Q&A 368.2
How should herbal medicines be managed in patients undergoing surgery?
Prepared by UK Medicines Information (UKMi) pharmacists for NHS healthcare professionals
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Date prepared: April 2015
Background
There are an increasing number of patients using herbal medicines and for various reasons these patients do not always disclose herbal medicine use to medical staff (1,2,3). Herbal medicines are often mistakenly considered to be safe because they are natural. However, herbal medicines do not have to comply with medicines legislation and many reach the market as unlicensed herbal remedies (4,5). For this reason the content and relative safety of herbal medicines is unpredictable and there is limited awareness of their adverse-effects and interactions with prescribed medications (4).
This Q&A summarises information from the current literature regarding commonly used herbal medicines and how to manage their use during the peri-operative period. It includes recommendations on discontinuation of herbal medicines prior to elective surgery.
A review of all herbal medicines is beyond the scope of this Q&A, it is intended as a guide only and is not intended to be exhaustive.
Answer
There is limited information regarding the use of herbal medicines and the risks during surgery and anaesthesia (3). There are no randomised controlled trials evaluating the effects of herbal medicines during the peri-operative period (6). There are no official standards or published guidelines on the pre-operative use of herbal medicines either internationally or in the United Kingdom (UK) (7, 8, 9).
One key message is that full disclosure of herbal medicines by patients and specific pre-operative questioning by medical staff is essential. This advice is provided by the Royal College of Anaesthetists in the UK, the Association of Anaesthetists of Great Britain, the Medicines Healthcare Regulatory Agency and the American Society of Anaesthesiologists (10).
There are several review articles that consider the implications of herbal medicines during peri-operative care (6, 11, 12, 13, 14, 15, 16). They concentrate on 8 to 10 of the most commonly used herbal medicines.
Herbal medicines may affect the peri-operative patient by having a direct pharmacological effect or by interaction with conventional medicines (11). If the pharmacokinetics and pharmacodynamics of an individual compound are used to make decisions regarding the management of herbal medicines in patients undergoing surgery then recommendations for discontinuation range from 24 hours to 2 weeks (6,11,14). A more straightforward approach is to discontinue all herbal medicines 2 weeks prior to surgery (6,11,12,13). This advice is supported by the American Society of Anaesthetists (6,13).
One review, which specifically considers the effects of complementary and alternative medicines on coagulation, also recommends that supplements should be stopped 2 weeks before surgery (16).
The risk of bleeding in surgical patients who use herbal medicines has been highlighted 17,18).
The importance of proper questioning of patients is highlighted by all of the reviews (6,11,12,13,14,15, 16). Education of medical practitioners, greater patient communication and integrative research are all needed to prevent adverse effects from herbal medicines in patients undergoing surgery.
The nine most common herbal medicines are considered below.
Echinacea is used for the prophylaxis and treatment of viral, bacterial and fungal infections (6,11,12). It should be avoided before transplant surgery because it may decrease the effectiveness of immunosuppressants (12,13). A case of acute hepatitis in an adult(19) and liver failure in a child ( 20) have been reported following the use ofechinacea, therefore it should be avoided in the peri-operative period as it is potentially hepatotoxic(15). Echinacea should be discontinued as far in advance as possible for any surgery (6) ideally 2 weeks prior to surgery (11,12, 15)
Ephedra, also known as ma huang, is used to promote weight loss, increase energy and treat respiratory conditions such as asthma and bronchitis (6,11,12). Ephedra contains several alkaloids including ephedrine and pseudoephedrine (15). Adverse effects of ephedra include increased blood pressure, palpitations, tachycardia, stroke and seizures (15). It may also affect cardiovascular function leading to cardiomyopathy (6,11,12,13, 15). It should be discontinued at least 24 hours (6, 15) and ideally 2 weeks prior to surgery (12).
Garlic has the potential to modify the risk of developing atherosclerosis by reducing blood pressure and thrombus formation and lowering serum cholesterol levels (6,11,12,13). Garlic may enhance existing anticoagulant therapy (1) and because it has been shown to decrease platelet aggregation it should be stopped 7 days prior to surgery especially if post-operative bleeding is a concern (6, 11, 15). Ideally, garlic should be discontinued 2 weeks prior to surgery (12).
Ginger is used for motion sickness and vertigo as well as post-operative nausea and vomiting, it is also used as an anti-inflammatory (11,12,13). Ginger can cause hypoglycaemia, and may increase the risk of bleeding due to its effect on platelet function. It should be stopped 2 weeks prior to surgery (11,12,15)
Ginkgo is used to prevent the effects of aging, to increase energy, improve stress and improve appetite (6,11,12). It is also used for tinnitus, vertigo, memory enhancement and sexual dysfunction (13). It may affect platelet aggregation and there have been isolated reports of serious adverse drug reactions after concurrent use with anti-platelet drugs (21). Ginkgo should be stopped at least 36 hours prior to surgery because of the bleeding risk (6,11, 15). Ideally, ginkgo should be stopped 2 weeks before surgery (12,15).
Ginseng is used for a wide range of conditions including stress, memory loss, bleeding disorders, appetite loss and cancer (6,11,12,13). Ginseng may cause hypoglycaemia in fasting patients and may also cause platelet inhibition (6,11,12,13). It should be stopped at least 7 days prior to surgery (6, 11) and ideally 2 weeks before surgery (12, 15).
Kava is used as an anxiolytic and sedative (6,11,12,13). It can potentiate the sedative effects of anaesthetics and should be stopped at least 24 hours prior to surgery (6, 15) and ideally 2 weeks before surgery (11,12, 17).
St John’s Wort is widely used as an antidepressant. It significantly affects the metabolism of many other drugs because it induces cytochrome P450 enzymes (6,11,12,13). The effects of many conventional medicines including warfarin, alfentanil, midazolam and lidocaine could all be reduced by St John’s Wort. It should be discontinued 5 to 7 days prior to surgery especially if transplant surgery or if the patient needs warfarin post surgery (6,11, 15). Ideally, St John’s Wort should be stopped 2 weeks prior to surgery (1,12).
Valerian is used for insomnia. Because it causes hypnosis, the dose should be tapered several weeks prior to surgery (6, 11, 12, 15). Valerian should not be stopped abruptly as it poses a risk of withdrawal syndrome (6,11,12).
Summary
- Based on the pharmacokinetics and pharmacodynamics of individual herbal medicines the recommendations for discontinuation vary between 24 hours and 2 weeks.
- It is generally advised that herbal medicines are stopped 2 weeks prior to elective surgery.
- Full disclosure of herbal medicines by patients and specific pre-operative questioning by medical staff is essential.
Limitations
There is a lack of published scientific information on the safety of herbal medicines in patients undergoing surgery. The list of herbal medicines included in this review is not exhaustive, absence from this Q&A does not imply that an herbal medicine is safe to use during the perioperative period.
References
1. Barnes J, Anderson LA and Phillipson JD. Herbal Medicines. 3rdEdition. Pharmaceutical Press: London. 2007.
2. Collins D, Oakley S and Ramakrishnan V. Perioperative use of herbal, complementary, and over the counter medicines in plastic surgery patients. Journal of Plastic Surgery. 2011; 11: 244-253.
3. Pass SE and Simpson RW. Discontinuation and reinstitution of medicines during the perioperative period. American Journal of Health-Syst Pharm 2004; 61: 899-912.
4.
accessed on 25/2/2015.
5. Javed F, Golagani A and Sharp H. Potential effects of herbal medicines and nutritional supplements on coagulation in ENT practice. The Journal of Laryngology and Otology 2008; 122: 116-119.
6. Ang-Lee MK, Moss J and Yuan CS. Herbal medicines and perioperative care. JAMA 2001; 286 No 2: 208-216.
7. McMillan R and Taylor L. Harmless herbal medicines in day surgery? The Journal of One-Day Surgery 2005; 15: 36-38.
8. Whelan N. Herbal medicines and surgery. Pharmacy Department. St Vincent’s University Hospital. 2003.
9. Joint Formulary Committee. British National Formulary. 63 ed. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; March 2012.
10. Hogg LA and Foo I. Management of patients taking herbal medicines in the perioperative period: a survey of practice and policies within the anaesthetic departments of the United Kingdom. European Journal of Anaesthesiology 2010; 27: 11-15.
11. Trapskin P and Smith KM. Herbal medications in the perioperative orthopaedic surgery patient. Orthopaedics 2004; 27: 819-822.
12. Hodges PJ and Kam PCA. The peri-operative implications of herbal medicines. Anaesthesia 2002; 57: 889-899.
13. Sabar MD, Kaye AD and Frost EAM. Perioperative considerations for the patient taking herbal medicines. Heart Disease 2001; 3: 87-96.
14. Whinney C. Perioperative medication management: General principles and practical applications. Cleveland Clin J Med 2009;76: S4: S126-S132
15. Wong A and Townley SA. Herbal Medicines and Anaesthesia. Cont Edu Anaesth Crit Care and Pain 2011;11:14-17.
16. Norred CL and Brinker F. Potential coagulation effects of preoperative complementary and alternative medicines. Alternative Therapies 2001; 7: 58-67.
17. Gray S, West LM. Herbal medicines- a cautionary tale. N Z Dent J. 2012; 108:68-72
18. Wong WW et al. Bleeding risks of herbal, homeopathic, and dietary supplements. A hidden nightmare for plastic surgeons? Aesth Surg J 2012; 32:332-46
19. Kocaman O, Hulagu S, Senturk O. Echinacea-induced severe acute hepatitis with features of cholestatic autoimmune hepatitis. Eur J Intern Med 2008;19:148
20. LawrensonJA et al. Echinacea-induced acute liver failure in a child. J Pediatr and Child Health 2014; 50;840-42
21. Stockley’s Herbal Medicines Interactions. 2nd Edition. Pharmaceutical Press: London. 2013. Accessed via Medicines Complete 25/2/2015.
Quality Assurance
Prepared by
Alison Yeo, Medicines Information Pharmacist (based on work by Emma Shepherd), South West Medicines Information and Training. University Hospitals Bristol NHS Foundation Trust.
Date Prepared
20th April 2015
Checked by
Julia Kuczynska
Date of check
14th May 2015
Search strategy
Embase [HERBAL MEDICINE] + SURGERY
Medline [HERBAL and MEDICINES] + SURGERY
Internet Search (Google Scholar Advanced Search: HERBAL MEDICINES and SURGERY)
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