Transcript Herbals and Anesthes..

Herbals And Anesthesia:
An Unsafe Concoction
Robert C. Jones, M.D.
Staff Anesthesiologist
Southern Maryland Anesthesia Associates
Doctors Community Hospital
12 April 2007
Copyright (C) 2007 Robert C. Jones, M.D.
Real Life O.R. Cases

1998: 30 year old patient for emergency surgery; BP 250s/140s;
required multiple antihypertensives including nitroglycerin iv;
postop, admitted to ephedra use
Copyright (C) 2007 Robert C. Jones, M.D.
Real Life O.R. Cases


1998: 30 year old patient for emergency surgery; BP 250s/140s;
required multiple antihypertensives including nitroglycerin iv;
postop, admitted to ephedra use
2002: patient undergoing oral surgery; massive, unexpected
bleeding; postop, admitted to ginseng use
Copyright (C) 2007 Robert C. Jones, M.D.
Real Life O.R. Cases



1998: 30 year old patient for emergency surgery; BP 250s/140s;
required multiple antihypertensives including nitroglycerin iv;
postop, admitted to ephedra use
2002: patient undergoing oral surgery; massive, unexpected
bleeding; postop, admitted to ginseng use
2002: “Garlic Man”: patient undergoing TKR; known garlic use,
but case proceeded because patient was air-evac from Italy;
massive bleeding despite tourniquet; required transfusion
Copyright (C) 2007 Robert C. Jones, M.D.
Real Life O.R. Cases




1998: 30 year old patient for emergency surgery; BP 250s/140s;
required multiple antihypertensives including nitroglycerin iv;
postop, admitted to ephedra use
2002: patient undergoing oral surgery; massive, unexpected
bleeding; postop, admitted to ginseng use
2002: “Garlic Man”: patient undergoing TKR; known garlic use,
but case proceeded because patient was air-evac from Italy;
massive bleeding despite tourniquet; required transfusion
2004: Young woman for appy: 1 liter blood loss (willow bark)
Copyright (C) 2007 Robert C. Jones, M.D.
Real Life O.R. Cases





1998: 30 year old patient for emergency surgery; BP 250s/140s;
required multiple antihypertensives including nitroglycerin iv;
postop, admitted to ephedra use
2002: patient undergoing oral surgery; massive, unexpected
bleeding; postop, admitted to ginseng use
2002: “Garlic Man”: patient undergoing TKR; known garlic use,
but case proceeded because patient was air-evac from Italy;
massive bleeding despite tourniquet; required transfusion
2004: Young woman for appy: 1 liter blood loss (willow bark)
2007: Patient undergoing elective back surgery; intraop and
postop: massive, unexpected bleeding/oozing; patient had taken
multiple herbals until 12 days prior to surgery
Copyright (C) 2007 Robert C. Jones, M.D.
Real Life Tragedy
2 Capsules of Cytodyne's Xenadrine contains:
335mgs of MaHuang
910mgs of Guarana
105mgs of White Willow Bark
125mgs of Citrus Aurantium (snyephrine)
100mgs of Acetyl L Carnitine
80mgs of L Tyrosine
50mgs of Ginger Root
40mgs of B5
Ingredients (including grammatical errors) from:
http://www.meganutrition.com/Lane_Labs/Xenadrine_RFA-1.htm
Feb 17, 2003: 23 YO pitcher dies at Orioles training
camp in Ft. Lauderdale; lawsuit by family alleges death
caused by Xenadrine® brand ephedra (Ma Huang)
Copyright (C) 2007 Robert C. Jones, M.D.
Copyright (C) 2007 Robert C. Jones, M.D.
Copyright (C) 2007 Robert C. Jones, M.D.
Oral/Maxillofacial Surgeons
are Concerned as well...
Copyright (C) 2007 Robert C. Jones, M.D.
Overview







Herbal Medicinals: “All Natural” and 0% FDA approved
A Little Something Extra with your Herbals, Ma’am?
Pharmacokinetics vs. Pharmacodynamics
Specific Herbals with Potential for Serious Interactions
Official Guidelines/Statements on Herbals + Anesthesia
So How Long Should Surgery be Postponed?
Questions
Copyright (C) 2007 Robert C. Jones, M.D.
“All Natural” = Safe?

Examples of 100% Natural Substances:
 Uranium
 Anthrax
 Puffer
fish poison (tetrodotoxin)
 Smallpox
 Destroying Angel and Death Cap mushrooms
 Cobra venom

Many of our most potent (and potentially deadly)
prescription drugs come from herbs: e.g., digitalis from
foxglove
Copyright (C) 2007 Robert C. Jones, M.D.
Herbals are Not Regulated by
the FDA


The dietary supplement industry lobbied Congress hard to pass the
1994 Dietary Supplement Health Education Act (DSHEA), which
treats DS as food, rather than as drugs
“The 1994 Dietary Supplement Act does not require that dietary
supplements (defined broadly to include many substances, such as
herbs and amino acids, that have no nutritive value) be shown to
be safe or effective before they are marketed. The FDA does not
scrutinize a dietary supplement before it enters the marketplace.
The agency is permitted to restrict a substance if it poses a
"significant and unreasonable risk" under the conditions of use on
the label or as commonly consumed.”
--Former FDA Commissioner David A. Kessler, MD, JD, in a
June, 2000 New England Journal of Medicine Editorial
Copyright (C) 2007 Robert C. Jones, M.D.
A little something extra with
your Herbals?
Copyright (C) 2007 Robert C. Jones, M.D.
A little something extra with
your Herbals?

Substances found in herbal preparations available over the
counter in the USA:
 carcinogens
(hexachlorobenzene, quintozene)
 pesticides (including OCPs)
 heavy metals (lead, mercury, arsenic, cadmium)
 sawdust
 male enhancement and other prescription drugs
 mold and other fungi
 little or no active ingredient
Copyright (C) 2007 Robert C. Jones, M.D.
Quality Control, Schmality
Control

Many scientific assays of dietary supplements/herbals
have found major problems:
 Variability
in product dosage, even from lot to lot by the
same manufacturer
 Little or no active ingredient
 Massive contamination
 Prescription drugs mixed in
Copyright (C) 2007 Robert C. Jones, M.D.
Copyright (C) 2007 Robert C. Jones, M.D.
(web quotes from www.consumerlab.com)
Pharmacokinetics and
Pharmacodynamics of
Herbals
There will be a test on the next slide following this lecture...
Copyright (C) 2007 Robert C. Jones, M.D.
From:
http://www.cop.ufl.edu/safezone/pat/pha5128/equations/5127-28-equations.pdf
Copyright (C) 2007 Robert C. Jones,
M.D.
Pharmacokinetics and
Pharmacodynamics of
Herbals




Pharmacokinetics: What the body does with a drug
Depends on known quantity of drug administered
Problem: Unknown interactions between dozens/hundreds of
substances in some herbal mixes (risk of adverse interaction
increases asymptotically after 8-10 drugs)
Problem: Lack of standardization of herbals plus polypharmacy of
mixtures makes physician prediction of plasma levels or total dose
(area under the curve) impossible for most preparations.
Copyright (C) 2007 Robert C. Jones, M.D.
Anyone care to speculate on
the clearance of all of these?
Copyright (C) 2007 Robert C. Jones, M.D.
Pharmacokinetics and
Pharmacodynamics of
Herbals



Pharmacodynamics: What a drug does to the body
Downregulation of receptors, altered renal physiology,
platelet effects (thrombasthenia), and/or hepatotoxicity
can take weeks to resolve after herbal use stops
“I stopped using alcohol two days ago, so I’m O.K.”:
maybe, maybe not... (DTs anyone?)
Copyright (C) 2007 Robert C. Jones, M.D.
Specific Bad Herbals

Cardiac Toxicity:


Ephedra, licorice, black cohosh, goldenseal (via aquaretic effect); all
weight loss products; guarana (caffeine); nitric oxide stimulants
Bleeding:
“The Bad Gs”: Garlic, Ginseng, Ginkgo Biloba, Ginger
 Also: feverfew, echinacea, vitamin E


Hepatotoxicity:


Synergism with sedatives/anesthetic agents:


Black cohosh, Echinacea, kava kava, chapparal leaf, comfrey
St. John’s Wort, valerian, kava kava
Interference with drug metabolism/P450 system induction

Numerous herbals
Copyright (C) 2007 Robert C. Jones, M.D.
Ephedra: worst of the worst




Also known as ma huang (“yellow horse”), ephedra
sinica, desert tea, etc.
Primary active ingredients ephedrine and
pseudoephedrine
Risk of cardiac toxicity, arrhythmias, sudden death,
severe hypertension, interaction with MAOIs, interaction
with oxytocin (hypertension)
Withdrawn from market in U.S. in 2004 by FDA
order...or was it?
Copyright (C) 2007 Robert C. Jones, M.D.
Looking for ephedra in all the
wrong places
Copyright (C) 2007 Robert C. Jones, M.D.
Bleeding: Not just for the
Middle Ages anymore




“The Bad Gs”: ginger, garlic, ginkgo, ginseng, plus feverfew,
echinacea and vitamin E
Will only affect INR if patient on warfarin; also have inherent
effects on platelet function
NO TEST can reliably predict surgical bleeding from platelet
inhibition (template bleeding time is useless: Semin Thromb
Hemost. 1990 Jan;16[1]:1-20)
Risk to patients: Intraoperative hemorrhage; needless exposure to
blood products and potential pathogens; postoperative “oozing”
requiring hematoma evacuation, etc.
Copyright (C) 2007 Robert C. Jones, M.D.
Hepatotoxicity
 Black
cohosh, Echinacea, kava kava, chapparal leaf,
comfrey; many Asian herbal tea concoctions
 Potential to decrease markedly hepatic metabolism of
anesthesia “poisons” perioperatively
 Can lead to... Fulminant hepatic failure associated with the use of black
cohosh: a case report. Liver Transpl. 2006 Jun;12(6):989-92
Copyright (C) 2007 Robert C. Jones, M.D.
Interactions with
Anesthetics/Sedatives



St. John’s Wort, valerian, kava kava
Potential for anesthetic overdose/post-operative sedation
and/or respiratory depression from CNS effects of these
herbals
Delayed emergence from general anesthesia has been
reported from St. John’s Wort (Anesthesiology:Volume 96(4)April
2002pp 1025-1027 )
Copyright (C) 2007 Robert C. Jones, M.D.
Interference with drug effects

Numerous herbals induce the cytochrome P450 (CYP)
system or other hepatic enzymes, thus reducing effects
of:
 Protease
inhibitors for HIV
 Corticosteroids
 Transplant rejection prevention drugs (cyclosporin)
 Digoxin
 Many anesthetic drugs
Copyright (C) 2007 Robert C. Jones, M.D.
Recommendations:
ASA (American Society of
Anesthesiologists)




“Natural” doesn’t always mean safe. Many herbal products on the
market can cause harmful side effects or interact with your other
medicines and anesthetics.
To prevent unforeseen complications, it is imperative that health
care providers as well as patients become aware of the interactions
of these products and that herbal use habits become a part of a
patient’s documented history and treatment plan.
Herbs and other dietary supplements do not undergo the same
strict research requirements as prescription drugs and are not
subject to FDA testing before being put on store shelves.
Patients should tell their physicians – and physicians should ask –
about all herbal, dietary or other over-the-counter preparations as
well as prescription medicine that the patient is taking.
Copyright (C) 2007 Robert C. Jones, M.D.
Recommendations:
AANA (American Association
of Nurse Anesthetists)







STOP taking the herbal product at least two weeks prior to the scheduled
procedure or surgery to prevent side effects.
Inform your surgeon and anesthesia provider that you are taking an herbal
product.
Offer accurate information about any herbal products you are taking.
When asked about your medication history, include all herbal products, overthe-counter drugs, dietary supplements, minerals, and teas.
If you are not sure of the contents of an herbal product, then bring the product
and the container it comes in with you for the preoperative anesthesia interview.
Make sure that someone close to you is aware that you take an herbal product.
In the event that you need emergency care, this person will need to share this
information with your healthcare providers.
Realize that herbal products need to be treated as medicine. Even if the product
is natural, it still may be harmful when combined with anesthetics.
Copyright (C) 2007 Robert C. Jones, M.D.
Recommendations:
ACS (American Cancer
Society)







The American Cancer Society (ACS) advises the public to be cautious of dietary
supplements: Don't depend on promoters -- promises, or on people's stories of success. Learn
as much as you can from reputable, expert sources about any herbal remedy you consider
taking, and about its possible benefits or dangers.
Following is a list of guidelines offered by the ACS:
Rule One: Investigate before you buy or use. There are many resources in food stores,
pharmacies, libraries and on the Internet. However, much of this information is produced by
promoters and it contains biased or incorrect information. Rely on materials developed by
trained experts in botanical medicine or the study of herbs.
Rule Two: Check with your doctor before you try an herbal medicine. He or she may or may
not be thoroughly versed in all herbals, but hopefully your doctor will help you make a safe
choice.
Rule Three: Do not take an herbal remedy instead of the medicine prescribed by your doctor
without discussing it first.
Rule Four: Avoid herbal remedies if you are pregnant or breast feeding.
Rule Five: Don't depend on any herbal to cure cancer or any other serious disease. It won't,
regardless of claims you might hear.
Copyright (C) 2007 Robert C. Jones, M.D.
So How Long Does the Patient
Have to be off of Herbals
Preop?
Copyright (C) 2007 Robert C. Jones, M.D.
So How Long Does the Patient
Have to be off of Herbals
Preop?





The surgeon and the patient should discuss the patient’s herbal use
with anesthesiologist/nurse anesthetist (because the surgeon asked in
the office, right?)
How invasive is procedure? MAC vs. General vs. Regional
anesthesia; toe surgery vs. hysterectomy/AAA
Urgent/Emergent operations: obviously will proceed; may involve
increase risk to patient
Elective procedures: recommendation in literature varies from 2
weeks to 1-2 weeks; explanation of the PANOYA syndrome and its
interrelationship with excessively concrete thinking
Best advice: Patient safety would be promoted by adhering to a flat
rule of 2 weeks (14 days) for the worst herbals; a few (e.g., saw
palmetto) are relatively benign; need to weigh risk/benefit ratio
Copyright (C) 2007 Robert C. Jones, M.D.
References
Copyright (C) 2007 Robert C. Jones, M.D.