www.Amazing-Health-Products.com

Getting Solid Advice About Herbs Before Surgery

Side Effects of Herbs:

Herbs act like medicine upon the body.  Like any medication, they may have side effects.  Many side effects can occur from the interaction of herbal medicines with pharmaceutical medications.  Vitamins and herbs should be used in conjunction with and not in place of conventional medical care.  The goal is to build up your body, blood and immune system for high quality of life and survivorship during surgeries and traditional cancer treatments.

Echinacea, one of the most popular herbs used to boost the immune system and battle colds, may also cause liver inflammation when it interacts with certain pharmaceutical compounds.  Echinacea may also prevent certain medications used to treat lupus and other immune-system disorders from working.

Some supplements also interact negatively with anti-clotting medications.
These supplements include Co-Q 10 and green tea extracts.

Anesthesiologists are conducting research to determine exactly how certain herbs and dietary supplements interact with certain anesthetics.  They are finding that certain herbal medicines may prolong the effects of anesthesia.  Others may increase the risks of bleeding or raise blood pressure.  Some effects may be subtle and less critical, but for anesthesiologists, anticipating a possible reaction is better than reacting to an unexpected condition.  So it is very important to tell your doctor about everything you are taking before surgery even if your doctor or anesthesiologist is not schooled in herbal medicine (most are not).

Herbalist Jonathan Treasure attended medical school at Cambridge University in England before switching careers to focus on herbalism, and although he does not have an MD degree, he has participated in designing research studies at Harvard Medical School.  Treasure is a practicing clinical herbalist, a Member of the National Institute of Medical Herbalists in the UK (MNIMH), and a member of the American Herbalist Guild.  He pointed out bias in the medical community and literature as well as specific flaws in the JAMA article, then recommended a different approach to the basic question of what to tell your doctor.

Treasure says, “Physicians usually do not know enough about herbs to give good advice about which herbs to continue taking and which to stop before surgery.  In the medical literature, there is a bias against herbal medicines and a lack of education on the part of physicians.  In the popular media, there is sensationalism and ignorance and push for readership.  Hysterical stories about the dangers of herbs attract more readers than plain, fact-oriented articles.”

The Climate of Opinion Obscures the Real Issues

Unfortunately, this climate of opinion in both medical literature and the popular press tends to obscure the real issues of herbal use and potential interactions between herbs and drugs.  According to Treasure, "When a patient is facing surgery, one group of physicians may say that garlic is the most dangerous substance in the world -- whereas another group of physicians cite placebo-controlled studies that say garlic doesn't work.  But you can't have it both ways: that garlic is simultaneously powerful and dangerous as well as weak and ineffectual.  Foods also affect drug metabolism."

Treasure points out that many foods also cause interactions with drugs.  "Grapefruit juice affects the metabolism of drugs (including the blood-thinner Warfarin) by its effects on the liver and gut -- yet we don't hear a hue and cry that grapefruit juice should be prescription only or that patients should stop drinking it two weeks before surgery.  Broccoli and the cabbage family contain compounds that affect drug metabolism, as strongly as St. John's wort in some cases, but we don't hear a call for patients to stop eating broccoli."

Physicians Need Better, Accurate Information

Because increasing numbers of Americans are using herbs, physicians need better, more accurate information both about the effects of herbs and potential interactions with drugs.  Treasure applauds JAMA and the ASA for drawing attention to the need for physicians to learn about herbal medicines, but adds, "Physicians need to look at the literature in herbal pharmacology instead of reading hysterical reports that are largely unsubstantiated when evaluated by scientific criteria."

JAMA Report Not Based on Solid Scientific Evidence

Of the 122 references in the JAMA article, Treasure points out that only 59 are primary literature.  Concerning the others, Treasure states, “There is an old joke in medical schools that the plural of anecdote is clinical evidence.  It has happened that editorial musings have been quoted -- and then other people repeat the quote -- and no one goes back to check the original source.  Or a journal publishes a letter about a potential interaction, and then other physicians write in saying, 'Me too, I had a patient,' and suddenly there is an entire climate of belief with no one doing a serious literature evaluation to establish what the risks actually are.”

The Real Issues For Herbs and Surgery

According to Treasure, “Certain herbal remedies can interact both positively and negatively with certain drugs.  If you are contemplating a surgical procedure, your surgical team needs to know what you are taking.  Surgical nurses have become very aware of this and now tend to ask about both over-the-counter drugs and dietary supplements.  So the first concern is to communicate what one is taking.  The second is which herbs might be of consequence.”

Several Chinese herbs that come under general category of blood movers (a Chinese term) act as anticoagulants.  Two examples would be dong quai and dan shen (red sage).  These and other herbs can be subtle parts of a formula with a different, perhaps dramatic name.

There are thousands of herbal products and dietary supplements currently on the market.  The following table shows the specific herbs and potential side effects named in the JAMA article and ASA pamphlet.  Not all available herbs are listed.

None of these possible side effects have been proven scientifically beyond a shadow of a doubt -- what the federal Food and Drug Administration (FDA) would call significant scientific agreement.  Both the JAMA article and ASA pamphlet used phrases like “may cause”, “may interact with”, “may prolong” throughout.  However, some degree of suggestive evidence does exist linking these herbs and potential side effects.

Other Considerations:

 guarana (caffeine)

Elevates blood pressure.

 Yerba maté (Paraguay tea)

May cause either hypertension or hypotension.

 Aconite (monkshood, friar's cap, helmet flower, or wolfsbane)

Used to treat pain.  Has been documented to cause ventricular arrhythmias unresponsive to procainamide, as well as complete cardiovascular collapse.  Its use should be strictly contraindicated in patients who are to receive anesthesia, particularly inhaled anesthetics.

 feverfew, ginger, ginkgo, horse chestnut, pau d'arco, danshen, dong quai, fenugreek, garlic, and saw palmetto

Alter coagulation either via pharmacokinetic interaction with warfarin or secondary to inherent antiplatelet or anticoagulant effects.  Case reports documenting post-operative bleeding complications have implicated danshen and gingko.

 danshen (the root of the Salvia miltiorrhiza plant), dong quai, and papain (proteolytic enzymes from the fruit of the papaya tree)

Botanical products documented to increase international normalized ratios (INRs) in patients taking warfarin as an anticoagulant.

 coenzyme Q10 (ubiquinone), Oriental ginseng, and green tea

A decrease in international normalized ratios (INRs) has been reported for patients taking warfarin in combination. Although the mechanism for the procoagulant effect of ginseng remains a mystery, it is known that dried green tea leaves contain substantial amounts of vitamin K and that coenzyme Q10 is structurally related to vitamin K2.  Thus, increased ingestion of vitamin K is the likely explanation for their mechanism of warfarin antagonism.  When included in skin care products, green tea is absorbed and supports the skin's antioxidant and immune power.

One of the ingredients in green tea is l-theanine, which has been scientifically proven to bring the brain into an alpha wave state, inducing relaxation and reduced feelings of anxiety.  It not only calms your worries but also increases concentration and energy (energy from caffeine).  Drinking any more than three cups a day may be a problem due to the caffeine content.

 turmeric, clove, onion, and bromelain, willow bark, poplar, and meadowsweet

Antiplatelet activity has been reported.  These herbal products should be considered theoretical risks for prolonged bleeding at this point.  Until more information becomes available, it would be wise to discourage use of any of these herbs in patients taking warfarin or who are undergoing any type of surgical procedure.

 angelica root, arnica flower, anise, celery, chamomile, fenugreek, horse chestnut, licorice, lovage root, parsley, passionflower herb, quassia, red clover, and rue

Believed to contain coumarin or coumarin derivatives and high concentrations of salicylates.  These herbal products should be considered theoretical risks for prolonged bleeding at this point.  Until more information becomes available, it would be wise to discourage use of any of these herbs in patients taking warfarin or who are undergoing any type of surgical procedure.

Advantages of Herbs:

Despite the criticism of herbal medicine among mainstream medical professionals, it is wise to remember that many common drugs we use today were derived from plant-based sources.  Scientists originally derived aspirin from willow bark; herbalists prescribe white willow for headaches and pain control.  Digitalis, a drug prescribed for certain heart conditions, comes from an extract of potentially toxic foxglove flowers.  While it's true that herbal supplement manufacturers often make bold or outrageous claims, critics shouldn't be so quick to dismiss herbal medicine as quackery.

The advantages of using herbal medicines are numerous.  Herbal medicines tend to be more effective for long-standing health complaints that don't respond well to traditional medicine.  Herbs typically have fewer side effects, and may be safer to use over time.

An example may be seen with herbs and alternative remedies used to treat arthritis. Vioxx, a well-known prescription drug used to treat arthritis, was recalled due to increased risk of cardiovascular complications.  Alternative treatments for arthritis, on the other hand, have few side effects.  Adjusting the diet to remove vegetables from the nightshade family, reducing white sugar consumption, and adding simple herbs to the diet have few side effects.  Most herbal medicines are well tolerated by the patient, with fewer unintended consequences than pharmaceutical drugs.

But never try to harvest herbs in the wild.  Even the experts are occasionally fooled with disastrous consequences.  Harvesting the wrong plant, using the wrong part, or preparing an incorrect dose can be dangerous or fatal.  Purchasing herbal supplements from reliable manufacturers also ensures that the doses are consistent, helping you to monitor and measure the success of the herbal medication more easily.

The bottom line is that herbs are medicines, and like taking medications, herbs have some advantages and disadvantages.

For sudden, serious illnesses, mainstream medicine still reigns supreme.  An herbalist would not be able to treat serious trauma, such as a broken leg, nor would he be able to heal an appendicitis or a heart attack as effectively as a conventional doctor using modern diagnostic tests, surgery, and drugs.  Modern medicine treats sudden illness and accidents much more effectively than herbal or alternative treatments.  Another disadvantage of herbal medicine is the very real risks of doing oneself harm through self-dosing with herbs.  While one can argue that the same thing can happen with medications, such as accidentally overdosing on cold remedies, many herbs do not come with instructions or package inserts.  There's a very real risk of overdose.  Harvesting herbs in the wild is risky, if not foolhardy, yet some people try to identify and pick wild herbs.  They run a very real risk of poisoning themselves if they don't correctly identify the herb, or if they use the wrong part of the plant.

If you are facing surgery, it would be a good idea to search the internet for information about the side effects of herbs in relation to medications, surgery and anesthesia targeting any particular herbs you are currently taking or plan to take.  Look for websites that are owned by herbalists with no monetary interest.

Conclusion:

A significant percentage of surgical patients use dietary supplements on a regular basis, yet many are reluctant to reveal this fact to their healthcare providers.  Care-givers should be aware of the many potential adverse effects that herbal products may have on patients undergoing surgery, including excessive sedation, increased risk of bleeding, and cardiac instability.  It is extremely important for healthcare professionals to take an accurate, non-judgmental, and thorough history of all medication use, including herbals.  This screening should be a routine part of pre-anesthetic assessment, and should occur far enough in advance to allow for discontinuation of potentially dangerous botanical products with relatively long half-lives.

The American Society of Anesthesiologists offers no official guidelines regarding the perioperative use of herbals.  However, educational materials released by this organization encourage patients to discontinue their herbal products at least 2 to 3 weeks before surgery.  Hodges and Kam have made a blanket recommendation that all botanicals should be stopped 2 weeks before surgery.

Although discontinuation of herbals 2 to 3 weeks before any surgical procedure is an admirable goal, it may not be practical in all cases.  Ang-Lee et al have emphasized the utilization of half-lives (the time required for 45% of any substance to be removed from the body, whether this occurs via renal clearance or hepatic metabolism) to determine the recommended discontinuation period.  If this value has been determined for the active ingredient in an herbal product, then a good estimate for discontinuation time would be the half-life multiplied by 5.  After 5 half-lives, the amount of any compound left in the body will be approximately 3% of the original serum concentration - a quantity unlikely to cause harm.  The table below summarizes discontinuation recommendations for those herbs utilized commonly in presurgical patients.  If a botanical product of concern does not appear in this table, it may be concluded that the half-life and/or the active ingredient remain unknown, and the default discontinuation recommendation should be at least 2 weeks before surgery.

Information used with permission.

References:
American Society of Anesthesiologists. “What You Should Know About Herbal Use and Anesthesia.” American Society of Anesthesiologists, pamphlet, 1999.

Healthy.net. “Herbal Medicines Can Affect Surgery.” Website article, July 2001.
healthy.net/asp/templates/news.asp?Id=2678.

Natural Products Insider website. “JAMA: Herb Use May Interfere with Post-Op Recovery.” Website article, 10 July 2001.
www.naturalproductsinsider.com/hotnews/17h1016177.html.

Jonathan Treasure, Member of the National Institute of Medical Herbalists in the UK (MNIMH), and member of the American Herbalist Guild. Personal communication, 24 July 2001.

Information in the two website articles was based on a study that appeared in the 11 July 2001 edition of the Journal of the American Medical Association, (286:208-16, 2001).  The study also appears on the JAMA website (jama.ama-assn.org) in an area limited to JAMA subscribers.

*** As set down by the Food and Drug Administration, vitamin supplement products cannot be advertised as intended to diagnose, treat, cure or prevent any disease. ***