Use of Herbal Supplements and Vitamins in Plastic Surgery: a Practical Review
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CME Use of Herbal Supplements and Vitamins in Plastic Surgery: A Practical Review George Broughton, II, Learning Objectives: After studying this article, the participant should be able M.D., Ph.D., Col., M.C., to: 1. Explain what governmental regulations control the labeling and distri- U.S.A. bution of herbal supplements. 2. List the more commonly used supplements and Melissa A. Crosby, M.D. their reported benefits. 3. List the possible postoperative complications from Jayne Coleman, M.D. consumption of the more commonly used herbal supplements. 4. Explain the Rod J. Rohrich, M.D. preoperative management of patients using herbal supplements. 5. Know ad- Dallas, Texas ditional resources to consult when unanswered questions arise. Background: The American public spends over $5 billion per year on herbal supplements, and approximately 20 percent of all Americans use prescription medications concurrently with herbal supplements. As the number of people who take alternative medicines rises, there is growing awareness among health care providers of the need to become educated and to educate their patients on the effects that such supplementation may have on their health. As plastic surgeons, we have an added responsibility to become informed because of potential adverse interactions with other medications and anesthesia in the elective surgical patient. Methods: Literature regarding commonly encountered herbal supplements and vitamins was reviewed and summarized to include reported indications for use and potential adverse effects and interactions specific to the perioperative patient. Results: Abundant literature exists regarding herbal supplementation, but very little scientific evidence exists to advocate the use of the majority of supplements available on the market. In addition, little is known about the positive and negative interactions that these supplements are capable of producing, and those interactions that are known are based on case reports. Conclusions: With the lack of quality scientific studies to support the efficacy of most herbal products available and the limited regulation of these products by the government, health care providers are faced with a significant public health dilemma. This article provides a brief overview of information published on commonly encountered herbal supplements and vitamins taken by plastic surgery patients. (Plast. Reconstr. Surg. 119: 48e, 2007.) idely used today, herbal medicine dates listic. It is based on the complementary forces yin back thousands of years and started in and yang. When yin and yang are in balance, the WIndia and China. Chinese medicine person is healthy; illness occurs when there is dates back approximately 4000 years and is ho- imbalance between the two forces. The Chinese evaluate the interactions between the environ- From the Department of Plastic Surgery, Nancy L & Perry ment (food, air, and drink) and the body Bass Advanced Wound Healing Laboratory, and the De- (waste). The cause (and treatment) of the im- partment of Anesthesia, University of Texas Southwestern balance is determined by examining the tongue, Medical Center. iris, and pulse. Treatment is usually a mixture of Received for publication December 16, 2005; accepted Feb- 1 ruary 9, 2006. herbs, massage, and acupuncture. The opinions or assertions contained herein are the private In India, Ayurvedic medicine dates back to views of the author and are not to be construed as official or 3000 BC. Ayurvedic medicine combines physio- as reflecting the views of the Department of the Army or the logic and holistic philosophies. It is based on the Department of Defense. concept that the human body, like the universe, Copyright ©2007 by the American Society of Plastic Surgeons is composed of five energy elements: earth, wa- DOI: 10.1097/01.prs.0000252661.72071.8d ter, fire, air, and space. Interaction of these ele- 48e www.PRSJournal.com Volume 119, Number 3 • Herbal Supplements and Vitamins ments gives rise to the three doshas (forces), percent),11 and there is no difference in botan- seven dhatus (tissues), and three malas (waste ical use between age groups.12 Herbal use is products). All diseases are attributed to an im- more prevalent among white, educated, and balance among the three doshas. Diagnosis is wealthy individuals.11,12 The American Society of made by an elaborate system of examinations of Anesthesiologists recommends that all surgical pa- physical and mental findings. Treatment is then tients stop herbal medications 2 weeks before personalized to these findings.2,3 surgery.13 In the United States, herbal therapy began in the colonial days as folk medicine. Women The Government’s Responsibility would brew botanicals in the home. Europeans, The U.S. Congress recognized that alternative Chinese, and Native Americans had a significant medicine was becoming more common and in impact on botanical remedies in the United 1992 established the Office of Alternative Medi- States. In the nineteenth century, a group of cine through the National Institutes of Health. In physicians known as Eclectics adopted the holis- 4 1998, Congress expanded the government’s inter- tic practice of herbal medicine. est by establishing the National Center of Com- THE PROBLEM plementary and Alternative Medicine to deter- mine the effectiveness of these therapies and Complementary and alternative medicine is support research in alternative medicine. There rarely taught in U.S. medical schools and generally are several important differences regarding the not practiced in U.S. hospitals. Complementary manufacturing, health claims, potency, and purity and alternative medicine includes herbal reme- of compounding herbal preparations when com- dies, massage, self-help groups, folk remedies, chi- pared with other medications. Herbal remedies ropractic manipulation, relaxation techniques, are not held to the same standards and regulations megavitamins, and others. Astonishingly, the ma- that the U.S. Food and Drug Administration main- jority of published information about herbal tains for the pharmaceutical industry. Phased tri- remedies can be located in the nursing and nu- als are not required, although the U.S. Food and tritional literature, with a minority in the med- 5 Drug Administration can “suggest” provision of ical literature. scientific data to consumers. Individual herbs can- There are more than 20,000 herbal medicines not be patented, although combinations of herbs on the market. Herbal medicine use has increased 5 may be. Although the Dietary Supplement Health 380 percent from 1990 to 1997. A recent survey and Education Act of 1994 places the burden of of 163 health food retail stores in the United States product safety assurance on the manufacturer, the revealed that the top 10 selling herbs are echina- U.S. Food and Drug Administration assumes the cea (Echinacea purpurea, Echinacea pallida, and Echi- responsibility of proving that a product is unsafe. nacea angustifolia), garlic, goldenseal (Hydrastis Therefore, if the U.S. Food and Drug Adminis- canadensis), ginseng (Asian Panax ginseng and tration has reason to believe that an herb is unsafe, American Panax quinquefolius), ginkgo (Ginkgo bi- it can remove the drug from the market. loba), saw palmetto (Serenoa repens), aloe (Aloe spe- Safety and health claim practices continued to cies), ma huang (Ephedra sinica), Siberian ginseng be of concern, and the U.S. Food and Drug Ad- (Eleutherococcus senticosus), and cranberry (Vac- 6 ministration put forth the “Regulations on State- cinium macrocarpon). Current movements suggest ments Made for Dietary Supplements Concerning St. John’s wort (Hypericum perforatum), valerian the Effects of the Product on the Structure or (Valeriana officinalis), and feverfew (Tanacetum Function of the Body” to address these concerns. parthenium) are likely soon to be listed among the Concerning these regulations, Sabar et al.6 ex- top 10 herbal agents.7 It is estimated that up to 32 plain how herbal manufacturers can sidestep U.S. to 97 percent of the U.S. population takes herbal Food and Drug Administration drug regulations: remedies on a regular basis.8,9 One in seven pa- tients report taking at least one herbal supplement under the proposal, dietary supplements that on a weekly basis, and one in five patients report expressly or implicitly claim to diagnose, treat, taking one or more herbal medications along with prevent, or cure a disease continue “to be re- their prescription medicine.10 Unbelievably, 70 garded as drugs and have to meet the safety and percent of patients do not reveal the use of these effectiveness standards for drugs under the Food, supplements to their health care providers.8 Drug, and Cosmetic Act.” The definition of dis- Among surgical patients, female patients more ease is “any deviation from, impairment of, or commonly take herbs (23.6 percent versus 19.2 interruption of the normal structure or func- 49e Plastic and Reconstructive Surgery • March 2007 tion of any part, organ, or system...ofthebody surgery, 42.7 percent consumed complementary that is manifested by a characteristic set of one and alternative medicines: 19.8 percent that in- or more signs or symptoms . ..” This definition hibit coagulation, 14.4 percent that affect blood allows the claim “promotes vascular health” while pressure, 7.4 percent with cardiac effects, and 8 disallowing the statement “decreases blood pres- percent with sedative effects.16 These concerns sure.” In response to the regulations, herbal have prompted some anesthesiologists and sur- manufacturers now add information that their geons to postpone elective surgical procedures.17 product “is not intended to diagnose, treat, cure, or A recent survey assessing the knowledge of herbal prevent any disease” and thus is not subject to the supplements by anesthesiologists found that only FDA drug regulations. 32 percent answered all questions correctly.18 Clearly, all physicians need additional and con- tinued training on herbal medicine. Until that Why Should You Care? time comes, at least one person in the operating It has been shown that herbal use is more room should have practical knowledge of herbal prevalent among white, educated, and wealthy medicine and its effects.