Patients On Herbal Medicines

By Mark B. Jacob, DDS, MS

Dept. of Maxillofacial Surgery

University of Illinois Hospital / Clinics

Veterans Administration Medical Center WS

Norweigan American Hospital

The following information was supplied by Dr. Mark Jacob as per the above affiliation as published in Anesthetic Management. Dr. Jacob states the following challenges to patient care among those consuming the following herbal supplements and/or nutriceuticals:

General Notes

• As many as 70% of patients do not reveal their use of  nutraceuticals; considering them as natural supplements rather than a form of medicine.

Definitions

Herbs - derived from flowers, shrubs, trees, algae, ferns, fungi, seaweed, and grasses

Potency of herbs can be most when fresh or some in other preparations or even dried. Herbs may be given as suppositories, oils [aromatherapy or baths ]

Tincture - plant preserved in alcohols; Teas of infusions; Decoctions - simmered herbs; Acetracts - extracts by vinegar use and placed in sucrose / fructose syrups, vegetable glycerin, or honey ( miels)

Tablets, capsules, pastes, concentrates may be 4-6 x the regular strength

Drug - this word is derived from an ancient word for root ; thus by definition herbs are drugs

Conditions and Challenges

People consider “herbs”  “Natural” or part of “Mother Nature” ;  further, the next association is “natural” and “Safe” ; like water and soil are to life and plants. People use herbs and nutraceuticals because:

1. Western Meds cannot cure all

2. Western Meds have high costs forcing less expensive therapies to be considered

3. Melting cultures causing exposure of different medicine approaches

4. Advice to eat “Healthier”, less fat = more greens, increased fiber intake, and less salt

5. Marketing “Safe” - many connect safe with nutritional supplements and herbs

Nutraceutical Use

• 20 - 40 % of the adult population in the US takes megavitamins, nutritional supplements irrespective of prescription drugs
• Herbal therapies have exceeded 5 billion dollars / year
• As previously mentioned, 70% of pts do not reveal nutraceutical use
• 42% of adult americans have used an alternative therapy within the last year

History Of Herbal Medicine

Western Meds were originally derived from plants:

• white willow bark - salicylic acid
• foxglove - digitalis
• cinchona bark - quinine
• periwinkle - vincristine
• poppy - opium
• Ezekiel’s book from 6BC
• “and the fruit thereof shall be for meat, and the leaf for medicine”
• 1st and 2nd century AD hieroglyphs show sienna pods for digestive problems, and scopalamine, hyoscyamus and opium for procedures
• Ancient Indians developed the Ayrurvedic system, a written book of herbology in the veda of ayrurvedic.
• 2800BC, Shen Nung, and in 2600BC, Huang Ti developed Nei Ching, a materia medica book
• 6 or 7 AD, Paulus Aegineta gave a complete review of the medical knowledge of the Romans, Greeks, and Arabians up to that time
• Middle Age practice of medicine was largely by word of mouth through the dark ages
• 1649, Nicholas Culpeper wrote the English Physician, a widely acclaimed manual available to the lay person, a first
• 1820, the first US pharmacopeia was published; it listed herbal drugs, dosages, purity, uses, properties
• 1985, one of the more widely circulated herb references Handbook of Medicinal Herbs by James A. Duke
• 2002 in the western world, some 30% of modern medicine is derived from plants
• Today, FDA does not hold herbal remedies to the same standards as the pharmaceutical industry
• The FDA cannot test all remedies before they are sold and can remove the product if the FDA has reason to believe it is unsafe, even though the Dietary Supplement Act of 1994 places the burden of product safety assurance on the manufacturer
• The revolving door between the FDA, drug policy-makers, and the pharmaceutical industry represents a gross consumer menace and public health risk.
• April 29, 1998 the FDA stated that dietary supplements claiming to diagnose, treat, prevent or cure a disease will be regarded as drugs and will be treated as under the FDA regulations. 
• Loop hole or consumer freedom? Herbal manufacturers now claim that their product are not intended to diagnose, treat, cure, or prevent any disease.
• 20,000 herbal over-the-counter products are available
•  
• A 2001 survey of 163 stores revealed the 10 best selling herbal products
• over 3.5 billion dollars was spent by US consumers in 1997
• St John’s Wort, Aloe and Feverfew are the next most popular herbs
• 20,000 herbal over-the-counter products are available
• A 2001 survey of 163 stores revealed the 10 best selling herbal products
• over 3.5 billion dollars was spent by US consumers in 1997
• St John’s Wort, Aloe and Feverfew are the next most popular herbs

Specific Herbs

• Eichinacea
• member of daisy family, medicinal families are pallida, purpurea, angustifolia [ cone flower family]
• Recommended for
• Reducing Respiratory Tract infections
• one study 36.7% placebo 29.3% eichinacea
• Wound Healing
• Mechanism - contains alkylamide and polysaccharide constituents with immunostimulation properties due to enhanced phagocytosis and nonspecific T-cell stimulation

Bauer R, Khan IA, Helv Chim Acta 1985;158:2192-9

• Side Effects -
• Bad Taste
• Tachyphylaxis with 8 weeks of use
• Anaphylaxis with a cross reaction of other sunflower family (asteraceae) allergens
• Hepatotoxic especially with other hepatotoxic agents
• Eichinacea Not Recommended in:
• Immuno-compromised
• Systemic and Auto Immune disorders
• Anesthesia/Drug Interactions
• Immunostimulatory effects may offset steroid or cyclosporin immunosuppressive effects
• Precipitated Toxicity with Hepatic metabolized agents like Phenytoin, Rifampin, Phenobarbital

• Garlic
• Acillin is the sulfur containing ingredient that gives the characteristic smells; crushing a clove activates acillinase to convert allin to acillin
• Recommended for
• Hypercholsterol, Hyperlipidemia 16 clinical trial showed a 16% reduction in serum cholesterol, no change in HDL levels

     Neil HAW, Sigaly CA, JRColl Physicians;1996;30:329-34

• HTN ??
• Anti-platelet, Fibrinolytic, Anti-oxidant Effects
• Mechanism -
• allicin has vasodialator properties, and decreased platelet aggregation properties

Bordia A, Athersclerosis, 1978;30:355-60

• Side Effects -
• Anti-platelet Effects 
• Garlic Not Recommended
• Pts on NSAIDS, ASA, Heparin, Warfarin
• Hematological Disorders involving coagulation
• Anesthetic/ Drug Interactions
• As noted above
• May have excessive post operative or peri operative bleeding   

• Ginger
• Recommended for
• Vomiting, Nausea, Motion Sickness, Vertigo

Holtman S, Clarke AH, Acta Otolaryngol; 1989;108:168-74

Grontved R, J Otolaryngol, 1986;48:282-6

• Mechanism
• Ginger constituents such as 6-shogaol and galanolactone also seem to act on serotonin receptors (5-HT receptors). Galanolactone seems to act primarily on 5-HT3 receptors in the ileum, which are the same receptors affected by some prescription antiemetics such as ondansetron (Zofran).
• There is some evidence that ginger constituents may also have central antiemetic activity. Some researchers speculate that certain constituents of ginger might inhibit cyclooxygenase and lipoxygenase pathways . The ginger constituent 6-gingerol , does seem to have anti-inflammatory effects by inhibiting thromboxane synthetase enzyme, prolonging bleeding time.
• Side Effects
• Anti-platelet Activity
• Not Recommended
• pts with NSAID, ASA, Warfarin, Heparin use
• Anesthesia/ Drug Interactions
• As above

• Gingko Biloba

From the ginko tree that has a life span of 1000 yrs; noted resilience that allowed it to survive the atomic blast in Hiroshima.One of the oldest used herbs for medicinal purposes; 3000BC.

Four used types : tanakan, tebonin, rokan, kaveri.  The  first three are EGB761

• Recommended for
• Memory loss / Dementia
• Tinnitus
• Vertigo
• Claudication / Circulation
• Cognitive fxn, Social functioning
• Premenstrual Syndrome
•  
• Mechanism
• Potential platelet activating factor inhibition; modulation of nitric oxide (neuro protective); anti inflammatory effects. 

     Gingko leaf flavonoids have antioxidant and free radical scavenging properties. These flavonoids seem to prevent or reduce cell membrane lipid peroxidation, decrease oxidative damage to erythrocytes, and protect neurons and retinal tissue from oxidative stress and injury following ischemic episodes. Protecting neurons and other tissues from oxidative damage might prevent progression of tissue degeneration in patients with dementia and other conditions.

• The ginkgolides A and B seem to decrease glucocorticoid biosynthesis, which might also play a role in gingko's proposed antistress and neuroprotective effects.

• Ginkgo leaf might also have some antimicrobial activity, including activity against Pneumocystis carinii and possibly some gram-positive bacteria and yeast. 
•  
• Side Effects
• Anti-platelet Activity
• Headaches, Mild GI upset
• Rare reports of  spontaneous hyphema
• Gingko toxin thought to be neuro toxic
• Not Recommended
• pts with NSAID, ASA, Warfarin, Heparin use
• Seizure history
• Anesthesia/ Drug Interactions
• Anticonvulsants may have decreased effectiveness due to increased liver enzyme activity
• Seizure threshold decreased
• THIAZIDE DIURETICS  Ginkgo leaf can increase blood pressure when used concomitantly with thiazide diuretics .
• MONOAMINE OXIDASE INHIBITORS (MAOIs) Theoretically, ginkgo might potentiate the activity of monoamine oxidase inhibitors.  However, this effect has not been demonstrated in humans
• INSULIN: Gingko leaf extract can alter insulin secretion and metabolism and might affect blood glucose levels. People taking insulin should monitor glucose levels closely. Insulin dose adjustments might be necessary.
• TRAZODONE (Desyrel): Use of ginkgo leaf extract with trazodone has been associated with coma. Coma might have been induced by excessive GABA-ergic activity. Ginkgo flavonoids are thought to have GABA-ergic activity and directly act on benzodiazepine receptors. Ginkgo might also increase metabolism of trazodone to active GABA-ergic metabolites, possibly by inducing cytochrome P450 3A4 metabolism
•  
• St John’s Wort

Used in Germany as an approved medication for depression.  It is the 7th most popular medicine.  2.7 million rx were written in 1993.  Other names goatweed, amber, hardhay, tipton weed. Also used for dye silk, wool violet red.

Hypericum means “over an apparition” in the belief it repels evil spirits.

• Recommended for
• Sleep related disorders
• Anxiety
• Vitiligo
• Depression
•  
• Mechanism
• Inhibition of monoamine oxidase and competitive inhibition of of GABA receptors, which explains the anti-depressant effect.
• Two constituents that play a significant role are hypericin and hyperforin . Hypericin inhibits catechol-O-methyl transferase (COMT) and monoamine oxidase (MAO) in vitro. However, hypericin does not seem to reach adequate concentrations in human tissue to achieve these effects.
• Hypericin also has affinity for sigma receptors and acts as a receptor antagonist at adenosine, benzodiazepine, GABA-A, GABA-B, and inositol triphosphate receptors.
• Recently hyperforin was also identified as a probable major player in St. John’s wort’s antidepressant activity.
• Hyperforin modulates the effects of serotonin, possibly through serotonin reuptake inhibition and 5-HT3 and 5-HT4 receptor antagonism. Hyperforin also inhibits synaptosomal uptake of gamma-butyric acid (GABA) and L-glutamate.
• St. John’s wort extracts can also prolong narcotic-induced sleep time, decrease barbiturate-induced sleep time, and antagonize the effects of reserpine
•  
• St. John’s wort and its constituents, hypericin and pseudohypericin, have activity against viruses and bacteria including influenza virus, herpes simplex virus types I and II, Sindbis virus, poliovirus, retrovirus, murine cytomegalovirus (CMV), hepatitis C, and Gram negative and Gram positive bacteria.
• Hyperforin can also inhibit growth of penicillin- and methicillin-resistant Staphylococcus aureus and other Gram positive organisms, but not Gram negative organisms.
• Topical preparations are thought to be beneficial for inflammatory skin conditions and superficial wounds by inhibiting epidermal inflammatory response. Both hypericin and hyperforin constituents likely contribute to this effect.
• Hypericin is photodynamically active and is thought to be the constituent responsible for phototoxic reactions.

• Induction of both intestinal P-glycoprotein/MDR-1 and intestinal and hepatic CYP3A4 decreases the intestinal absorption and increases hepatic first pass clearance of numerous drugs such as cyclosporine, indinavir, and amitriptyline.  St. John’s wort does not appear to affect N-acetyltransferase (NAT2).
•  
• Side Effects
• Insomnia
• Dry Mouth
• Dizziness
• Fatigue
• Nausea
• Constipation
• Hallucinations
• Autonomic dysfunction
•  
• Not Recommended
• pts with photosensitive drugs
• with MOA inhibitor drugs
• Serotonin Reuptake Inhibitors
• with Digitalis
• Cardiac Conduction abnormalities
•  
• Anesthesia/ Drug Interactions
• MAO’s
• Digitalis - increased metabolism of leading to cardiac dysrhythmias
• Photosensitive Drugs like piroxicam, tetracycline
• B-Sympathomimetic amines like pseudoephedrine, ma huang
• Serotonin Reuptake Inhibitors like fluoxetine, paroxetine will cause Serotoninergic Syndrome [hypertonic, myoclonic, hyperthermic]

 

• Ginseng

Active part is ginsenoside.  Used in the past as an aphrodesiac, anti-ager, and energy booster.  Today it is also noted as an antioxidant.  It is labeled as an Adaptogenic or aiding in adrenal steroidgenesis.  Panax ginseng is the American or Oriental medicinal compound, the Siberian is not and of a different genus.

 

• Recommended for
• Lethargy
• Improving general well being
• Diabetes
• Immune support
• Athletic Stamina
•  
• Mechanism
• There is some evidence that it might work against stress by affecting the hypothalamic-pituitary-adrenal (HPA) axis. Panax ginseng saponins seem to increase serum cortisol concentrations and stimulate adrenal function.
• Panax ginseng appears to stimulate natural-killer cell activity and possibly other immune-system activity. It might also have some antitumor activity.  Extracts of Panax ginseng decrease the production of tumor necrosis factor, diminish DNA strand breakage, and inhibit the formation of induced skin tumors.
• Panax ginseng also increases antioxidant plasma levels and antioxidant activity.
•  
• Side Effects
• Insomnia
• Headache
• Hypertension
• Constipation
• Nausea
• Epistaxis
• Stevens - Johnson Syndrome
•  
• Not Recommended
• Pregnancy
• Other Sympathomimetics
• CV Disease
• Volume Depleted conditions, ie athletes or geriatric populations
• Cardiac Conduction abnormalities
• With Antiplatelet Drugs
•  
• Anesthesia/ Drug Interactions
• Antiplatelet DrugsASA, NSAIDs, Warfarin, Heparin
• ANTIDIABETES DRUGS: Theoretically, concomitant use might enhance blood glucose lowering effects. Monitor blood glucose levels closely. Some antidiabetes drugs include glimepiride (Amaryl), glyburide (Diabeta, Glynase PresTabs, Micronase), insulin, pioglitazone (Actos), rosiglitazone (Avandia), and others.
• CAFFEINE: There is some concern that long-term use of 3 grams of Panax ginseng daily in combination with caffeine might lead to hypertension in some patients
• IMMUNOSUPPRESSANTS: Theoretically, concurrent use might interfere with immunosuppressive therapy. Panax ginseng might have immune system stimulating properties
• Anesthesia/ Drug Interactions
• FUROSEMIDE: There is some concern that Panax ginseng might contribute to diuretic resistance. There is one case of resistance to furosemide diuresis in a patient taking a germanium-containing ginseng product.
• ACTIVATED PARTIAL THROMBOPLASTIN TIME (aPTT), THROMBIN TIME (TT): Theoretically, Panax ginseng might prolong aPTT, TT, and increase test results.
• INR), PROTHROMBIN TIME (PT): Panax ginseng can reduce PT/INR and test results in patients treated with warfarin
• GLUCOSE: Panax ginseng might reduce fasting blood glucose concentrations and test results.
  GLYCOSYLATED HEMOGLOBIN (HbA1c): Panax ginseng might improve glucose control and reduce HbA1c values in patients with type 2 diabetes

 

• Feverfew

Is used as an insecticide in Mexico and as an aspirin alternative in Spain.  Also called midsummer’s daisy, featherfew, bachelor’s button.

 

• Recommended for
• Migraines
• Headaches

A double blind, placebo study found a 70% reduction in migraines  Murphy J,et al; Lancet; 1988;2:189-92

A second study did not find effective migraine relief

De Weerdt C, et al; Physomed; 1996;3:225-30

• Arthritis
• Menstrual Irregularities
• Fever
•  
• Mechanism
• Feverfew also appears to block prostaglandin synthesis by inhibiting phospholipase, which prevents the release of arachidonic acid. Chrysanthenyl acetate, an essential oil of feverfew, has been suggested as one active component.  Chrysanthenyl acetate inhibits prostaglandin synthetase and might have analgesic properties.
• Feverfew also contains melatonin which might contribute to its pharmacological effect
• Preliminary research shows that extracts of fresh feverfew leaves and parthenolide might cause irreversible inhibition of vascular muscle contraction.
•  
• Side Effects
• Insomnia
• Headache
• Hypertension
• Constipation
• Nausea
• Epistaxis
• Stevens - Johnson Syndrome
•  
• Not Recommended
• Diahrrea
• Abdominal Pain
• CV Disease
• Post-Feverfew Syndrome - HA’s, Joint Stiffness Anxiety, Insomnia
• Contact Dermatitis
• With Antiplatelet Drugs
•  
• Anesthesia/ Drug Interactions
• Antiplatelet DrugsASA, NSAIDs, Warfarin, Heparin

 

• Iron Containing preparations reduced availability

 

• Chromium Picolinate
• Chromium is sometimes referred to as glucose tolerance factor (GTF), but GTF is actually a complex of molecules found in the body that includes chromium bound to single molecules of glycine, cysteine, glutamic acid, and two molecules of nicotinic acid. Chromium is thought to be the active component of the complex.

 

•  
• Recommended for
• Diabetes
• Weight Loss
• Exercise Supplement/ Muscle Mass
• Increase Energy
• Increase HDL with concomitant  Beta- Blocker use
•  
• Mechanism - chromium-containing peptide called chromodulin has been identified, which potentiates the actions of insulin at its receptors, including activation of receptor tyrosine kinase activity. In patients with diabetes, these actions seem to translate into decreased insulin resistance, improved glucose tolerance, and lower blood glucose levels
• It is theorized that chromium might also sensitize insulin-sensitive glucoreceptors in the brain, resulting in appetite suppression, activation of the sympathetic nervous system and stimulation of thermogenesis, and down-regulation of insulin secretion
• It is also theorized that chromium might enhance glucose utilization in the brain, stimulate norepinephrine release, and increase serotonin synthesis, which could lead to beneficial effects in dysthymic disorder (mild depression)
• Chromium is also hypothesized to increase muscle mass by increasing amino acid uptake into muscle cells via potentiation of insulin activity
•  
• Side Effects
• HA’s
• Weight gain without exercise
• Insomnia
• Mood Changes
•  
• Not Recommended for

 

• Renal Insufficiency
• Leather Allergy
• Psychiatric Disorders

 

• Anesthesia / Drug Reactions
• Decreased Chromium retention with antacids , H2 blockers, Proton Pump inhibitors
• with Beta Blocker use increases HDL serum levels
• Corticosteriods  induced hypergylcemia reduced
• NSAIDs increase chromium serum levels, decrease excretion

 

 

• Ma Haung, Ephedra

Used as a prescribed medicine since 1st century AD.  Native Americans used it topically to heal skin ailments.

•  
• Recommended for
• Flu, Cold
• Allergic Symptoms
• Bronchitis
• Low Blood Pressure
• Asthma
• Arthritis
• Athletic Stimulant
• Weight Loss
•  
• Mechanism
• The principle alkaloid constituents are ephedrine, pseudoephedrine, and sometimes small amounts of phenylpropanolamine.
• Ephedrine and pseudoephedrine are both non-selective alpha- and beta-receptor agonists. The ephedrine and pseudoephedrine constituents can directly and indirectly stimulate the sympathetic nervous system. They can increase systolic and diastolic blood pressure and heart rate cause peripheral vasoconstriction, bronchodilation and central nervous system stimulation
• Ephedrine also seems to have antitussive, bacteriostatic, and anti-inflammatory activity
• Ephedra alkaloids have been linked to myocarditis and myocardial infarction. This has been attributed to coronary artery vasoconstriction and possibly vasospasm caused by ephedra. Ephedra might also cause cardiac arrhythmia due to adrenergic effects that shorten the cardiac refractory period, causing re-entrant arrhythmias.
• Cerebral hemorrhage associated with ephedra has been attributed primarily to hypertensive effects and possibly due to cerebral vasculitis, which has been reported with other adrenergic drugs. Ischemic stroke has been attributed to ephedra’s vasoconstrictive effects on cerebral vasculature and possibly platelet aggregation effects due to adrenergic stimulation
• Ephedrine causes relaxation of the smooth muscle in the gastrointestinal tract, urinary retention by relaxing the detrusor muscle, and diminishes contraction of the bladder sphincter
• Ephedra can have either hypoglycemic or hyperglycemic effects
• It can also stimulate uterine contraction, and theoretically can be catabolized to mutagenic nitrosamines.
•  
• Side Effects
• Insomnia
• Headache
• Hypertension
• Dysrhythmias
• MI
• Psychosis
• Seizures
• Antitussive
•  
• Not Recommended
• HTN
• CVA history
• CV Disease
• Insomnia
• Cardiac Disease
• MAO’s
• other Sympathomimetics

 

• Anesthesia/ Drug Interactions
• DEXAMETHASONE (Decadron): Theoretically, concomitant use might reduce the effectiveness of dexamethasone, due to the ephedrine contained in ephedra. Ephedrine increases the clearance rate of dexamethasone
• DIGOXIN (Lanoxin): Theoretically, concomitant use might cause cardiac arrhythmias.
• DIABETES DRUGS: Ephedra can raise blood glucose levels and interfere with diabetes drug therapy. Monitor blood glucose concentrations closely
• URINARY ALKALINIZERS: Theoretically, concomitant use of ephedra and urinary alkalinizing drugs might increase the ephedrine-related effects of ephedra. Urinary alkalinizing drugs reduce ephedrine excretion
• OXYTOCIN: Theoretically, concomitant use might cause hypertension.
• RESERPINE: Theoretically, concomitant use might antagonize the indirect sympathomimetic effects of the ephedrine contained in ephedra .
• THEOPHYLLINE: Theoretically, concomitant use might increase the risk of stimulatory adverse effects of theophylline and ephedrine (contained in ephedra).
•  

Other Concerns

• Anesthetic Interactions with Commonly Prescribed / Used Agents in Oral/ Maxillofacial Surgery
• Penicillin
• Guar Gum= decr. PEN absorption
• Gingko = lowers seizure threshold
• Acetaminophen
• Increased Hepatotoxic Risk = Bishop’s weed, Beer

      Vit C decreases elimination by 75%

• Increased analgesia by up to 40% = Mate
• Decreased blood levels = Smokeless tobacco
• Narcotics, Agents w/ Liver Dependent Metabolism
• Gingko = decreases liver enzyme activity
• Benzodiazepines
• Grapefruit, Chamomile,   increase sedative effects
• Green tea, caffeine,  decrease sedative effect
• L tryptophan induces Parkinsonian like rigidity
• Clindamycin
• Kaolin decreases absorption
• GHB
• Exercise Supplement can induce a coma, respiratory arrest if mixed w/ narcotics, alcohol
• Other Anesthetic Interactions : Diets
• Protein Diets
• Pts might be for more dehydrated than clinically presenting; anesthetics can potentiate the delicate state
• This diet should be accompanied by 10 16oz or 500ml glasses of water per day - minimal !!

 

Speaking of water -

• Water is
• 75% of brain
• 75% of muscle
• 22% of bone
• 92% of blood
• 8 x 16oz per day!
• Avg person is highly dehydrated drinking only

4.6 glasses per day

 

• Water with caffeine additives, herbal additives further complicates the pts pre anesthetic history

 

 

Posted by DR. LEONARD G. HOROWITZ as a public service.

www.healthyworlddistributing.com