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Herbal Agents and Anesthesia

(Originally posted 14 August 2000 on About Anesthesiology)

The use of herbal agents and related over-the-counter supplements has increased at an incredible rate in recent years. While the use of herbs and similar agents have been used to treat diseases and symptoms of diseases for many years and in many countries, their use fell out of favor in the United States when the discovery of more "traditional" medications occurred. Recently, however, there has been a resurgence in the popularity of, interest in and usage of herbal medications due to such factors as:

  • Increased consumer interest in health
  • Increasing awareness of issues related to fitness
  • Dissatisfaction and high cost associated with traditional medical practice
  • Promotion of these supplements by the media
  • Promotion of these supplements by companies seeking to make a profit (sales
    of these products are estimated to reach over two billion dollars by the year 2001)

Many different medical organizations have released statements and warnings concerning these different agents and emphasized the importance of patients informing their physicians when they are taking these substances. (For example, see the American Society of Anesthesiologists press release on this matter.) In addition, many medical journals have warned that these medications interact with prescription drugs and can cause a multitude of serious problems. For example:

  • Patients on anticoagulants and "blood thinning" medications have been reported to have excessive bleeding from wounds, gums, eyes, etc.
  • People with epilepsy have been reported to have seizures despite taking their anti-seizure medications correctly and on schedule.
  • People with diabetes have experienced severe swings in their blood sugar levels.

It is estimated from various surveys that over fifteen million adults in the United States are taking some type of herbal supplement. Despite the prevalence of usage and the many warnings from medical groups and the media, most patients don't inform their physicians about these supplements. Many reasons exist for this phenomena including:

  • Patients believe that since the medications are over the counter they must
    be safe.
  • Patients believe that since the supplements come from "natural" sources they
    must be safe.
  • These supplements are often taken for reasons that patients consider
    embarrassing (weight loss, depression, etc.)

Another problem is the lack of firm regulation concerning the content of herbal supplements. Studies have shown that herbal medications often include additional ingredients not disclosed on their labels which may exert chemical effects. Perhaps even worse, these products may include a different substance altogether versus what the supplement is advertised to contain. Some of the supplements even contain materials that are considered toxic to humans!

Common side effects of these medications include:

  • Headache
  • Nausea
  • Vomiting

Many of these medications have been associated with strange complications - for example lead poisoning as a result of adulterated components added to the medication in manufacturing.

Other rarer complications that have been reported include:

  • Myocardial infarction (heart attack)
  • Stroke
  • Liver failure and
  • Death.

Some of the agents have been shown to contain materials that are carcinogenic (that is they contain agents known to cause cancer). These agents include:

  • Borage
  • Calamus
  • Colts foot
  • Comfrey
  • Life root and
  • Sassafras

Other agents are known to be hepatotoxic (that is, damaging to the liver). These include:

  • Germander
  • Chaparral and
  • Life root

Even in those supplements that do contain what they say they contain - the actual amount of the ingredient varies widely from almost none to more than 150% of what is claimed on the label. This type of variation in any controlled prescription medication would be unacceptable and lead to a recall of that medication. Variation of this type may mean that consumers are, at the very least, wasting their money or, at the worst, endangering their lives without even knowing it.

Anesthesiologists need to be aware of the widespread use of these medications and the fact that patients often forget or are unwilling to discuss them. Some basic questions during the preoperative assessment will help assure that this topic is covered:

  • Do you take any medications?
  • Do you take any non-prescription medications?
  • Is there anything over the counter that you take on a regular basis?
  • Do you take vitamins or supplements?

Often, the anesthesiologist will need to ask the patient to bring the actual supplement in order to determine what actual substance is being ingested. In addition, anesthesia providers should be aware that what is on the label is not always what is in the supplement. Lastly, it is important to know the effects that these medications can have and the potential drug interactions with anesthetic agents and other drugs the patient might receive as part of the hospital stay and surgery.

Common anesthetic concerns will include:

  • Stimulant potential (feverfew, St. John's Wort, guarana, gotu kola, goldenseal, ma huang, milk thistle, yohimbine)
  • Depressant interactions with pharmacologic agents
  • Sedation (kava, hawthorn, valerian, lemon verbena, muwort, lavender)
  • Fluid and electrolyte imbalances
  • Coagulation Disorders (alfalfa, garlic, ginkgo, chaomille, ginseng, feverfew, echinacea, dong quai root, willow bark, ginger, goldenseal, guarana, horse chestnut)
  • Alterations in blood glucose level (ackee fruit, alfalfa, aloe, argimony, barley, bitter melon, burdock root, carrot oil, chromium, coriander, dandelion root, devil's club, eucalyptus, fenugreek seeds, fo-ti, garlic, ginseng, grape seed, guayusa, gymena, juniper, neem seed oil, onions, periwinkle, yellow root)


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