Herbal Medications and Surgery

            A few issues back I wrote about concerns related to anabolic steroids and surgery.  While many people may appreciate the dangers of anabolics and other prescription medications, there may not be the same concern with herbal medications. Recent surveys have found widespread use of herbal products among surgery patients. While these substances may be safe in normal circumstances, there are dangers when combined with anesthetic medications. Complications such as heart attack, stroke, bleeding, prolonged or inadequate anesthesia and interference with medications have been reported.

            While as many as 1,800 herbal medications are sold in the United States, the most popular eight account for over 50 percent of all single herbal preparations. Each of these has profound effects on the patient undergoing surgery. It is therefore extremely important to inform your surgeon of the use of herbal as well as prescription medications. 

            Individuals concerned with their health, appearance and well-being are more likely to use these substances. However, studies have shown that the majority of surgery patients failed to disclose their use. It may be that the patient felt the doctor either wasn't knowledgeable about herbal medications, or was prejudiced against their use. Others may have felt the substances were not related to their medical care. In fact, herbal medications may adversely affect the surgical patient by virtue of their own properties or their interaction with other drugs. 

            The most significant herbal medications concerned with surgery are Echinacea, ephedra, garlic, ginko, ginseng, kava, St. John's wort and valerian.

• Echinacea. Three species of Echinacea, a member of the daisy family, are used for the prophylaxis of viral, bacterial and fungal infections. While short-term use may cause stimulation of the immune response, use for longer than eight weeks is accompanied by the potential for immunosupression and the increased risk of poor wound healing and infections. There are also concerns about possible liver toxicity, especially when combined with the use of some anesthetic agents. The use of Echinacea should be discontinued several months prior to surgery.

• Ephedra is also known as ma Huang. It's used to promote fat loss, increase energy and treat asthma. It contains substances called alkaloids, including ephedrine, pseudoephedrine, norephedrine, methylephedrine and norpseudoephedrine. Ephedra causes dose-related increases in blood pressure and heart rate. The more you take, the greater the effect.  These effects can cause both cardiac and central nervous system complications. During surgery it can cause constriction and spasm of the blood vessels to the heart and brain, causing heart attack and stroke. When combined with some anesthetics like halothane, it can promote abnormal heart rhythms. Long-term use can cause depletion of the body's natural stores of these substances. Use of ephedra and some anti-depressants known as MAO inhibitors can lead to coma. Ephedra is fairly rapidly eliminated from the body, so it's safe to discontinue use 24 hours prior to surgery. 

• Garlic is used to lower cholesterol levels. However, it also affects blood clotting by inhibiting platelet aggregation. And it has been shown to lower blood pressure. Post-operative bleeding is a major concern.  Garlic should be discontinued at least seven days prior to surgery.

• Ginko is used to improve memory and other cognitive functions.  Ginkgo is another substance that can alter platelet function and cause increased bleeding. Based on pharmacokinetic data, the use of ginko should be discontinued at least 36 hours prior to surgery.

• Ginseng is supposed to protect the body against stress. There are different species of ginseng, the most popular being Asian and American ginseng. The various species have somewhat different chemical properties. Most species have the ability to lower blood glucose levels. This may create hypoglycemia in patients who have fasted before surgery. Ginseng also has an effect in slowing blood clotting. It's best to discontinue use of ginseng seven days prior to surgery.

• Kava is usually used for its sedative effects in the treatment of anxiety.  The effects are dose related. This can increase the effects of general anesthetic agents and prolong the process of coming out of anesthesia. It should be discontinued at least 24 hours prior to surgery. 

• St. John's wort has been used to treat mild depression. It works by inhibiting serotonin, norepinephrine and dopamine uptake by neurons.  It can significantly increase the metabolism of many concomitantly administered drugs. Thus, larger dosages of these drugs, including some anesthetics, would be required to get the desired effects. Use of St. John's wort should be discontinued at least five days prior to surgery.

• Valerian has been used as a sedative in the treatment of insomnia.    The effects are dose related. Valerian will potentiate the sedative effects of anesthetics and increase the depth and recovery time from anesthesia. Abrupt stoppage of valerian has been shown to cause withdrawal symptoms, so the dosage should be tapered gradually starting several weeks before surgery.

It's important to recognize the effects of these substance on both anesthesia and peri-operative conditions. Patients should inform their surgeons of the use of any of these herbal medications, as well as anabolics, diuretics or other medications. If you feel your surgeon may not be knowledgeable about these substances, give them the following reference: Ang-Lee MK, Moss J, Yuan C-S: Herbal medicines and perioperative care. JAMA, 2001 Jul 11;286(2):208-16