Herbs & Supplements What you should know before surgery Lidie M. Lajoie

Over 60 million Americans use herbal medications and supplements on a regular basis. People who use herbal remedies tend to be well educated and want to take an active role in promoting their health, preventing and treating disease, and aging gracefully. Over half of the people who have elective surgery have used herbal supplements in their lifetime, and at least one-third use herbal remedies on a regular basis.

Despite the fact that so many people use herbal medications and supplements, studies have found that less than 10% of all herbal supplement users inform their physicians before surgery. Often, people believe that since herbal medications and supplements are promoted as natural, they are safer and less likely to cause side effects than prescription medications. This is not always the case.

The fact is that 30% of all modern, conventional medicines are derived from plants, and herbal supplements often have significant medicinal activity, as well as potential for adverse effects and drug interactions.

Your surgeon needs to know if you have been using herbal medicines or supplements in order to prevent avoidable complications associated with common medications and stress on the body during surgery. This guide is designed to provide information about some of the most commonly used herbal medications and supplements in the United States and the complications associated with their use during surgery. If you use any herbal medication or supplement it is prudent to follow the general recommendation of the American Society of Anesthesiologists and discontinue their use 2-3 weeks before your scheduled surgical procedure.

Ginko Biloba

Uses: improve memory, Herbal Alzheimer’s dementia, vascular disease Supplements Surgical Complications: Known To increases bleeding Increase especially around brain and spinal cord, prolongs Bleeding sedation, allergic skin reaction Many herbal medications Discontinue 36 hours and supplements can before surgery significantly increase bleeding during and after surgery. This not only Garlic Tablets adds to the length of the Uses: lowers blood pressure procedure, but also increases the risk of and cholesterol levels, infection, postoperative protects against heart pain, and scar formation. disease Surgical Complications: Ginko biloba increases bleeding Garlic Discontinue one week Ginger before surgery Ginseng

Ginger Omega-3 Vitamin E Uses: nausea, motion Chondroitin sickness, aids digestion Dong quai Surgical Complications: increases bleeding, Saw palmetto increases blood sugar Feverfew Discontinue one week Bromelain before surgery Ginseng Omega-3, EFA, Uses: increases physical or Flax & Fish Oil mental energy, enhances Uses: rheumatoid arthritis, performance protects against heart Side Effects: insomnia, disease, some skin headaches, nosebleeds disorders Surgical Complications: Surgical Complications: increases bleeding, increases bleeding Lowers blood sugar Discontinue 2-3 weeks Discontinue one week before surgery before surgery

Saw Palmetto Glucosamine & Chondroitin Use: male urinary Use: osteoarthritis complaints related to Surgical Complications: enlarged prostate increases bleeding Surgical Complications: Discontinue 2—3 weeks increases bleeding before surgery Discontinue 2-3 weeks before surgery Feverfew Dong Quai Use: migraines Side Effects: may cause Uses: menstrual & headaches, insomnia, or menopausal complaints joint pain if stopped Surgical Complications: abruptly increases bleeding Surgical Complications: Discontinue 2-3 weeks increases bleeding before surgery Discontinue one week before surgery

Herbal Medications with Serious Complications or Drug Interactions During Surgery Ephedra/Ma Huang - seizure, heart attack, stroke St. John’s Wort heart failure Kava - coma Valerian - heart failure, delerium Ginko Biloba - bleeding in brain & spinal cord Licorice - heart attack Ephedra/Ma Huang Herbal Supplements Uses: increase energy, weight loss, asthma Which Increase Side Effects: heart Sedation palpitations, chest pain, panic attacks Many herbal supplements can Surgical Complications: prolong sedation during and interacts with anesthesia after surgery, which slows recovery from anesthesia. and can cause seizures, heart attack, or stroke Ginko Biloba Discontinue 24 hours before surgery Echinacea St. John’s Wort St John’s Wort Valerian Uses: mild depression, Kava anxiety, sleep disorder Goldenseal Side Effects: sensitivity to sunlight Surgical Complications: interacts with anesthesia, can cause Valerian heart failure, prolongs Uses: sleep aid, mild sedation relaxant Discontinue 5 days Surgical Complications: before surgery delirium, heart failure, prolonged Kava sedation Uses: anxiety Discontinue 1 week Side Effects: “kava before surgery dermatopathy” causes red eyes, scaly skin, and Licorice yellow discoloration of skin, hair, & nails. Uses: sore throat, Surgical Complications: stomach ulcers interacts with Surgical Complications: increases bleeding, anesthesia, coma, prolonged sedation may cause heart Discontinue 24 hours attack before surgery Discontinue 2—3 weeks before surgery Vitamin E Some Herbal Supplements Uses: protects the heart are known to affect the - especially in diabetics, skin and may cause: slows skin aging Sun Sensitivity Surgical Complications: or Allergic Rash increases bleeding, impairs wound healing St John’s Wort – especially tendons Ginko Biloba Discontinue 2—3 weeks before Kava surgery Echinacea Goldenseal Echinacea Arnica Uses: stimulates immune system Side Effects: suppresses Goldenseal immune system with long- Uses: gastrointestinal and term use skin infections Surgical Complications: Surgical Complications: prolongs sedation, poor prolongs sedation, wound healing, allergic sensitivity to sunlight reaction Discontinue 2—3 weeks Discontinue 2—3 weeks before surgery before surgery

Resources:

Center for Food Safety and HerbMed: Applied Nutrition, Food & http://herbmed.org Drug Administration: http://vm.cfsan.fda.gov/~dms/ ConsumerLab: supplmnt.html http://www.consumerlab.com

National Center for American Botanical Council: Complementary and Alternative http://www.herbalgram.org Medicine, National Institutes of Health: Office of Dietary http://nccam.nih.gov Supplements, National Institutes of Health: Quackwatch: http://dietary- http://www.quackwatch.com supplements.info.nih.gov References:

Adusumilli PS, Ben-Porat L, Leung JM, Dzankic S, Manku K, Pereira M, Roesler D, & Yuan S. “The Prevalence Leitman M. “The Prevalence and Predictors of the Use and Predictors of Herbal of Alternative Medicine in Medicine Use in Surgical Presurgical Patients in Patients.” J Am Coll Surg Five California 2004; 198(4):583-590. Hospitals.” Anesth Analg 2001; 93(4):1062-1068. Ang-Lee MK, Moss J, & Yuan C. “Herbal Medicines and Petry JJ. “Surgically Perioperative Care.” JAMA Significant Nutritional 2001; 286(2):208-216. Supplements.” Plast Reconstr Surg; Ciocon JO, Ciocon DG, & 97(1):233—240. Galindo DJ. “Botanicals can affect surgical Pribitkin E & Boger G. outcomes and follow-up.” “Herbal Therapy: What Geriatrics 2004; Every Facial Plastic 59(9):20-24. Surgeon Must Know.” Arch Facial Plast Surg 2001; Dinehart SM & Henry L. 3:127-132. “Dietary Supplements: Altered Coagulation and Tessier DJ & Bash DS. “A Effects on Bruising.” Surgeon’s Guide to Dermatol Surg 2005; Herbal Supplements.” J 31(7-2):819-826. Surg Research 2003; 114(1):30-36. Heller J, Gabbay JS, Ghadjar K, Jourabchi M, et al. “Top-10 List of Herbal and Supplemental Medicines Used by Cosmetic Patients: What the Plastic Surgeon Needs to Know.” Plast Reconstr Surg 2006; 117(2):436-445.