Herbal Remedies and Anaesthesia

Herbal Remedies and Anaesthesia

اسلاید 1: www.tabaye.ir

اسلاید 2: Herbal Remedies and AnaesthesiaAdrian WONGSpecialist Registrar Anaesthetics/ITUWessex Deanery

اسلاید 3: ContentsBackgroundExtent of useIssuesEfficacyRegulationsCommon herbal medicinesEffects on anaesthesiaGuidelines

اسلاید 4: Declaration of Interest

اسلاید 5: Foxglove (Digitalis purpurea)

اسلاید 6: Periwinkle

اسلاید 7: Purported use of herbal remediesAsthmaInflammatory Bowel DiseaseHIV/AIDSPsoariasisArthritisEczemaImpotenceLack of energyDepressionInsomniaGlandsObesityCancer

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اسلاید 9: Extent of UseUK4.8% of patient useannual expenditure - £1.6 billionAmerica12% general surgical55% cosmetic surgery$27 billionEurope40% of breast cancer patients20% of lung cancer patientsWorld Health Organisation80% of world population

اسلاید 10: The IssuesHerbal medicines are ‘safe’Natural does not equal safeHerbal does not equal benign40% of population - “safe” (MORI 2008)Lack of disclosure/enquiry Efficacy and evidence-based practice

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اسلاید 12: National Institute of Medical Herbalists

اسلاید 13: The IssuesHerbal medicines are ‘safe’Natural does not equal safeHerbal does not equal benign40% of population - “safe” (MORI 2008)Lack of disclosure/enquiry Efficacy and evidence-based practiceFunding/Product regulation

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اسلاید 15: regulation and licensing of herbal products

اسلاید 16: regulation and licensing of herbal productsLack of international consensusHerbal products marketed as food supplements or cosmeticsMedicine Act 1968Exemption from statutory controlEU Medicines Directive 1994Traditional Herbal Medicinal Products Directive (THMPD) 2004

اسلاید 17: UK legislationUnlicensed herbal remediesSupplied to individual after face to face consultationRegistered traditional herbal medicine (2005)Specific standards of safety and quality“Agreed indication based on traditional use”Licenced Herbal RemediesWhen seeking a licence for herbal medicines, many companies have had difficulty meeting conventional requirements to prove efficacy. This was one factor that led to the introduction of the Traditional Herbal Registration Scheme and many products are likely to follow that regulatory route. 

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اسلاید 19: MHRA - Safeguarding public health report70 suspected adverse drug reports relating to herbal remediesHandful of identified UK deathsSteady flow of cases entailing very serious illness e.g. kidney or liver failureBUT increasing study and scientific understanding of herbal medicines would be expected to improve safety profile

اسلاید 20: BAD MEDICINE - More cases of adverse side effects (The Singapore Straits Times, 11 October 2011)

اسلاید 21: Anaesthetic Concerns“There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we dont know. But there are also unknown unknowns. There are things we dont know we dont know.”

اسلاید 22: Anaesthetic concernsUnknown effects of herbal remediesPotential interactions with drugsPre-operativeIntra-operativePost-operativeEffects on patient physiology

اسلاید 23: most common herbal medicines in the UKEchinaceaGingerSt Johns WortGarlicSaw palmettoEphedraGinsengGingkoValerianKava Kava

اسلاید 24: Echinacea (Echinacea Pururrea)UsesCommon coldWounds/BurnsUTIURTIPossible side effects/interactionsHepatotoxicityDecrease efficacy of corticosteroids

اسلاید 25: St Johns Wort (Hypericum perforatum)UsesDepressionAnxietyPossible side effects/interactionInduction of P450 3A4Serotonin syndromeDecrease efficacy of anti-HIV drugsProlong effect of anaesthesiaOrgan rejection due to reduce immunosurpressants

اسلاید 26: Ephedra (Ephedra Sinica)UsesAntitussiveWeight loss supplementPossible side effects/interactionsArrhythmiasEnhanced sympathomimeticMAOIDeath

اسلاید 27: Garlic (Allium sativum)UsesLipid loweringBlood pressure controlAntiplatelet/AntithromboticAntioxidantsPossible side effects/interactionsPotent inhibitor of thromboxane synthetaseIncreased bleeding timeEpidural haematoma

اسلاید 28: ginseng (panax ginseng)UsesAntioxidantsEnergy level enhancerExam successPossible side effects/interactionsGinseng abuse syndromesleepinesshypertoniaoedemaInteractions with antipsychoticsAntiplatelet propertiesIncreased bleedingHypoglycaemiaCVS instability

اسلاید 29: Canadian Anesthesiologists Society

اسلاید 30: Can I take herbal and dietary supplements?The use of herbal medicines is common. Herbal medicine is defined as a plant-derived product used for medicinal and health purposes; commonly used herbal supplements include echinacea, garlic, ginseng, ginkgo biloba, St John’s wort and valerian. Herbal medicines can have a variety of effects on surgery and interact with anaesthetic drugs. Ginkgo, ginseng and garlic all impair blood clotting and promote excessive bleeding. Prolongation of action of anaesthesia drugs can occur with valerian and St John’s wort. Herbal dietary supplements should be stopped two weeks prior to surgery. Fish oil supplements are also popular as a dietary supplement. They have potential in reducing cholesterol and hence may reduce the risk of heart attack and stroke. They also have anti-inflammatory properties and may be used to treat arthritis. The Therapeutic Goods Administration says that omega 3, which is found in fish oil, has no effect on bleeding and can be continued before surgery.

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اسلاید 33: RCoA Patient Information LeafletIt is important for you to bring a list of:all the pills, medicines, herbal remedies or supplements you are taking, both prescribed and those that you have purchased over the counterIf you are taking medicines, you should continue to take them as usual, unless your anaesthetist or surgeon has asked you not to. For example, if you take drugs to stop you getting blood clots (anticoagulants), aspirin, drugs for diabetes or herbal remedies, you will need specific instructions.

اسلاید 34: British association of Day Surgery (BADS)

اسلاید 35: british Association of Day Surgery (BADS)

اسلاید 36: “Current” UK practiceMcKenzie and Simpson - Survey of AAGBI members (2005)90% - never or seldom asked about herbal medicines65% - thought there could be potential harm75% - perioperative usage of herbal medicine is important“Unequivocally” poor knowledgeHogg and Foo - Survey of all anaesthetic dept (2010)7.3% have perioperative herbal medicine policy98.3% did not have specific section documenting herbal medicine use15.7% routinely asked about herbal medicine useHighly variable advice given (not in accordance to existing guidelines)

اسلاید 37: ConclusionThe use of herbal remedies in patients undergoing anaesthesia is under-reported.Side-effects and herb-drug interactions can be unknown.Elective surgery - all herbal medication should be stopped for between 2 and 3 weeks prior.Emergency surgery - carry on.Improved education and knowledge crucial.

اسلاید 38: ReferencesMHRA Public Health Risk with Herbal Medicines: An Overview (2010)Hogg LA and Foo I. Management of patients taking herbal medcines in the perioperative period: a survey of practice and policies within Anaesthetic Departments in the UK. EJoA 2010; 27: 11-15.American Society of Anesthesiolgist. What You Should Know About Your Patients’ Use of Herbal Medicines and Other Dietary Supplements (2010).McKenzie AG and Simpson KR. Current management of patients taking herbal medicines: a survey of anaesthetic practice in the UK. EJoA 2005; 22: 597-602.Cheng B, Hung CT, Chiu W. Herbal medicine and anaesthesia. HKMJ 2002; 8: 123-130.Skinner CM and Rangasami J. Preoperative use of herbal medicines: a patient survey. BJA 2002; 89(5): 792-795. Batra YK and Rajeev S. Effect of common herbal medicines on patients undergoing anaesthesia. IJoA 2007; 51(3): 184-192.Hodges PJ and Kam PCA. The peri-operative implications of herbal medicines. Anaesthesia 2002; 57: 889-899.Ang-Lee M, Moss J and Yuan CS. Herbal Medicines and Perioperative Care. JAMA 2001; 286: 208-216.