Herbal Remedies and Over-The-Counter Drugs
Miguel Bejar
Hernando Desoto
CASE SUMMARY
A 32-year-old woman presents to the operating room at 9:00 PM for surgical control of oropharyngeal bleeding. She had a tonsillectomy 12 hours earlier, secondary to chronic tonsillitis. On reviewing her chart, you notice that she was previously normal but she has been on observation secondary to diffuse bleeding after the surgery. Her previous anesthetic was uneventful.
Preoperatively she appears calm. Her blood pressure is 90/65 mmHg, heart rate 110 bpm, and oxygen saturation 98%. She is not obese. Her airway examination is unremarkable but diffuse oozing of blood is noticed in the oropharynx. The patient has vomited twice since the end of surgery and remains nauseous despite being given 4 mg of ondansetron and 12.5 mg of promethazine. Postoperatively, she has received 1.5 L of fluids and currently is receiving an infusion of 1 L of an isotonic solution. The hematocrit is 33% (down from 36% that morning), and the platelet count is 168. The results of coagulation profiles are pending.
Due to persistent oropharyngeal bleeding, a decision is made to take the patient back to the operating room for reexploration. A rapid-sequence induction with etomidate and succinylcholine is performed. The laryngoscopic view is somewhat hindered by blood, but endotracheal intubation is successful. Maintenance of anesthesia is achieved with isoflurane/oxygen. Additionally, 100 µg of fentanyl, 4 mg of ondansetron (4 mg), and 8 mg of dexamethasone are administered. After hemostasis is achieved, the procedure concludes without problems, but the patient is slow to emerge from anesthesia. She is taken to the postanesthesia care unit (PACU) still intubated. Finally, after 45 minutes in the PACU, she follows commands and is extubated without complications. The next day during your postoperative visit, you inquire about any previous problems after anesthesia, which she denies. Upon questioning about any other medications or vitamins she may be taking, she responds “nothing in particular”, except for Gingko plus 4 and Cholest to help her with her fatigue, and to help her avoid problems with cholesterol. She states that she is always dizzy, and someone told her it could be because of high cholesterol.
Why Should Health Care Professionals Be Concerned about the Unregulated Use of Herbal Remedies and Over-the-Counter Drugs?
The increased use of natural products and herbals among the general public is part of a growing concern with the effects of industrialization upon the environment and human health. The importance of this alternate pathway for maintaining or improving health is steadily getting the attention of health care professionals in an era where evidence-based medicine is part of the core in the approach for treating disease. The use of these products may have unintended pharmacologic effects with potential perioperative complications. They may cause unwanted interactions with drugs that the patient is taking or may interact with the pharmacologic agents used in the perioperative period and affect the outcome of a planned surgery.
What Is the Importance of Herbal Remedies?
Our society has seen not only health care costs increase markedly in the last 20 years, but has also become more knowledgeable about the impact of the long-term effects of smoking, hypertension, diabetes, and obesity on the quality of life. Therefore, the use of polypharmacy and managed care has been touted as the panacea for the sickest and oldest of our patients. In addition, although western medicine is moving in the direction
of evidence-based care, the general population is increasingly aware and in constant search for alternative medicines and health options that have a potential favorable impact on their lifestyle.
of evidence-based care, the general population is increasingly aware and in constant search for alternative medicines and health options that have a potential favorable impact on their lifestyle.
Population surveys performed by an industry consulting firm found that during a 5-year period (1999 to 2003), the use of vitamins and minerals among the population in the United States reached 84% and 56%, respectively,1 whereas the use of herbal supplements declined from 42% to 34%. The nutraceutical industry is a multibillion dollar-a-year industry that is not subjected to the same standards for manufacturing compared to drugs approved by the U.S. Food and Drug Administration (FDA). Therefore, these products are not required to be proven safe and efficacious before their release. Their manufacturing process follows existing regulations for food, rather than the more strict practices required for drugs. Moreover, they do not have to substantiate their data to the FDA; instead, the Federal Trade Commission controls the veracity of the claims made to the public.2
Who Is Using Herbal Supplements?
Herbals are supplements that are components of wood or herbaceous plants. They are available without prescription in the form of teas, liquid extracts, powders, tablets, capsules, and many other forms. Two nationally representative surveys in 1997 and 1999 showed that the use of herbals was approximately 10% to 12% (an increase of 380% from a similar survey in 1990).3 Because of their natural origin, these supplements are generally believed to be innocuous by the people who use them.
A confounding factor is the lack of disclosure of herbal supplement use by the general population during the perioperative period. Medical practitioners compound the problem by failing to properly identify and query patients concerning their use. Tsen et al. reported herbal use among patients presenting for surgery to be approximately 20% to 30%.4 Table 65.1 shows the groups more likely to utilize herbals and over-the-counter (OTC) drugs. In the year 2002, a US national health survey found a prevalence of herbal use of 13% in the elderly population (age >65-years) compared with 8.9% from 1997 to 1998.5 The difference was partially explained by the influence of chronic disease in this group of patients, leading to the increased use of herbals as a complement to medical therapy.6
TABLE 65.1 Patients Likely to Use Herbal and Over-the-Counter Drugs | |||||||
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How Effective Are Herbal Supplements?
Until recently, herbals have been dismissed by contemporary medical practice as innocuous and ineffective, but because of their increased popularity, traditional medicine has shifted their interest from disregard to evaluation of the claims made about herbal supplements. In 1998, the Congress of the United States established the National Center for Complementary and Alternative Medicine under the scope of the National Institutes of Health (NIH) to scientifically evaluate, research, and educate the professionals and the public about the effectiveness of complementary medicine.
There is increasing medical research regarding the claims of the most established herbals. Ginkgo biloba has proved to be effective for symptomatic treatment of dementia and claudication.7 St. John’s wort have been proven as an effective antidepressant for the treatment of moderate depression.8 On the other hand, evening primrose, an oil popular for the treatment of premenstrual symptoms, has not shown to be better than placebo in a review of 11 randomized clinical trials.7 Garlic consumption produces a statistically significant reduction in serum lipids, although not clinically important.9
How Should We Approach Patients Taking Herbals and Over-the-Counter Drugs?
The practitioner must recognize that a significant number of patients taking herbal and OTC drugs do not inform anesthesia care providers of their use during a routine preoperative assessment. In a survey of practicing members of the Association of Anaesthetists of Great Britain, 91% admitted to never asking their patients about herbal use; furthermore, 82% acknowledged that they lacked the proper information regarding their use.10 In another survey of certified registered nurse anesthetists, only 17% expressed confidence in their familiarity with the interactions between herbal supplements and anesthesia, and only 23% identified correctly the American Society of Anesthesiologists (ASA) recommendation of discontinuation of herbals 2 weeks before surgery.11
From these surveys, we must conclude that anesthesia providers, in general, lack sufficient knowledge of the use, interactions, and side effects of this group of compounds. This can potentially have a negative impact on the anesthetic and perioperative management of many patients.
TABLE 65.2 Common Uses of Herbal Medicines and Over-the-Counter Drugs | ||||||||||||||||||||||||||
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What Is the Primer of Common Herbal Medicines and Over-the-Counter Drugs?
The following is a list of the most popular herbals and OTC drugs, the most common uses of which are listed in Table 65.2.
▪ GINKGO BILOBA
One of the most popular herbals, ginkgo is extracted from the leaves of a 120-ft tree that can live up to 400 years. It has anti-inflammatory properties (decreases migration of eosinophils) and reduces platelet aggregation (by means of inhibiting the platelet activating factor), and its flavonoids have free radical-scavenging properties, prolonging the half-life of nitric oxide by its action (scavenging superoxide anions). In doses of 120 mg per day, it has shown to improve cognitive performance in patients with dementia and cerebral insufficiency; it also decreases symptoms of intermittent claudication. However, there are several reports in the literature of intracranial bleeding in patients taking solely ginkgo, and a report of bleeding after laparoscopic cholecystectomy in a 34-year-old man taking this herbal.12
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