Gloucestershire Hospitals
NHS Foundation Trust
Guidelines for the management of patients undergoing surgery
who use oral herbal preparations
There is generally very limited information on interactions and adverse effects with herbal
medicines compared to conventional medicines. However there is some information to indicate
that certain herbal medicines can interact with medication used in the peri-surgical period, as
well as cause effects that may be detrimental during surgery.
Wherever possible, based on limited available information, elective surgical patients
should discontinue herbal medications at least two weeks prior to surgery, unless
dependant upon them (see valerian and kava below).
An alternative approach is to make decisions regarding management based on the
pharmacokinetics and pharmacodynamics of the individual compound. When this approach is
used, recommendations for discontinuation may range from 24 hours to 2 weeks (see table
below).
For emergency surgery the table below provides guidance on possible adverse effects with
some more commonly used herbal preparations.
For further information please contact Medicines Information at Gloucestershire Hospitals NHS
Trust: either Gloucestershire Royal Hospital: Ext. 6108 or Cheltenham General Hospital: Ext.
3030
References:
1. Ang-Lee M.K etal. Herbal medicines and peri-operative care. J. Am. Medical Associate;
2001; 286: 2: 208-216.
2. Trapskin P. Smith K. Herbal medications in the perioperative orthopedic surgery patient.
Orthopedics; 2004; 27: 8:819-822.
3. Natural Medicines Comprehensive Database. www.naturaldatabase.com. Accessed 26th
March 2008.
4. Mayo Clinic. Herbal supplements: How they can interfere with surgery.
www.mayoclinic.com. Accessed 16th January 2008.
5. Baxter K (ed), Stockley’s Drug Interactions. [online] London: Pharmaceutical Press <
http://www.medicinescomplete.com/ > (Accessed on 27th March 2008).
S/WADE/Medicines & Information GRH 2004 – Updated March 08
Next review 03/11
HERB
ALOE VERA
CHONDROITIN
DANSHEN
DONG QUAI
ECHINACEA
RELEVANT EFFECTS
Impairs platelet
aggregation. May
interact with sevoflurane
which also inhibits
platelet aggregation.
Anticoagulant and
antiplatelet effects
Inhibits platelet function
and clotting. Also has
positive inotropic
effects.
Contains coumarin
constituents that inhibit
platelet function.
Activates cell –
mediated immunity
EPHEDRA
Increases heart rate
and blood pressure
FEVERFEW
GARLIC
Inhibits platelet function
Inhibits platelet
aggregation
Inhibits platelets and
prostaglandins.
Hypoglycaemic, also
has positive cardiac
inotropic effects.
Inhibits platelet
activating factor
Lowers blood glucose,
inhibits platelet
aggregation
GINGER
GINKGO
GINSENG
GLUCOSAMINE
LICORICE (not
including licorice
sweets)
KAVA
SAW PALMETTO
ST JOHN’S
WORT
VALERIAN
Raises blood glucose
and reduces insulin
sensitivity
Can raise blood
pressure and suppress
renin and aldosterone
levels
Sedation
Inhibits platelet
aggregation
Inhibits neurotransmitter
re-uptake and can
significantly increase
the metabolism of
certain drugs.
Sedation
CONCERN DURING
SURGERY
Increased risk of bleeding
Discontinue at least 2 weeks before surgery.
Increased risk of bleeding
Discontinue at least 2 weeks before surgery.
Increased risk of bleeding
Discontinue at least 2 weeks before surgery.
Increased risk of bleeding
Discontinue at least 2 weeks before surgery.
Allergic reactions; reduction of
effectiveness of
immunosuppressive drugs;
poor wound healing; increased
risk of infection
Risk of myocardial infarction
and stroke. In patients
anaesthetised with halothane:
ventricular arrhythmias
Discontinue at least 2 weeks before surgery
but ideally discontinue as far in advance of
surgery as possible.
Increased risk of bleeding
Increased risk of bleeding
RECOMMENDATIONS
Discontinue at least 24 hours before
surgery.
Because of safety concerns products
containing ephedra should only be used
under the supervision of a healthcare
practitioner.
Discontinue at least 2 weeks before surgery.
Discontinue 7 days before surgery
Increased risk of bleeding,
hypoglycaemia.
Discontinue at least 7 days before surgery
Increased risk of bleeding
Discontinue at least 7 days before surgery
Hypoglycaemia; increased risk
of bleeding; however can also
decrease anticoagulation
effect of warfarin
Hyperglycaemia
Discontinue at least 7 days before surgery
Hypertension, oedema, ECG
changes, arrhythmias
Discontinue at least 2 weeks before surgery
Could increase sedative effect
of anaesthetics
Reduce dose gradually over several weeks
to prevent withdrawal, ideally discontinue at
least 2 weeks before surgery, or if patient is
dependent on kava take up until day of
surgery. If withdrawal occurs treat with
benzodiazepines.
Discontinue 7 days before surgery
Increased risk of bleeding
Interaction with other drugs
including; alfentanil,
midazolam, lidocaine, calcium
channel blockers, SSRIs,
anticonvulsants, cyclosporin,
digoxin, warfarin, NSAIDs (this
list is not exhaustive).
Could increase sedative effect
of anaesthetics, long term use
could increase the amount of
anaesthetic required
S/WADE/Medicines & Information GRH 2004 – Updated March 08
Discontinue at least 2 weeks before surgery
Discontinue at least 7 days before surgery
Reduce dose gradually over several weeks
to prevent withdrawal, ideally discontinue at
least 2 weeks before surgery, or if patient is
dependent on valerian take up until day of
surgery. If withdrawal occurs treat with
benzodiazepines.
Next review 03/11