzodiazepines, intensifies effects of meperidine  Valerian-- anesthetics, barbiturates, benzodiazepines  Kava--alcohol, benzodiazepines, barbiturates, anti-Parkinson drugs, anesthetics Enzyme Induction  St. John’s Wort--anti-retrovirals (Indinavir), digoxin, OCP’s--decreased effects and blood levels  Grapefruit juice--may raise blood levels of certain drugs through effects on liver enzymes Allergy  Chamomile and Echinacea --May have cross reaction in those with Ragweed or Daisy family (Asteraceae) allergies Direct effects  Ephedra--offsets effects of antihypertensives, guanethidine, increases effects of MAOI’s, digoxin, halothane, oxytocin  Cat’s Claw--increased effect of NSAID’s and salicylates. May affect absorption of other drugs like iron, hormones, insulin Direct Effects  Licorice—sodium and water retention, HTN, EKG and electrolyte changes, potentiates corticosteroids, antihypertensives, diuretics, hormones, neutralizes antibiotics. Affects meds prolonging QT interval (procainamide, quinidine, terfenadine)  90% of use of licorice in US is in tobacco products for flavoring What About Side Effects? Drug-herb Interactions? Know Mechanism of Action to Know Drug-Herb Interactions  Platelet inhibition and effects on bleeding (The 4 G’s: ):  Garlic  Ginkgo  Ginger  Ginseng   Feverfewaffects platelets SJW—affects liver enzymes and clotting factors “Herbal Medicines and Perioperative Care” [Review Article] Ang-Lee M, Moss J, Yuan CS. JAMA 286(2); 11 July 2001; 208-216 Review: MEDLINE and Cochrane Collaboration    Extraction of safety, pharmacodynamic, pharmacokinetic information Based on studies, case reports, and reviews Data synthesis: Echinacea, ephedra, garlic, ginkgo, kava, St. John’s wort, valerian reviewed Conclusions     Elicit and document hx of herbal use Be familiar with potential effects these herbs Learn to prevent, recognize, and treat potentially serious problems associated with use and discontinuation of herbal therapies Am Soc of Anesthesiologists’ 1999 guidelines of stopping all herbs 2-3 weeks before surgery can be refined with a targeted approach on herb by herb basis Echinacea    Caution: in pts with asthma, atopy, allergic rhinitis, esp ragweed allergy Caution: in pts w liver dysfx or transplants/ immuno-supression D/C prior to surgery (unknown pharmacodyamics) Ephedra (Ma huang)      Sympathomimetic effects, alpha, beta1, beta2 Halothane sensitizes myocardium. Risk of ventricular arrhythmias w/ ephedra Cardiomyopathy, tachyphylaxis, MAOI interactions 5.2 hr half-life D/C 24 hrs before surgery Garlic    Platelet aggregation inhibition Also has antihypertensive, antineoplastic, antilipemic, antibiotic effects D/C 7 days before surgery Ginkgo     Inhibits platelet activating factor Antioxidant, vasoregulation Half-life 3-10 hrs D/C 36 hrs before surgery Ginseng      Lowers blood glucose May affect coagulation and platelet aggregation May raise or lower blood pressure Half life 0.8-7.4 hrs Stop a week before surgery Kava     Coma reported with kava and alprazolam interaction Kavalactones have sedativehypnotic effects on CNS, potentiate GABA inhibitory neurotransmission, prolong barbituate sleep time in animals Half-life 9 hours D/C 24 hrs before surgery St. John’s Wort     Has CNS effects on serotonin, NE, DA, COMT Possible serotonin syndrome with SSRI’s No in vivo MAOI effects Main concern is drug-herb interactions. Affects cytochrome P450 isoforms increasing metabolic activity St. John’s Wort     Can reduce levels of cyclosporine (transplant rejection), indinavir (AIDS), OCP’s, digoxin (P-glycoprotein transporter), many others. Can also affect coagulation factors Half-life 43.1 hrs (hypericin) and 9 hrs (hyhperforin) Stop at least 5 days before surgery Valerian    Sesquiterpenes and valerenic acid modulate GABA neurotransmision and receptors Possible potentiation of anesthetics and adjuvants (BZD) Short lived effects but taper before surgery; BZD for withdrawal “Alternative Medicine Use in Presurgical Patients” Tsen LC, Segal S, Pothier M, Bader A. Anesthesiology 93(1); July 2000 Results of Patient Survey Questionnaire 3106 patients Brigham and Women’s Hospital, Harvard  22% of presurgical patients reported the use of herbal remedies  51% used vitamins  Women and patients 40-60 y/o more likely to use herbal medicines Most commonly used herbs in this study were (in order of frequency)      Echinacea Gingko biloba St. John’s Wort Garlic Ginseng “Preoperative Considerations with Herbal Medicines” Murphy J. AORN Journal. 69(1); January 1999: 173-183 Precaution to Patients—Boston Children’s Hospital  “If your child is taking (or may recently taken) any herbal therapy or natural remedy 9such as St. John’s wort) or any weight-reduction medications, please notify the nurse practitioner or physician during your preoperative appointment. Some of these herbs and medications can interact with drugs used during anesthesia.” Some Dangerous Herbs      Ephedra (Ma huang)—CV, CNS (“herbal ecstasy,” “cloud nine(caffeine/ephedra),” weight loss aid) Coltsfoot, sassafras—carcinogenic Comfrey, germander, chaparral—hepatotoxic Yohimbe—HTN, tachycardia, paralysis, death Lobelia—respiratory depression, tachycardia hypotension, coma, death “Herbs and the Perioperative Patient” [Home Study Program] Brumley C. AORN Journal. 72(5); November 2000; 783-804 Case Studies  45 y/o WF scheduled for elective TAH had been taking ginkgo for several weeks   PT 18, PTT 29, Hgb 9.0 Surgery postponed Case Studies  67 y/o LAM with AODM admitted for dizziness, h/a. Had a black toe scheduled for amputation.    Admitted to chewing 2 packs tobacco a day (high licorice content) K 2.9, hypertension, EKG with ischemic and rhythm changes, FBS 243 Surgery postponed AND IF YOU CAN REMEMBER ONLY ONE THING ABOUT HERBS…..  It should be to ASK if your patients are using them ----(or other OTC supplements) especially prior to surgery or prescribing new medications. Then look it up if you don’t know about it…... Blumenthal, M, Goldberg A, Brinckman J. 2000. Herbal Medicine— Expanded Commission E Monographs. Boston, MA: Integrative Medicine Communications Integrative Health Care: Complementary and Alternative Therapies for the Whole Person By: Victor S. Sierpina, MD FA Davis Philadelphia, 2001 www.b&n.com www.amazon.com http://atc.utmb.edu/altmed Internet Resources on Herbs      UTMB— http://atc.utmb.edu/altmed—Resources: HealthNotes Online NIH--- www.nccam.nih.gov American Botanical Council— www.herbalgram.org Herb Research Foundation— www.herbs.org Duke’s Phytochemical and Ethnobotanical Database http://www.ars-grin.gov/duke/ Resources in Herbal Medicine      Murray M, Pizzorno J. 1998. Encyclopedia of Natural Medicine. Rocklin, CA: Prima Pub. Ottarian SG. 1999. Medicinal Herbal Therapy—A Pharmacist’s Viewpoint. Portsmouth, NH: Nicolin Fields Publishing, Inc. PDR for Herbal Medicines. 1998. Montvale, NJ: Medical Economics Co. Pizzorno JE, Murray MT. 1999. Textbook of Natural Medicine. Edinburgh: Churchill Livingstone. Robbers JE, Tyler, VE. 1999. Tyler’s Herbs of Choice— The Therapeutic Use of Phytomedicinals. New York: The Haworth Press, Inc. Resources in Herbal Medicine     Sierpina, V. 2001. Integrative Health Care: Complementary and Alternative Therapies for the Whole Person. Philadelphia: FA Davis. Blumenthal M. (ed). 1998. The Complete German Commission E Monographs—Therapeutic Guide to Herbal Medicines. Boston, MA: Integrative Medicine Communications. ——. (ed), Goldberg A, Brinckman J. 1999. Herbal Medicine—Expanded Commission E Monographs. Newton, MA: Integrative Medicine Communications. Dincin Buchman D. 1979. Herbal Medicine. New York: David McKay Company, Inc. Resources in Herbal Medicine     Duke JA. 1997. The Green Pharmacy. Emmaus, PA: Rodale Press. Hoffman D. 1996. The Complete Illustrated Holistic Herbal. New York: Barnes and Noble Books. Lininger S (ed), Wright J, Austin S, Brown D, Gaby A. 1998. 2nd edition 1999. The Natural Pharmacy. Rocklin, CA: Prima Pub. ——. (ed), Gaby AR, Austin S, Batz F, Yarnell E, Brown DJ, Constantine G. 1999. A-Z Guide to Drug-Herb-Vitamin Interactions. Rocklin, CA: Prima Pub.