Herbal Remedies and Anaesthesia

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Herbal Remedies and Anaesthesia

• Adrian WONG
• Specialist Registrar Anaesthetics/ITU
• Wessex Deanery

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Contents

• Background
• Extent of use
• Issues
• Efficacy
• Regulations
• Common herbal medicines
• Effects on anaesthesia
• Guidelines

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Declaration of Interest
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Foxglove (Digitalis purpurea)
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Periwinkle
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Purported use of herbal remedies
Cancer
Inflammatory Bowel Disease
HIV/AIDS
Asthma
Impotence
Eczema
Lack of energy
Psoariasis
Depression
Arthritis
Glands
Insomnia
Obesity
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Extent of Use

• UK
• 4.8 of patient use
• annual expenditure - 1.6 billion
• America
• 12 general surgical
• 55 cosmetic surgery
• 27 billion
• Europe
• 40 of breast cancer patients
• 20 of lung cancer patients
• World Health Organisation
• 80 of world population

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The Issues

• Herbal medicines are safe
• Natural does not equal safe
• Herbal does not equal benign
• 40 of population - safe (MORI 2008)
• Lack of disclosure/enquiry
• Efficacy and evidence-based practice

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National Institute of Medical Herbalists
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The Issues

• Herbal medicines are safe
• Natural does not equal safe
• Herbal does not equal benign
• 40 of population - safe (MORI 2008)
• Lack of disclosure/enquiry
• Efficacy and evidence-based practice
• Funding/Product regulation

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regulation and licensing of herbal products
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regulation and licensing of herbal products

• Lack of international consensus
• Herbal products marketed as food supplements or
  cosmetics
• Medicine Act 1968
• Exemption from statutory control
• EU Medicines Directive 1994
• Traditional Herbal Medicinal Products Directive
  (THMPD) 2004

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UK legislation

• Unlicensed herbal remedies
• Supplied to individual after face to face
  consultation
• Registered traditional herbal medicine (2005)
• Specific standards of safety and quality
• Agreed indication based on traditional use
• Licenced Herbal Remedies
• "When seeking a licence for herbal medicines,
  many companies have had difficulty meeting
  conventional requirements to prove efficacy. This
  was one factor that led to the introduction of
  the Traditional Herbal Registration Scheme and
  many products are likely to follow that
  regulatory route." 

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MHRA - Safeguarding public health report

• 70 suspected adverse drug reports relating to
  herbal remedies
• Handful of identified UK deaths
• Steady flow of cases entailing very serious
  illness e.g. kidney or liver failure
• BUT increasing study and scientific understanding
  of herbal medicines would be expected to improve
  safety profile

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BAD MEDICINE - More cases of adverse side effects
(The Singapore Straits Times, 11 October 2011)
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Anaesthetic Concerns
There are known knowns. These are things we know
that we know. There are known unknowns. That is
to say, there are things that we know we don't
know. But there are also unknown unknowns. There
are things we don't know we don't know.
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Anaesthetic concerns

• Unknown effects of herbal remedies
• Potential interactions with drugs
• Pre-operative
• Intra-operative
• Post-operative
• Effects on patient physiology

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most common herbal medicines in the UK

• Echinacea
• Ginger
• St Johns Wort
• Garlic
• Saw palmetto
• Ephedra
• Ginseng
• Gingko
• Valerian
• Kava Kava

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Echinacea (Echinacea Pururrea)

• Uses
• Common cold
• Wounds/Burns
• UTI
• URTI
• Possible side effects/interactions
• Hepatotoxicity
• Decrease efficacy of corticosteroids

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St Johns Wort (Hypericum perforatum)

• Uses
• Depression
• Anxiety
• Possible side effects/interaction
• Induction of P450 3A4
• Serotonin syndrome
• Decrease efficacy of anti-HIV drugs
• Prolong effect of anaesthesia
• Organ rejection due to reduce immunosurpressants

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Ephedra (Ephedra Sinica)

• Uses
• Antitussive
• Weight loss supplement
• Possible side effects/interactions
• Arrhythmias
• Enhanced sympathomimetic
• MAOI
• Death

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Garlic (Allium sativum)

• Uses
• Lipid lowering
• Blood pressure control
• Antiplatelet/Antithrombotic
• Antioxidants

• Possible side effects/interactions
• Potent inhibitor of thromboxane synthetase
• Increased bleeding time
• Epidural haematoma

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ginseng (panax ginseng)

• Uses
• Antioxidants
• Energy level enhancer
• Exam success
• Possible side effects/interactions
• Ginseng abuse syndrome
• sleepiness
• hypertonia
• oedema
• Interactions with antipsychotics
• Antiplatelet properties
• Increased bleeding
• Hypoglycaemia
• CVS instability

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Canadian Anesthesiologists' Society
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Can I take herbal and dietary supplements? The
use of herbal medicines is common. Herbal
medicine is defined as a plant-derived product
used for medicinal and health purposes commonly
used herbal supplements include echinacea,
garlic, ginseng, ginkgo biloba, St Johns wort
and valerian. Herbal medicines can have a
variety of effects on surgery and interact with
anaesthetic drugs. Ginkgo, ginseng and garlic all
impair blood clotting and promote excessive
bleeding. Prolongation of action of anaesthesia
drugs can occur with valerian and St Johns wort.
Herbal dietary supplements should be stopped two
weeks prior to surgery. Fish oil supplements are
also popular as a dietary supplement. They have
potential in reducing cholesterol and hence may
reduce the risk of heart attack and stroke. They
also have anti-inflammatory properties and may be
used to treat arthritis. The Therapeutic Goods
Administration says that omega 3, which is found
in fish oil, has no effect on bleeding and can be
continued before surgery.
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RCoA Patient Information Leaflet

• "It is important for you to bring a list of
• "all the pills, medicines, herbal remedies or
  supplements you are taking, both prescribed and
  those that you have purchased over the counter"
• "If you are taking medicines, you should continue
  to take them as usual, unless your anaesthetist
  or surgeon has asked you not to. For example, if
  you take drugs to stop you getting blood clots
  (anticoagulants), aspirin, drugs for diabetes or
  herbal remedies, you will need specific
  instructions."

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British association of Day Surgery (BADS)
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british Association of Day Surgery (BADS)
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Current UK practice

• McKenzie and Simpson - Survey of AAGBI members
  (2005)
• 90 - never or seldom asked about herbal
  medicines
• 65 - thought there could be potential harm
• 75 - perioperative usage of herbal medicine is
  important
• Unequivocally poor knowledge
• Hogg and Foo - Survey of all anaesthetic dept
  (2010)
• 7.3 have perioperative herbal medicine policy
• 98.3 did not have specific section documenting
  herbal medicine use
• 15.7 routinely asked about herbal medicine use
• Highly variable advice given (not in accordance
  to existing guidelines)

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Conclusion

• The use of herbal remedies in patients undergoing
  anaesthesia is under-reported.
• Side-effects and herb-drug interactions can be
  unknown.
• Elective surgery - all herbal medication should
  be stopped for between 2 and 3 weeks prior.
• Emergency surgery - carry on.
• Improved education and knowledge crucial.

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References

1. MHRA Public Health Risk with Herbal Medicines An
   Overview (2010)
2. Hogg LA and Foo I. Management of patients taking
   herbal medcines in the perioperative period a
   survey of practice and policies within
   Anaesthetic Departments in the UK. EJoA 2010 27
   11-15.
3. American Society of Anesthesiolgist. What You
   Should Know About Your Patients Use of Herbal
   Medicines and Other Dietary Supplements (2010).
4. McKenzie AG and Simpson KR. Current management of
   patients taking herbal medicines a survey of
   anaesthetic practice in the UK. EJoA 2005 22
   597-602.
5. Cheng B, Hung CT, Chiu W. Herbal medicine and
   anaesthesia. HKMJ 2002 8 123-130.
6. Skinner CM and Rangasami J. Preoperative use of
   herbal medicines a patient survey. BJA 2002
   89(5) 792-795.
7. Batra YK and Rajeev S. Effect of common herbal
   medicines on patients undergoing anaesthesia.
   IJoA 2007 51(3) 184-192.
8. Hodges PJ and Kam PCA. The peri-operative
   implications of herbal medicines. Anaesthesia
   2002 57 889-899.
9. Ang-Lee M, Moss J and Yuan CS. Herbal Medicines
   and Perioperative Care. JAMA 2001 286 208-216.