British Journal of Anaesthesia, 2002, Vol. 89, No. 5 792-795
© 2002 The Board of Management and Trustees of the British Journal of Anaesthesia
Commentary |
Preoperative use of herbal medicines: a patient survey
1 Royal Berkshire Hospital, Reading, UK. 2 Department of Anaesthesia, Wexham Park Hospital, Wexham Street, Slough, Berkshire SL2 4HL, UK*Corresponding author
Accepted for publication: July 5, 2002
Abstract
Background. There has been recent concern in the media over the possible detrimental effects of herbal medicines on the perioperative period. Perceived by the public as ‘natural’ and therefore safe, herbal remedies may have led to adverse events such as myocardial infarction, bleeding, prolonged or inadequate anaesthesia and rejection of transplanted organs. In addition, herbal remedies can interact with many drugs given in the perioperative period. In this article we summarize the potential perioperative complications that can occur.
Methods. In order to determine the extent of use of herbal medicines, we conducted a survey of patients presenting for anaesthesia. During a 3-month period, patients were directly asked by anaesthetic staff if they were currently self-administering herbal medication.
Results. Of 2723 patients, 131 (4.8%) were taking one or more herbal remedy. In only two cases was this recorded in the patients’ notes. Women and patients aged 40–60 yr were most likely to be taking a herbal product (P<0.05 and P<0.001 respectively). The most commonly used compounds were, in descending order, garlic, ginseng, ginkgo, St John’s wort and echinacea.
Conclusion. Self-administration of herbal medicines is common in patients presenting for anaesthesia. Because of the potential for side-effects and drug interactions it is important for anaesthetists to be aware of their use.
Br J Anaesth 2002; 89: 792–5
Keywords: complications, herbal medicines; interactions (drug)
There has been increasing concern in the American medical press about the potential complications arising in the perioperative period as a result of patients’ use of complementary medicines.1 The assumption by patients and doctors that these products ‘are natural and therefore safe’ is clearly dangerous. Morbidity and mortality are more likely in the perioperative period because of the polypharmacy and assaults on normal physiology that occur.2 Such complications may include myocardial infarction,3 bleeding,4 5 prolonged6 or inadequate anaesthesia7 and organ transplant rejection.8
The exact degree of cause for concern remains unclear. Very few of the huge number of herbal remedies have been formally researched and therefore most information is pooled from case reports and other anecdotal evidence.
In Table 1 we summarize the most commonly used herbal remedies together with their possible modes of action and perioperative complications.5–7 9–24
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There appears to be increasing public interest in the use of complementary medicine. In the USA the self-prescribing of herbal medicines in the presurgical patient has been studied. Tsen and colleagues reported the use of herbal remedies in 22% of presurgical patients25 and in a similar study Kaye and colleagues reported 32%.26 More than 70% of these patients failed to disclose their use of herbal medicines to their attending anaesthetist.
It remains to be seen if the enthusiasm for such remedies is as high in this country. The aim of this study was to quantify the use of herbal remedies in patients attending for anaesthesia in a British district general hospital.
Method
During a 3-month period, operating department practitioners and anaesthetic nursing staff questioned all patients about their current use of herbal remedies immediately before administration of anaesthesia. The questioning formed part of the routine preoperative checklist and asked if the patient was presently taking, or at some point in the last 2 weeks had taken, herbal medication.
A list of 16 commonly used medications was made available to the patient and questioner to act as a guide, as not all the questioners were familiar with herbal remedies. However, if the patient was taking another form of alternative medicine not mentioned on the list this was also recorded. Vitamins and minerals were not included in this survey. Non-English speakers were excluded from questioning.
The questionnaire recorded age, sex and the name(s) of the herbal medicines currently taken. In the case of patients taking such remedies, their notes were examined retrospectively for any mention of the herbal medicine in the preassessment clerking or drug information section of the anaesthetic form.
Results were tabulated and analysed using appropriate descriptive statistical analysis. Differences with respect to the influences of patient sex and patient age on the prevalence of herbal medication use were tested by using 
2 analysis. A P value of <0.05 was considered statistically significant.
Results
During the 3-month period, 3349 patients underwent anaesthesia at Wexham Park Hospital. Forms were received from 2723, giving a response rate of 81.3%.
A total of 131 patients reported the use of herbal medications (4.8%). Eighty-three patients were taking a single herbal remedy and 48 patients were taking more than one. Of these patients, 42 reported using two herbal medicines, four reported using three, one reported using four and one reported using five remedies. Female patients (80 out of 1387) used herbal medicines more frequently than males (51 out of 1336; 2=5.65, P<0.05) (Table 2).
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Our data indicate an influence of age on the prevalence of herbal medication use (Table 2).
The most commonly used medications reported are shown in Table 3. Garlic, ginseng, ginkgo, St John’s wort and echinacea were the most frequently reported remedies in order of highest to lowest.
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In only two cases was there written documentation of the patient’s use of herbal remedies in the medical notes. In both cases the documentation was in the preassessment clerking. There were no records of the patients’ use of herbal preparations on any anaesthetic forms.
Discussion
Our survey showed that substantially fewer patients are self-administering herbal remedies when compared with similar surveys carried out in the USA. However, it remains that a significant proportion of the presurgical population are taking potentially harmful medications without the knowledge of their anaesthetist.
Although the pharmacodynamics and pharmacokinetics of the majority of these remedies have yet to be fully clarified, reports of adverse events in the perioperative period suggest their importance and certainly that anaesthetists should become more aware of their use.
In the UK the majority of herbal medicines are exempt from the licensing requirements set out in Section 12 of the Medicines Act 1968.27 Approximately 20% of companies choose to seek a licence as a sign of a higher quality product. This process, however, is long and expensive and it can prove difficult to meet conventional requirements to prove product efficacy. In addition, herbal medicines cannot be patented, and this further removes the incentive to undertake costly research. In effect, this leaves the vast majority of herbal remedies exempt from the safety and efficacy requirements and regulations that prescription-only and over-the-counter drugs must fulfil (i.e. preclinical animal studies, controlled clinical trials and post-marketing surveillance). This current lack of regulation of herbal medicines also allows the potency of the herbal content to vary from manufacturer to manufacturer.28 This can therefore lead to significant variations in the pharmacological effects of a given remedy.
Despite the exemption from regulatory laws, in October 1996 the Yellow Card Scheme [the voluntary, spontaneous adverse drug-reaction reporting scheme run by the Committee on Safety of Medicines (CSM/Medicines Control Agency UK)] was extended to include reporting of suspected adverse reactions to unlicensed herbal medicines. As of May 28, 2002, the CSM/Medicines Control Agency had received 1260 reports of adverse reactions that were suspected to be associated with herbal medicines via the Yellow Card Scheme. Of these, 31 had a fatal association (CSM, personal communication).
In addition, at the international level, 5000 suspected reactions were reported to the WHO before 1996,29 and between 1993 and 1998 a further 2621 adverse events, including 101 deaths, were reported to the US Food and Drugs Administration.30 Of concern is that there is no doubt that these figures are grossly underestimated, as medical staff are often ignorant of the pharmacology of these medications.
In our survey there was no documentation of herbal medications on the anaesthetic forms of patients using such products. We must assume that this was because either the patients or their anaesthetists did not consider them to be of importance. We believe that anaesthetists should elicit and document a full drug history, including the use of herbal remedies, in every patient.
Because pharmacokinetic data are lacking, the American Society of Anesthesiologists recommends that patients discontinue use of herbal medications 2–3 weeks before surgery.31 32 However, it remains that many patients will still be taking herbal remedies before surgery, either because they are unaware of this recommendation, or because they are presenting for non-elective surgery. This means that all anaesthetists must familiarize themselves with the potential perioperative complications that can occur with the commonly used remedies. Anticipating a possible reaction is better than reacting to an unexpected condition.
Acknowledgements
We acknowledge the help of Miss Claire Davies (senior pharmacovigilance scientist) and Miss Lesley Curwen (scientific assessor, Pharmacoviligance Group Post Licensing Division) of the Medicines Control Agency.
References
1 Ang-lee MK, Moss J, Yuan C-S. Herbal medicines and perioperative care. JAMA 2001; 286: 208–216
2 Bovil JG. Adverse drug reactions in anaesthesia. J Clin Anesth 1997; 9 (Suppl 6): 3S–13S[Medline]
3 Haller CA, Benowitz NL. Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids. N Engl J Med 2000; 343: 1833–8
4 Rose KD, Croissant PD, Parliament CF, Levin MB. Spontaneous spinal epidural haematoma with associated platelet dysfunction from excessive garlic ingestion. Neurosurgery 1990; 26: 880–2[Web of Science][Medline]
5 Fessenden JM, Wittenborn W, Clarke L. Ginkgo biloba: a case report of herbal medicine and bleeding postoperatively from a laparoscopic cholecystectomy. Am Surg 2001; 67: 33–35[Web of Science][Medline]
6 Almeida JC, Grimsley EW. Coma from the health food store: interaction between kava and alprazolam. Ann Intern Med 1996; 125: 940–1
7 Ernst E. Second thoughts about the safety of St. John’s wort. Lancet 2000; 354: 2014–6
8 Breidenbach T, Hoffman MW, Becker T, Schlitt H, Klempnauer J. Drug interaction of St. John’s wort with cyclosporin. Lancet 2000; 355: 1912[Web of Science][Medline]
9 See DM, Broumand N, Sahl L, Tilles JG. In vitro effects of Echinacea and ginseng on natural killer and antibody-dependent cell cytotoxicity in healthy subjects and chronic fatigue syndrome or acquired immunodeficiency syndrome patients. Immunopharmacology 1997; 35: 229–35[Web of Science][Medline]
10 Boullata JI, Nace IS. Safety issues with herbal medicine. Pharmacotherapy 2000; 20: 257–69[Web of Science][Medline]
11 Pepping J. Echinacea. Am J Health Syst Pharm 1999; 56: 121–122
12 Miller LG. Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions. Arch Intern Med 1998; 158: 2200–11
13 Gurley BJ, Gardener SF, Hubbard MA. Content versus label claims in ephedra-containing dietary supplements. Am J Health Syst Pharm 2000; 57: 963–9
14 Nightingale SL. From the Food and Drug Administration. JAMA 1997; 278: 15
15 Srivastava KC. Evidence for the mechanism by which garlic inhibits platelet aggregation. Prostaglandins Leukot Med 1986; 22: 313–21[Web of Science][Medline]
16 Stevinson C, Pittler MH, Ernst E. Garlic for treating hypercholesterolaemia: a meta-analysis of randomized clinical trials. Ann Intern Med 2000; 133: 420–9
17 Chung KF, Dent G, McCusker M, Guinot P, Page CP, Barnes PJ. Effect of ginkgolide mixture (BN 52063) in antagonizing skin and platelet responses to platelet activating factor in man. Lancet 1987; 1: 248–51[Web of Science][Medline]
18 Maitra I, Marcocci L, Droy-Lefaix MT, Packer L. Peroxyl radical scavenging activity of Ginkgo biloba extract EGb 761. Biochem Pharmacol 1995; 49: 1649–55[Web of Science][Medline]
19 Vale S. Subarachnoid haemorrhage associated with Ginkgo biloba. Lancet 1998; 352: 36
20 Kimura Y, Okuda H, Arichi S. Effects of various ginseng saponins on 5-hydroxytryptamine release and aggregation in human platelets. J Pharm Pharmacol 1988; 40: 838–43[Web of Science][Medline]
21 Park HJ, Lee JH, Song YB, Park KH. Effects of dietary supplementation of lipophilic fraction from Panax Ginseng on cAMP and cGMP in rat platelets and on blood coagulation. Biol Pharm Bull 1996; 19: 1434–9[Web of Science][Medline]
22 Pepping J. Kava: Piper methysticum. Am J Health Syst Pharm 1999; 56: 957–8, 60
23 Shelton RC, Keller MB, Gelenberg A, et al. Effectiveness of St. John’s wort in major depression. JAMA 2001; 285: 1978–86
24 Ortiz JG, Nieves-Natal J, Chavez P. Effects of Valeriana officinalis extracts on flunitrazepam binding, synaptosomal GABA uptake and hippocampal GABA release. Neurochem Res 1999; 24: 1373–8[Web of Science][Medline]
25 Tsen LC, Segal S, Pothier M, Bader AM. Alternative medicine use in presurgical patients. Anesthesiology 2000; 93: 148–51[Web of Science][Medline]
26 Kaye AD, Clarke RC, Sabar R, et al. Herbal medications: current trends in anaesthesiology practice—a hospital survey. J Clin Anesth 2000; 12: 468–71[Web of Science][Medline]
27 Medicines Control Agency. Licensing of medicines: Policy on herbal medicines. Available at http://www.mca.gov.uk/ourwork/licensingmeds/herbalmeds.htm
28 Consumer Reports. Herbal roulette. Consumer Rep 1995; (November): 698–705
29 Edwards R. Monitoring the safety of herbal medicine: WHO project is under way. Br Med J 1995; 311: 1569–70
30 Consumer Reports. Herbal Rx—the promises and pitfalls. Consumer Rep 1999; (March): 44–8
31 Leak JA. Herbal medicines: what do we need to know? ASA Newsletter 2000; 64
32 American Society of Anesthesiologists. Anesthesiologists warn: if you’re taking herbal products, tell your doctor before surgery. Available at: http://www.asahq.org/PublicEducation/herbal.html.
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