By Jeremy Appleton, ND
Healthnotes Newswire —Doctors should obtain detailed information about their patients’ use of herbal medicines well in advance of surgery, according to a study published in yesterday’s Journal of the American Medical Association.1 Supplementation with herbal medicines has the potential to create complications in and around surgery, unless the herbs are discontinued far enough in advance. The new study attempts to establish a "rational strategy," based on the existing herbal research, for when to discontinue the use of eight of the most important herbs currently used by consumers.
Although no controlled trials have evaluated the effects of herbal medicine use on surgery outcomes, the new JAMA review compiles and interprets the results of various studies and case reports on the drug-like actions of popular herbal remedies. Based on this review, the authors make specific recommendations for the appropriate presurgical discontinuation of echinacea, ephedra, garlic, ginkgo, ginseng, kava, St. John’s wort, and valerian. These herbs account for more than 50% of all single-herb preparations used by the American public.2
The following is a summary of the authors’ cautions and recommendations:
• Echinacea (E. angustifolia, E. purpurea, E. pallida): May interfere with drugs used to suppress the immune system. No recommendation on when to discontinue.• Ephedra (Ephedra sinica): May increase risk of heart attack and stroke. Discontinue at least 24 hours before surgery.
• Garlic (Allium sativum): May increase risk of bleeding. Discontinue at least seven days before surgery.
• Ginkgo (Ginkgo biloba): May increase risk of bleeding. Discontinue at least 36 hours before surgery.
• Ginseng (Panax ginseng, Panax quinquefolius): May increase risk of low blood sugar or postsurgical bleeding. Discontinue at least seven days before surgery.
• Kava (Piper methysticum): May increase sedative effects of anesthetics. Discontinue at least 24 hours before surgery.
• St. John’s Wort (Hypericum perforatum): May interfere with metabolism of many drugs. Discontinue at least five days before surgery.
• Valerian (Valeriana officinalis): May increase sedative effects of anesthetics. No recommendation on when to discontinue.
Taken as a whole, these recommendations are a "safe", but perhaps less than optimal, approach to preventing drug-herb interactions in surgery. In the case of herbs that increase the risk of bleeding (e.g., garlic, ginkgo), temporarily discontinuing the herb is probably the most rational strategy. However, the drug interactions of St. John’s wort are not dissimilar to those of many prescription medications. Surgeons and anesthesiologists have routinely addressed such interactions by increasing or decreasing the doses, as appropriate. Critics question the wisdom of withdrawing an effective antidepressant herb to prevent interactions that might otherwise be dealt with by dose modifications.3 If a physician recommends discontinuing effective medication for a bona fide medical condition (e.g., St. John’s wort extract for clinical depression4 5), should they not also ensure that the condition continues to be effectively managed, while reducing surgical risks?
Many patients are wary of medical doctors’ attitudes and knowledge about dietary supplements.6 This may explain why half of patients in one study failed to report use of herbal medicines unless specifically asked about them.7 On the other hand, about the same proportion of these patients also failed to report use of other nonprescription medications, like aspirin, that should similarly be avoided before surgery. Herbs are generally safe in the nonsurgical setting and, with appropriate communication between doctors and patients, any potential risk associated with surgery could easily be eliminated. A more challenging problem to address is the poor communication between doctors and patients that results in widespread nondisclosure of herb, supplement, and over-the-counter medication use by surgical patients.
The new study was written by three anesthesiologists who admit that they often do not meet a surgical patient until the day of surgery. In the conclusion of their study, they urge other doctors to have their patients bring their herbal medications and dietary supplements with them to their preoperative consultation.
References1. Ang-Lee MK, Moss J, Yuan C-S. Herbal medicines and perioperative care. JAMA 2001;286:208–16.
2. Commission on Dietary Supplement Labels. Report of the Commission on Dietary Supplement Labels, Report to the President, Congress, and The Secretary of the Department of Health and Human Services. Washington, DC: US Government Printing Office; 1997.
3. Alan R. Gaby, MD. Personal communication.
4. Harrer G, Sommer H. Treatment of mild/moderate depressions with Hypericum. Phytomedicine 1994;1:3–8.
5. Ernst E. St. John’s wort, an antidepressant? A systemic, criteria-based review. Phytomedicine 1995;2:67–71.
6. Blendon RJ, DesRoches CM, Benson JM, et al. Americans’ views on the use and regulation of dietary supplements. Arch Intern Med 2001;161:805–10.
7. Hensrud DD, Engle DD, Scheitel SM. Underreporting the use of dietary supplements and nonprescription medications among patients undergoing a periodic health examination. Mayo Clin Proc 1999;74:443–7. Jeremy Appleton, ND, is a licensed naturopathic physician, writer, and educator in the field of evidence-based complementary and alternative medicine. Dr. Appleton is Chair of Nutrition at the National College of Naturopathic Medicine and Senior Science Editor at Healthnotes.