Perioperative Considerations for Herbal Medicinals
| HERB | USE (S) | PROPOSED MECHANISM OF ACTION/EFFECTS | DRUG INTERACTIONS | OTHER CONSIDERATIONS |
| Black Cohosh | treatment of PMS and dysmenhorrhea alleviate menopausal symptoms |
active components are triterpene glycosides and formononetin (an isoflavanoid), which may have estrogen-like hormonal activity suppresses leutenizing hormone secretion in menopausal women |
caution when administered with other drugs that can reduce BP |
may lower BP side effects are generally mild (GI, headache, weight gain, dizziness) limit use to 3 months |
| Chamomile | anxiolytic/sedative treatment of GI spasm or irritation treatment of menstrual disorders |
also contains bioflavinoids which are considered to be active apigenin competitively inhibits binding of several benzodiazepines contains coumarin, which exerts an antispasmotic effect |
no reports of coagulation disorders, but effects on coagulation system have not been studied; avoid concurrent administration of (or closely monitor) warfarin may make other drugs less effective when administered concurrently |
sedative effects noted from a 6 oz. cup of strong tea can cause skin irritation, allergic conjunctivitis, and/or severe allergic reactions long-term consumption may have cumulative effects consider discontinuing 2 weeks prior to surgery |
| Echinacea |
|
enhances "nonspecific" cell immunity by enhancing release of cytokines and phagocytic activity stimulates autoimmune processes |
may counteract immunosuppresant drugs (e.g. corticosteroids); do not administer together |
hepatotoxic effects may be associated with prolonged use or if administered with other hepatotoyjc agents immune suppression can result from prolonged use (> 10- 14 days) |
| Ephedra (Ma Huang) | treatment of asthma nasal decongestant appetite suppressant CNS stimulant |
active constituent is ephedrine CNS, weight loss, or athletic enhancement stimulant effects are potentiated by the addition of caffeine-containing botanicals (cola nut, mate, guarana) high doses produce euphoria |
likely to have the same drug interactions as ephedrine Raises blood pressure and blood glucose, especially when combined with caffeine-containing botanicals |
can see palpitations, raises BP; misuse has resulted in death combined with caffeine-containing botanicals to promote weight- loss or enhance athletic performance (Metabolife, Formula One) herbal |
| Evening Primrose Oil | treatment of PMS lowers serum cholesterol allergic/inflammatory conditions (eczema, psoriasis) autoimmune disease (MS, lupus) |
extract contains 60-80% linoleic acid and 8-14% - linolenic acid (an omega-6 fatty acid formed by desatruration of linoleic acid) lowers platelet aggregation |
may interact with anticoagulant c or antiplatelet d drugs to raise risk of bleeding use caution when administered with drugs that lower seizure threshold (e.g. phenothiazines, tricyclics) |
side effects are generally infrequent (GI, headache) may lower seizure threshold |
| Feverfew | prevention and treatment of migraines anti-inflammatory agent (used to treat fever, menstrual problems, arthritis) |
suggested to be serotonin release during aggregation of platelets; inhibits platelet aggregation antagonizes actions of autocoids and vascular agonists potentially involved in migraines and chronic inflammation antipyretic and antiplatelet effect may be due to phospholipase inhibitor that prevents the release of arachidonic acid, a precursor to prostaglandins and leukotrines |
may interact with anticoagulant or antiplatelet drugs to raise risk of bleeding use caution when administering with drugs that raise serotonin (fluoxetine, sumatriptan, etc.) |
abrupt discontinuation may cause rebound headache or pain with stiff joints and muscles can cause mouth sores and loss of taste do not take for > 4 months consider discontinuing 2 weeks prior to surgery |
| Fish Oil Supplements (Omega-3 fatty acids) | management of severe dyslipidemia, lowers risk of coronary heart disease, lowers BP |
possibly via effects on prostaglandins, thromboxanes and leukotrines decreases platelet aggregation, decreases thromboxane A2 and increases bleeding times incorporated in RBCs, leading to lower blood viscosity |
although no drug interactions have been reported, it would be prudent to avoid anticoagulant and antiplatelet drugs |
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| Garlic | lowers serum cholesterol lowers blood pressure |
active constituents are sulfur compounds and the alliin-splitting enzyme alliinase inhibits cholesterol synthesis has vasodilator and antioxidant properties effects on coagulation include inhibition of platelet aggregation, antithrombotic activity, mean plasma viscosity and hematocrit |
may interact with anticoagulant and antiplatelet drugs to increase risk of bleeding may potentiate antihypertensive drugs |
report of spontaneous epidural hematoma and postopertive bleeding may increase INR chronic or excessive doses may decrease production of Hb side effects include GI discomfort, dizziness, allergic reactions, headache, sweating, and garlic odor of breath/skin hypoglycemic effects consider discontinuing 2 weeks prior to surgery |
| Ginger | prevention of nausea and vomiting digestive problems muscle pain and swelling |
potent agonist at the serotonin receptor exerts effect in GI tract, not in CNS multiple effects on platelet aggregation (potent inhibition of thrombaxane synthetase, prostacyclin agonist) |
may interact with anticoagulant and antiplatelet drugs to increase risk of bleeding increases calcium uptake by heart; may alter CCB drug effects |
may increase bleeding time may effect blood glucose may effect BP consider discontinuing 2 weeks prior to surgery |
| Ginkgo Biloba | treatment of dementia symptoms or other conditions associated with cerebral or peripheral vascular insufficiency treatment of vertigo or tinnitus of vascular or involutional origin |
medicinal extracts contain 22-27% flavanoid glycosides, 5-7% terpene lactones (ginkgofides A,B and C and bilobalide) and < 5 ppm ginkgolic acids several active constituents are potent antioxidants and free-radical scavengers inhibits age-related decline of muscarinic cholinergic receptors and a2-adrenergic receptors ginkgolides, especially ginkgolide B, inhibit platelet activating factor and antagonize thrombus formation |
may interact with anticoagulant and antiplatelet drugs to increase risk of bleeding ginkgo toxin in Ginkgo leaf and seed may reduce effectiveness of carbamazepine, phenytoin and phenobarbital in epileptic patients do not use with drugs that lower seizure threshold |
several cases of spontaneous bleeding reported (subdural and subarachnoid hematomas, bleeding from iris into anterior chamber of the eye consider discontinuing 2 weeks prior to surgery |
| Ginseng | heighten resistance to stress enhance physical and mental performance increase stamina elevate mood |
active ingredients thought to be ginsenosides increases activity of CNS neurotransmitters by lowering their removal from neuronal synapse; increase in serotonin useful when treating anxiety and depressive disorders may potentiate activity of GABA steroidal mechanism of action has been suggested; possibility of hormone-like or hormone- inducing effects cannot be ruled out ginsenosides inhibit platelet aggregation and enhance fibrinolysis |
may interact with anticoagulant and antiplatelet drugs to increase risk of bleeding avoid concurrent administration of hypoglycemic drugs avoid concurrent administration of MAO I |
varying effects on blood pressure hypoglycemic effect; caution in diabetics avoid in patients with manic- depressive disorders or psychosis (due to steroid effects) may potentiate action of MAO inhibitors limit use to 3 months |
| Hops | sedative-hypnotic, digestive aid |
acts as a mild depressant on higher nerve centers contains substances with estrogenic activity |
may have additive effects with other CNS depressants drugs metabolized by the cytochrome P450 liver enzyme system |
avoid in depressive states |
| Horse Chestnut | reduce leg edema improve symptoms of chronic venous insufficiency |
main active constituent is aescin contains coumarin constituents |
may interact with anticoagulant and antiplatelet drugs to increase risk of bleeding |
side effects include nausea, stomach discomfort, allergic skin reactions, itching and muscle spasms may turn urine red can cause kidney or liver damage can cause severe bleeding or bruising consider discontinuing 2 weeks prior to surgery |
| Kava Kava | sedative anxiolysis |
active constituents are the kavalactones (kawain, dihydrokawain, methysticin, and dihydromethysticin) kavalactones may act on central GABA and BZD binding sites; may decrease excitability of the limbic system may antagonize dopamine and inhibit MAO uptake kawain (a kavalactone) has been shown to have antiplatelet effects due to lowering platelet aggregation secondary to inhibition of cycloxygenase |
kavalactones potentiate effects of other CNS depressants, including opioids, barbiturates and BZDs decreases effectiveness of levodopa (due to dopamine antagonism) theoretical additive effects with other anticoagulant and antiplatelet drugs to increase risk of bleeding use caution with MAO inhibitor and other psychopharmacologic agents |
avoid in depression; may increase suicide risk due to its CNS depressant effects can impair motor function continuous heavy use can cause changes in blood chemistry, pulmonary hypertension, exaggerated kneecap reflex, reddened eyes, shortness of breath, weight loss and dry, flaking, discolored skin limit use to 3 months no evidence of potential for dependency consider discontinuing 1-2 weeks prior to surgery |
| Passion Flower | relaxation sleep |
active constituents may be glycosides (harmala compounds), maltone and ethyl-maltone, and flavanoids chrysin (primary component; a flavanoid) has BZD receptor activity |
possible additive effects with other CNS depressants avoid MAO I |
reports of hepatotoxicity and pancreatic toxicity no evidence of potential for dependency |
| Saw Palmetto | treatment of benign prostatic enlargement |
thought to act similar to finasteride (antiandrogenic activity); may have antiestrogenic activity antinflammatory and antioxidant actions in experimental models of inflammation |
may be prudent to avoid concomitant use of other hormonal therapies due to potential of additive effects |
can cause HTN and GI disturbances |
| St. John's Wort | treatment of mild-moderate depression, anxiety |
hypericin (presumed active ingredient) shows affinity for serotonin, GABA, and BZD receptors inhibits MAO A & B (MAO inhibitor effects are thought to be minor) primary mechanism of action of hypericin is thought to be inhibition of serotonin reuptake, as well as down-regulation of serotonin receptors and neurohormonal mechanisms hypericin and psuedohypericin may induce hepatic enzymes (case report of increased theophylline, clearance resulting in subtherapeutic theophylline level) |
although no drug-drug or drug-food interactions have been reported, it may be prudent to avoid concomitant use with MAO inhibitor, meperidine and sympathomimetics, as well as traditional antidepressants |
considered an atypical antidepressant can cause photosensitivity in fair- skinned people (dose-related) potentially can cause serotonin syndrome may prolong effects of anesthesia |
| Valerian | sedative anxiolysis |
interacts and binds with GABA; valerenic acid component may inhibit breakdown of GABA, thereby enhancing activity Japanese valerian contains kessyl gycol diacetat which has BZD-like anxiolyfic effects and antidepressant effects (possibly due to blockage of MAO uptake) high concentration of glutamine in valerian extracts could explain sedative properties; glutamine is metabolized to GABA once it crosses BBB possible direct relaxing effect on smooth muscle (thought to be due to GABA present in valerian) may also weakly antagonize BZD receptors too high initial dose can cause excitability |
may have additive effects with other CNS depressants, including barbiturates, benzodiazepines , and opioids will likely potentiate effects from barbiturates Antabuse; there is alcohol in many of the extract products |
does not appear to affect driving ability, potentiate effects of alcohol or result in morning hangover side effects include headache and morning grogginess can cause cardiac disturbances can cause liver damage effects are not immediate (2-4 weeks) does not seem to cause dependence |
a Herbs are classified as dietary supplements and not approved by the FDA to be used as drugs. The uses, proposed mechanism of action, effects, drug interactions and other considerations are based on reports in the literature. The body of literature does not always agree on each herbs specific properties, effects and uses.
b This is a very conservative recommendation for discontinuing these herbs prior to surgery, thereby allowing normal hematologic function to return. Gingko biloba is believed to be the herbal product with the most serious side effects, with several case reports in the literature of spontaneous bleeding. In two cases, the patient was also taking chronic aspirin or warfarin.
c Anticoagulant drugs include warfarin, heparin and low molecular weight heparin
d Antiplatelet drugs include aspirin, nonsteroidal antinflammatory agents, dipyridamole, ticlopidine, and sulfinpyrazone
Key:
PMS = premenstrual syndrome
BP = blood pressure
MS = multiple sclerosis
RBC = red blood cell
GI = gastrointestinal
CNS = central nervous system
GABA = gamma amino butyric acid
BZD = benzodiazepine
MAO = monamine oxidase
ppm = parts per million
Julie Golembiewski, Pharm. D., University of Michigan Health System
