HERBAL MEDICINES
ANESTHETIC IMPLICATIONS
M. Ron Eslinger
CRNA, MA, APN
www.aamsn.com
A 35 year old athletic woman with a history of
migraines presents for ACL reconstruction. Her
only pertinent history is previous PONV after 3
GA’s for gynecologic procedures. She
completed a preop screening form and
consultation in the preop clinic was deferred.
She indicates multivitamin use on her
questionnaire.
She is very motivated to avoid PONV this time.
A 35 year old otherwise healthy mother of three
presents for posterior lumbar fusion for chronic
back pain that has failed conservative treatment.
Because of her unremarkable history, her
consultation in preop clinic was deferred. She is
attended by her mother as she and her spouse are
separated.
A 35 year old athletic woman with a history of
migraines presents for ACL reconstruction.
History of PONV.
Feverfew
Ginger
35 year old for posterior spinal fusion.
St. John’s Wort
HERBAL MEDICINE
HISTORY
• Early archaeological evidence - Neanderthal
• 16th Century Medicinal Plants
• Scientific method and the marginalization of
Herbal Medicine - 19th Century
• Rebirth of herbal medicine and natural health in
the 1960’s
• Establishment of Office of Alternative Medicine,
National Institutes of Health 1992
• 1994 FDA Dietary Supplement and Health
Education Act
HERBAL MEDICINE
EPIDEMIOLOGY
• 3 - 93% of U.S. population use herbals
• Generally higher internationally
Incidence of Herbal Medicine Use Among Age
Groups
30
25
20
15
%
10
5
0
<20
20-30
31-40
41-50
51-60
61-70
71-80
>80
Age group
Tsen, et al, Alternative medicine Use in Presurgical Patients, Anesthesiology, 93, 148-51
% of patients using herb
8
Herbal medication use
7
6
5
4
3
2
1
0
Aloe
Cranberry
Echinacea
Garlic
Ginkgo biloba
Ginseng
Goldenseal
Saw palmetto St. John's ort
Herb
n=3106
Tsen, et al, Alternative medicine Use in Presurgical Patients, Anesthesiology, 93, 148-51
Top Ten Selling Herbs
1995 Survey of 163 Health Food Retail Stores
(Winslow and Kroll, 1998)
ECHINACEA
GARLIC
GOLDENSEAL
GINSENG
GINKGO
SAW PALMETTO
ALOE
MA HUANG
SIBERIAN GINSENG
CRANBERRY
(ST. JOHN’S WORT, VALERIAN, FEVER FEW)
ECONOMICS AND REIMBURSEMENT
•
•
•
•
•
$553 million in 8000 health food stores - 1994
$ 1.2 billion from all sources
20% annual growth rate
largest growth area in retail pharmacies
increasing coverage of herbals and alternative
therapies by insurance and managed care industries
QUALITY CONTROL
1994 Dietary Supplement and Health Education Act
Compromise act
No requirements for:
Proof of efficacy
Proof of safety
Standards for quality control
Cannot promise a specific cure, but may claim effect
Burden of proving product unsafe lies with FDA
QUALITY CONTROL
• Variability between manufactures and batches
• Potency affected by growing conditions,
storage, handling, and preparation - up to
10,000 fold difference in potency
QUALITY CONTROL
• Inaccuracy of labels
• Contamination with other substances
– Mandrake(scopolamine) or Snakeroot (reserpine) in
Ginseng preparations
– Use of additives not found on label (NSAID’s,
steroids, antibiotics, sedatives, hypnotics)
– Belladonna poisoning in herbal tea (NYC)
– Digitalis intoxication from mislabeled plant extract
– Heavy metals (lead, arsenic, cadmium, copper,
mercury) in preparations from some foreign
countries
EFFICACY AND SAFETY
• No profit in conducting controlled studies in U.S.
• Reported effects stem from anecdotal reports and a few
well controlled clinical trials
• System for reporting ADR’s for herbals and dietary
supplements is poor (FDA web site available at:
http://www.fda.gov
• Potential safety issues include:
– Drug-herb interactions
– Herb-body interactions (inhibition or stimulation of
microsomal liver enzymes)
– Toxicity from contaminants
– Delayed intervention with allopathic treatment
ORGAN SYSTEM TOXICITY
(from Winslow and Kroll, 1998)
GASTROINTESTINAL
HEPATOTOXIC (MILD TO SEVERE)
Chinese herbal teas, Mistletoe, Germander, Chaparral, Comfrey
NAUSEA/VOMITTING
Dandelion, Garlic, Ginseng, Chaparral
DIARRHEA
Herbal teas, Aloe, Ligustrum, Dandelion, Prunelia, Garlic, Ginseng
HEMATOLOGIC
ANTICOAGULANT/ANTIPLATELET
Yarrow, Red clover, Tang-kuei, Pau d’arco, Salvia
ORGAN SYSTEM TOXICITY
(from Winslow and Kroll, 1998)
CENTRAL NERVOUS SYSTEM
NERVOUSNESS / AGITATION/INSOMNIA / MOOD CHANGES
DEPRESSION / CONFUSION / HALLUCINATIONS
Ginseng (long-term and higher doses)
HALLUCINOGENIC
Catnip, Hops, Kava kava, Khat, Lobelia, Mandrake, Nutmeg, Jimson weed, Valerian, Yohimbe
CHOLINERGIC TOXICITY
(CONTAINS ATROPINE, SCOPOLOMINE, HYOSCYAMINE)
Jimson weed
SEDATION
Peony, Salvia, Tang-kuei
SEIZURES / PSYCHOSIS / COMA
Ephedra
ORGAN SYSTEM TOXICITY
(from Winslow and Kroll, 1998)
PULMONARY
PULMONARY HYPERTENSION
Chinese herbal teas
ALLERGIC / IMMUNOLOGIC
CONTACT DERMATITIS
Propolis, Garlic, Echinacea, Melaleuca oil
SYSTEMIC LUPUS ERYTHEMATOSIS
Alfalfa
RENAL
DIURESIS
Burdock, Astragalus, Peony, Dandelion
HYPERTENSION / SODIUM AND WATER RETENTION / HYPOKALEMIA
Licorice, Glycyrrhiza glabra, Glycyrrhiza radix
ORGAN SYSTEM TOXICITY
(from Winslow and Kroll, 1998)
ENDOCRINOLOGIC
GYNECOMASTIA / VAGINAL BLEEDING
Ginseng (estrogen-containing)
GOITERS / HYPERTHYROIDISM / HYPOTHYROIDISM
Kelp (iodine-containing)
INHIBITION OF IODINE UPTAKE
Garlic
HYPOGLYCEMIA
Atractylodes, Scrofularia, Lycium, Burdock
ORGAN SYSTEM TOXICITY
CARDIOVASCULAR
HYPOTENSION
Astragalus, Codonopsis, Prunella, Scrofularia, Salvia
HYPERTENSION
Ginseng
HYPERTENSION / CORONARY SPASM / PALPITATIONS
Ephedra
• ECHINACEA
Echinacea purpurea and angustifolia
ECHINACEA
Echinacea purpurea, pallida, and angustifolia
USES
Immune system stimulant (E. augustifolia)
Anti-infective (E. pallida)
Wound healing (E. purpurea)
MECHANISM
Alkylamide and polysaccharide consituents result in immunostimulation
secondary to enhanced phagocytosis and non-specific T-cell stimulation in
vitro and in vivo.
STUDIES
1) Decrease in flu-like symptoms from 10 to 7 days
2) 15% reduction in number of colds
TOXICITY
tachyphylaxix, ?hepatotoxicity, shivering, fever, weakness, potential cross
allergy with daisy and sunflower families, autoimmune exacerbations
GINKGO
Gingko biloba
GINGKO
Gingko biloba
GINKGO
Gingko biloba
USES
Antioxidant, Enhances Cerebral Blood Flow, Reduces symptoms of
peripheral vascular disease and Raynaud’s, Alleviates vertigo and
tinnitus
MECHANISM
Ginkgolides antagonize PAF(gingkolide B)
antioxidant activity of flavenoid, terpenoids, organic acids
STUDIES
1) improvement in 2 of 3 clinical parameters of cognitive function at
12 weeks in 309 pateients in placebo controlled study
2) improvement in two tests of cognitive function in 2020 Alzheimer’s
patients with no difference in adverse effects compared to placebo
GINKGO
Gingko biloba
TOXICITY
GI upset, headache
spontaneous hyphema (case report)
spontaneous bilateral subdural hematomas (case report)
?neurotoxicity (gingkotoxin in both leaf and seed)
POTENTIAL DRUG INTERACTIONS
NSAID’s, aspirin, anticoagulants
ANESTHETIC CONSIDERATIONS
Regional anesthesia, preoperative bleeding history, ?labs,
intraoperative bleeding
St. John’s
Wort
ST. JOHN’S WORT
Hypericum perforatum
USES
Antidepressant for mild to moderate depression
Possible anti-inflammatory and anti-viral activity
MECHANISM
10 constituents which may contribute to pharmacoloical effects
(naphthodianthroms, flavonoids, xanthose, bioflavonoids)
weak MAOI or selective serotonin reuptake inhibition
STUDIES
Hypericum extracts superior to placebo and equivalent to
amitriptyline or imipramine with less side effects in meta analysis
of 1757 patients
ST. JOHN’S WORT
Hypericum perforatum
TOXICITY
photosensitivity (hypericin)
MAOI (NIH sponsored study ongoing)
possibly serotonism (headache, sweating, dizziness, agitation)
DRUG INTERACTIONS
beta-symphathomimetics, ephedra, meperidine, serotonin reuptake
inhibitors, photosensitizing medications
ANESTHETIC CONSIDERATIONS
as above, ?discontinue prior to surgery
may prolong effects of anesthesia
GARLIC
GARLIC
Allium sativum
Allium sativum
GARLIC
Allium sativum
USES
Antispasmodic, antiseptic, bacteriostatic, antiviral, promotor of
leukocytosis, hypotensive, hypocholesterolemic
MECHANISM
not stated
inhibition of epinephrine induced in vitro platelet aggregation
STUDIES
hypotensive effect in many animal studies
modest decrease in serum cholesterol and triglycerides in human
studies using large doses (300mg TID)
GARLIC
Allium sativum
TOXICITY
inhibition of spermatogenesis in rats
decreased platelet aggregation with one case report of spontaneous
spinal epidural hematoma in an 87 yo man
elevated INR
DRUG INTERACTIONS
antiplatelet agents
warfarin potentiation
ANESTHETIC CONSIDERATIONS
as above
GINSENG
Asian Panax ginseng
American Panax quinquefolius
Siberian Eleutherococcus senticosus
GINSENG
Asian Panax ginseng
American Panax quinquefolius
Siberian Eleutherococcus senticosus
USES
Adaptogen, mood and energy level enhancer, antioxidant,
hypoglycemic
MECHANISM
?augmentation of adrenal steroidogenesis via pituitary
immunomodulation via increased IgG and IgM responses to primary
and secondary challenges associated with increased interferon
production
enhancement of cell mediated immunity and natural killer cell
activity
hypoglycemic via ginsenoside Rb2 and panaxans I, J, K, and L
GINSENG
Asian Panax ginseng
American Panax quinquefolius
Siberian Eleutherococcus senticosus
STUDIES
animal studies of immune effects
Double-blind, placebo controlled study of 36 type II diabetics revealed
subjective improvement in mood, vigor, well-being, decreased
weight and increased physical activity, and moderately lower
fasting serum glucose
TOXICITY
Ginseng abuse syndrome (>15g/day) - sleepiness, hypertonia, edema
hypertension, insomnia, vomiting, headache, epistaxis
Stevens-Johnson Syndrome (case report)
Vaginal bleeding with oral and topical use (case reports)
Mastalgia and diffuse breast nodularity (case report)
?fetal adrogenization (Siberian ginseng) (case report)
GINSENG
Asian Panax ginseng
American Panax quinquefolius
Siberian Eleutherococcus senticosus
DRUG INTERACTIONS
Possible interaction with antiplatelet drugs and anticoagulants based
on case report of decreased INR in patient on warfarin
Possible potentiation of CNS stimulants or excacerbations of manic or
psychotic symptoms in predisposed individuals
ANESTHETIC CONSIDERATIONS
as related to above
Golden Seal GOLDENSEAL
Hydrasis canadensis
GOLDEN SEAL
Hydrasis canadensis
USES
Diuretic
Anti-inflammatory
Laxative
Hemostatic
TOXICITY / PRECAUTIONS
Oxytotic (pregnancy)
Overdose may cause paralysis
Aquaretic (not diuretic)
May worsen edema and/or hypertension
SAW PALMETTO
Serenoa repens
Saw Palmetto
SAW PALMETTO
Serenoa repens
USES
Benign prostatic hypertrophy
Diuretic, urinary antiseptic, anabolic
MECHANISM
antiandrogenic acivity of hexane extract
inhibits binding of dihydrotestosterone at receptors and 5-alphareductase activity
STUDIES
2 double blind studies showed significant improvement in objective
and subjective data versus placebo and finasteride
SAW PALMETTO
Serenoa repens
TOXICITY
GI upset
DRUG INTERACTIONS
caution with hormonal therapies
Valeriana officinalis
VALERIAN
Valeriana officinalis
USES
Mild sedative
Mild anxiolytic
MECHANISM
not stated
STUDIES
decreased sleep latency in 2 studies, one showing mild EEG changes
suggesting hypnotic effect
VALERIAN
Valeriana officinalis
ANESTHETIC CONSIDERATIONS
Will likely potentiate barbiturate and benzodiazepine effects
(Should not be used with alcohol)
Feverfew
FEVERFEW
Tanacetum parthenium
FEVERFEW
Tanacetum parthenium
USES
Migraine
MECHANISM
Suppresses prostaglandin production by 86-88% (no anticyclooxygenase activity)
?parthenolide
STUDIES
shown effective in reducing number of episodes in 2 placebocontrolled, blinded studies of 17 and 72 patients
FEVERFEW
Tanacetum parthenium
TOXICITY
GI irritation or aphthous ulcerations in 5-15%
Inhibits platelet activity
Rebound headaches
Post-feverfew syndrome - nervousness, tension, headache, insomnia,
stiffness, joint pain, tiredness
DRUG INTERACTIONS
anti-platelet agents, anticoagulants
ANESTHETIC CONSIDERATIONS
bleeding history, ?labs, discontinue preop
GINGER
Zingiger oficinale
GINGER
Zingiger oficinale
USES
antinauseant
antispasmodic
MECHANISM
not stated for primary use
thromboxane synthetase inhibition
STUDIES
not found
GINGER
Zingiger oficinale
TOXICITY
potent inhibitor of thromboxane synthetase - bleeding
DRUG INTERACTIONS
NSAID’S, aspirin, anticoagulants
ANESTHETIC CONSIDERATIONS
Bleeding history, ?preop labs, intraop bleeding
Discontinue prior to surgery
EPHEDRA
Ephedra sinica
EPHEDRA (MA HUANG)
Ephedra sinica
USES
Diet aid
Bacteriostatic
Antitussive
MECHANISM
release of endogenous catecholamines (indirect
sympathomimetic)
STUDIES
Not found
EPHEDRA (MA HUANG)
Ephedra sinica
TOXICITY
hypertension (mild to severe), tachycardia, cardiomyopathy,
dysrhythmia, MI, CVA, seizure, psychosis, death
DRUG INTERACTIONS
MAOI’s, cardiac glycosides, halothane, oxytotics
ANESTHETIC CONSIDERATIONS
Discontinue prior to surgery
As related to above
World Wide Web Resources
Organization Address
FDA
http://www.fda.gov
Links
MEDWATCH
special nutritionals adverse
event monitoring system
American
Botanical
Council
http://www.herbs.org Herb Research
Foundation
University of http://www.nnlm.nlm. MEDLINE, pictures
Washington nih.gov
Medicinal Herb
Garden
Winslow and Kroll, Herbs as Medicines, Archives of
Internal Medicine, 158, 2192-2199.
Miller, L., Herbal Medicinals: Selected Clinical
Considerations Focusing on Known or Potential DrugHerb Interactions, Archives of Internal Medicine, 158,
2200-2211.
Murphy, Preoperative Considerations with Herbal
Medicines, AORN Journal, 69(1), 173-183.
Tsen, et al, Alternative Medicine Use in Presurgical
Patients, Anesthesiology, 93, 148-151.
World Wide Web Resources
American Botanical Council
www.herbalgram.org
NIH Office of Alternative Medicine altmed.od.nih.gov
U.S. Dept of HHS
www.healthfinder.gov
(search “alternative
medicine”)
U.S. Pharmacopeia
www.usp.org