Tuesday, June 12, 2007

Herbal Suppliments and Plastic Surgery

Many people take herbal supplements these days for many reasons. Chondroitin and glucosamine (My husband swears by them. My 14 yr old labrador, Girlfriend takes them.) are supplements that are taken together. Both are components of the normal cartilaginous matrix and are used to treat osteoarthritis. Echinacea is often used for prevention and treatment of viral and bacterial infections. It has been shown that echinacea, both in vitro and in vivo, possessing immunostimulation properties because of enhancing phagocytosis and nonspecific T-cell stimulation. Ginkgo biloba has become widely used for its efficacy in treating peripheral and cerebral circulatory disturbances, including claudication and memory impairment (e.g., Alzheimer’s Disease). Garlic is taken to aid in the reduction of atherosclerosis and hypercholesterolemia. It is also taken as an antioxidant, an antibiotic, a diuretic, an antitussive, to remove “evil” spirits, strengthen the stomach and spleen, and relieve diarrhea. Ephedra is used to promote weight loss, increase energy, and treat respiratory tract conditions, such as asthma and bronchitis. It is contained in many over-the-counter “slimming preparations.”

Many people take these suppliments with no thought of "side effects" or interactions with their prescriptions. Chondrotin and heparin are similar in chemical composition and researchers speculate that bleeding complications may arise from chondroitin use, particularly when used in combination with other blood-thinning medications. Because echinacea does have immunostimulation properties, it is contraindicated in systemic and autoimmune diorders. The immunostimulatory effects can offset the immunosuppressive actions of corticosteroids and cyclosporin. Side effects of echinacea also include GI upset, headache, dizziness, and potential allergic reactions. Prolonged use of ecchinacea (8 weeks) has been documented to cause tachyphylaxis through an unknown mechanism. Echinacea is also an inhibitor of cytochrome P450, 3A4, and sulfotransferase and can potentiate the toxicity of drugs that are metabolized by these pathways (benzodiazepines, barbiturates). Gingko biloba has the ability to inhibit platelet-activation factor and possesses an anti-inflammatory effect. Gingko biloba has induced spontaneous hyphema (bleeding from the iris in the anterior chamber of the eye), subarachnoid hemorrage, and spontaneous bilateral subdural hematomas. It should not be used with other anticoagulants. Other side effects of gingko include headache, GI symptoms, and allergic skin reactions. The active ingredient in garlic is allicin, which has been reported to inhibit platelet aggregation. It should not be taken with other coagulation inhibitors (e.g. warfarin, heparin, nonsteroidal anti-inflammatory inhibitors, and aspirin). Other side effects of garlic include halitosis, nausea, hypotension, headache, bloating, and possible allergic reaction. Ephedrine, a chemical contained in ephedra, has medical uses, mostly in operating rooms and intensive care units. It is sympathomimetic agent and causes positive inotropic and chronotropic responses to raise blood pressure and heart rate, respectively; dilates bronchioles; and increases metabolic rate. Side effects such as psychiatric disturbances, heart attack, cardiac dysrhythmias associated with volatile general anesthetic agents (e.g., halothane) and cardiac glycosides (e.g., digitalis), stroke, and even death. Of note, patients taking ephedra under general anesthesia can have severe hypotension that can be controlled with phenylephrine instead of ephedrine.

It has become important to ask patients about suppliments. It is important to caution them to stop them prior to surgery. Gingko biloba should be discontinued at least 36 hours before surgery. Garlic should be discontinued at least 1 week prior to surgery. The exact time for chondrotin is unknown, so recommendations are based on guidelines from the American Society of Anesthesiologists, which advises that all herbal medicines without formal study be discontinued at 2 to 3 weeks before an elective surgical procedure. Echinacea should be discontinued 2-3 weeks prior to surgery. Ephedra should be discontinued at least 24 hours prior to surgery.

Herbal suppliments are being studied as medications, but still too much is unknown. If you are the patient, tell your doctor which ones you are taking. If you are scheduled for an elective surgery, stop taking the suppliments for 2-3 weeks prior to surgery.

Some references:
1. Kleiner, S. M. The true nature of herbs. Phys. Sports Med. 23: 13, 1995.

2. Eisenberg, D. M., and Kessler, R. C. Unconventional medicine in the United States: revalence, costs and patterns of use. N. Engl. J. Med. 328: 246, 1993.

3. Kaye, A. D., Kucera, I., and Sabar, R. Perioperative anesthesia clinical considerations of alternative medicines. Anesthesiol. Clin. North Am. 22: 125, 2004

4. Ang-Lee, M. K., Moss, J., and Yuan, C. Herbal medicines and perioperative care. J.A.M.A. 286: 208, 2001

5. Heller, Justin B.S.; Gabbay, Joubin S. M.D.; Ghadjar, Kiu; Jourabchi, Mickel; O'Hara, Catherine B.A.; Heller, Misha B.S.; Bradley, James P. M.D. Top-10 List of Herbal and Supplemental Medicines Used by Cosmetic Patients: What the Plastic Surgeon Needs to Know. Plastic & Reconstructive Surgery. 117(2):436-445, February 2006.

6. Broughton, George II M.D., Ph.D., Col., M.C., U.S.A.; Crosby, Melissa A. M.D.; Coleman, Jayne M.D.; Rohrich, Rod J. M.D. Use of Herbal Supplements and Vitamins in Plastic Surgery: A Practical Review. Plastic & Reconstructive Surgery. 119(3):48e-66e, March 2007.

1 comment:

Coffee Addict said...

Thanks for the informative post. I have let a couple of elderly patients slip through to surgery with glucosamine on board. It is easy to overlook such things in a regular H&P especially when one is in a hurry to go through a long pre-admissions list in a public hospital.