صفحه 1:
صفحه 2:
Herbal Remedies and Drug
Interactions
JEANNA M. HICKS MSN, RN.
OCTOBER 2010
صفحه 3:
A Bit Of History
® The practice of herbal medicine is
as old as mankind itself
’Every human culture on every
continent has practices it in one
form or another
صفحه 4:
A Bit Of History
1 0 يوج
>» About 25% of Tease s drugs contain
ingredients isolated from plants
® Salicylic acid (Aspirin) is derived
from while willow bark
® Vincristine (A form of chemotherapy)
® Morphine is derived from the opium
poppy
صفحه 5:
A Bit Of History
<< "<< لح سس
In the US, botanical products are
now a $1.5 billion per year industry
It is estimated that 60 to 70% of
the American population is taking
botanical products
However less than one third of
these inform their medical
practitioners of their use
صفحه 6:
A Bit Of History
_ 0
© Because herbs are sold as food
supplements, companies are not
required to prove their efficacy.
® Side effects or interactions are also
not required to be determined or
disclosed.
®No government agency reviews these
products for safety, dosage, or quality.
صفحه 7:
A Bit Of History
In 1994, the 7 Supplement
and Health Education Act (DSHEA)
was enacted.
Created the new category of
dietary supplements.
This exempts herbal products from
the rigorous safety and efficacy
testing required by the FDA.
صفحه 8:
A Bit Of History
ا ل
»Manufacturers and distributors may
now market any herbal or botanical
product without prior approval by the
FDA as long as the label does not
claim effectiveness for the treatment
or prevention of a specific disease.
° Must have a disclaimer stating that
the FDA has not evaluated the
product.
صفحه 9:
A Bit Of History
سس 0-
© The manufacturer alone is
responsible for quality control.
© The burden of proof regarding
safety issues lies with the FDA.
صفحه 10:
A Bit Of History
سس 0-
® Many products are perfectly safe.
© However, 2621 adverse events
associated with dietary supplements,
including 101 deaths, were reported
to the FDA over a 5-year period.
صفحه 11:
Common Pitfalls
سس لاس
® Multiple ingredients are present
in the same bottle.
Products are sometimes
mislabeled or misidentified
® Potency can vary depending on
the climate and soil in which the
herbs are grown.
صفحه 12:
Common Pitfalls
© When a drug is prescribed, the
dosage and quality of the product is
more or less assured.
© This is not the case with herbs since
there is no real quality control.
صفحه 13:
Drug-Herb Interactions
سل( ایس
Pharmacokinetic interactions :
Having to do with absorption,
distribution, and metabolism.
’ Pharmacodynamic interactions:
Additive activity meaning that
certain herbs increase the actions
of certain medications.
صفحه 14:
, سل(
® Some herbs have hydrocollated
carbohydrate components such as
gums and mucliage.
These are soluble in water but
poorly absorbable.
® Examples are psyllium, rhubarb,
flaxseed, and marshmallow.
صفحه 15:
Absorption
ا ا غ2
© Bind to other drugs, particularly when
consumed in their whole or powdered
forms.
® Psyllium inhibits the absorption of
lithium.
® Rhubarb and aloe can cause diarrhea
which reduces the actions of drugs that
have a narrow therapeutic index
(digoxin, warfarin)
صفحه 16:
Pt Kinetic -t
Absorption
سس ©
®In order to prevent an herb from
binding with drugs, the drug should
be taken one hour before or two
hours after these herbal products.
صفحه 17:
Distribution
Ses
® Meadowsweet and black willow contain
pain reducing salicylates.
» These may displace highly protein
bound drugs such as warfarin and
carbamezepine (Tegretol).
® This increases the adverse effects of
these drugs.
° Do not take these products concurrently
صفحه 18:
When taken as an herb, licorice
decreases the metabolism of
corticosteroids.
» This leads to adverse and toxic
effects from the buildup of
corticosteroids.
® St. John’s wort increases the
metabolism of drugs in the liver.
صفحه 19:
Interactions و۳۳99
® Additive activity
® The hypnotic activity of
benezodiazepines is increased by
valerian.
® Anticoagulant action of warfarin
is enhanced by ginko
صفحه 20:
® Used by elderly persons because of
its ability to improve cognitive
function in persons with
Alzheimer’s and dementia.
© Reports of bleeding associated with
ginkgo use have been reported.
صفحه 21:
9 موف biloba)
® Patients ۳ from 33 to 78 years old
®One person was taking no other drugs
concurrently.
>» Others were taking aspirin, warfarin,
acetaminophen, or an ergotamine-
caffeine preparation concurrently.
® Episodes were both minor and major
®One death from cerebral hemorrhage.
صفحه 22:
® Caution patients who are also taking
Vitamin E, warfarin, aspirin, and low
molecular weight heparin about the
potential interactions with ginkgo.
If taking ginkgo, counsel them to
report any unusual bleeding, bruising,
or an new onset of dizziness,
headache, or blurred vision to their
healthcare provider.
صفحه 23:
Flaxseed (Linum usitatissimum)
سس سس رس سس
® Flax is one of the oldest cultivated plants
in the world.
°A bulk-producing, stool softening agent
that lowers levels of cholesterol,
triglycerides, and low-density lipoproteins.
® Binds to bile acids in the intestinal tract
and interferes with the reabsorption of
fats.
صفحه 24:
Flaxseed (Linum usitatissimum)
سس سس
© When soaked, flaxseeds can bind with
other drugs, especially cardiac
glycosides rendering them unabsorable.
® Take flaxseed wither two hours before
or two hours after taking other meds.
® Concurrent use with laxatives and stool
softeners should be avoided because of
possible potentiation of the laxative
effect.
صفحه 25:
Feverfew (Tanacetum parthenium)
0
® Most commonly used to reduce the
number and severity of migraine
headaches.
Inhibits platelet activity, so it should
not be taken concurrently with warfarin
or other drugs that affect clotting.
A member of the daisy family, it is
contraindicated in patients with allergy
to ragweed.
صفحه 26:
Ginger officinale) وه
e Used =a ۳۳۳۳ as an antinausea
and antispasmodic agent with good
results.
® Potent inhibitor of thromboxane
synthetase.
© Prolongs bleeding times.
If taking warfarin or other drugs
that affect platelet activity, avoid
ginger in tablet form.
صفحه 27:
Kava Kava (Piper methysticum)
لح 0 تس
® Relieves anxiety, nervousness,
and tension.
Does not affect alertness.
Acts as a dopamine antagonist.
® May increase tremor and
decrease response to anti-
Parkinsonian meds.
صفحه 28:
Kava Kava (Piper methysticum)
سس سس 9 سس
© Potentiates alcohol
© Potentiates tranquilizers
© Potentiates antidepressants
® Do not take any of these
concurrently with Kava
صفحه 29:
One of the most ۳ تب herbs in
the US for the treatment of
depression.
١ Current research shows that it
acts as a selective serotonin
reuptake inhibitor (SSRI)
® Because of this, concurrent use
with SSRIs is prohibited.
صفحه 30:
perforatum)
سس 9
® Patients should wait 2 weeks after taking
an SSRI before beginning St. John’s wort.
® Newest research suggests that it may act
in the cytochrome P-450 of the liver.
®Interferes with metabolism of certain
protease inhibitors used in the treatment
of HIV.
صفحه 31:
perfortum)
es ل
۶ Associated with photosensitivity.
© Do not take concurrently with other
photosensitizing herbs or drugs.
® If taking St. John’s wort, limit sun
exposure.
صفحه 32:
Implications For Anesthesia and Moderate
Sedation
® Morbidity secondary to botanical
product use may be more
prevalent in the perioperative
period because of multiple drug
use and increased physiological
susceptibility to adverse effects.
صفحه 33:
Implications For Anesthesia and Moderate
Sedation
سس )_(_---_---——
© The problem is complicated by
patients’ reluctance to report their
use of herbal medicines or dietary
supplements.
© 70% of presurgical patients failed to
disclose their use of such products
during routine preoperative
assessment.
صفحه 34:
Reasons For Not Reporting Use of Herbal
Medications
° A belief that because such products
are “natural,” they must be safe.
» Fear of how healthcare providers
would respond to self-medication.
© Fear that their physician may be
prejudiced against use of botanicals.
صفحه 35:
Adverse Effects
سس 0-
® Cardiac Instability
© Electrolyte disturbances
© Prolonged bleeding
° Excessive sedation
صفحه 36:
Cardiovascular Effects of Anesthesia
لصا
© Decreased myocardial contractility
® Decreased vascular smooth muscle
tone
® Arrhythmias
® Decreased cardiac output
® Avoid botanicals with blood pressure
altering or arrhythmogenic potential
صفحه 37:
7 Alkaloids
۰ 1 37 as ma-huang
»Common ingredient in many herbal
weight loss and energy boosters
® Often packaged in combination with
guarana (caffeine)
Use has been linked to hypertension,
palpitations, tachycardia, seizures,
stroke, heart attack, and sudden
death.
صفحه 38:
Ephedra Alkaloids
سس لاس
® Ephedra has been identified as
the herbal product with the
greatest potential for harm in
perioperative patients.
صفحه 39:
Prolonged Bleeding
© Feverfew
© Ginger
® Gingko
® Horse chestnut
© Pau d’arco
® Danshen
® Garlic
® Saw palmetto
صفحه 40:
Prolonged Bleeding
Gingko has been linked to a
spontaneous hyphema ina 70 year
old man who took 40mg of Gingko
extract twice a day along with 325
mg of Aspirin daily for one week.
Also bilateral subdural hematomas
in a 33 year old woman who took
60 mg of Gingko twice a day for
two years.
صفحه 41:
© Certain herbs increase INR
® Danshen
® Dong quai (Used primarily in
China but gaining popularity in
the US)
© Paparin
صفحه 42:
1 د Bleeding
© Certain herbs contain coumarin
or coumarin derviatives
® Angelica root
® Anise
® Licorice
© Red clover
© Rue
صفحه 43:
Bleeding ماو
۰ 2 activity
© Tumeric
® Clove
8 Onion
® Bromelain
® Willow bark
أع 16200175117 ©
صفحه 44:
Excessive Sedation
سس( اس
® Any herb with inherent sedative effects
can potentially delay emergence from
anesthesia.
® Sedative herbs include kava,
hawthorne and St. John’s wort.
© There has been a report of an
interaction between kava and
alprazolam that resulted ina
semicomatose state.
صفحه 45:
Excessive Sedation
سس( اس
® St. John’s wort is believed to have
some of the same effects as MAOIs.
® MAOIs may result in hypotension and
exaggeration of the respiratory and
CNS depressant effects of the
narcotics.
Because of this St. John’s wort should
be discontinued before a procedure
where narcotic analgesia is anticipated
صفحه 46:
Excessive Sedation
سس لایس
Valerian is a popular herb used as »>
a sleep aid and anxyiolytic.
® An extract of valerian containing
valeric acid has been shown to
prolong barbituate induced
sleeping time.
» Considered safe as a food additive
but has the potential for prolonging
sedation.
صفحه 47:
Echinacea
سس زاس
Used to boost the immune system
and guard against colds and flu.
May cause hepatotoxicity
especially when used with certain
hepatotoxic drugs.
Examples are methotrexate or
anabolic steroids.
صفحه 48:
Echinacea
® Many medications used during
anesthesia are metabolized in the liver.
® Hepatic dysfunction may be a risk in
certain patients who use echinacea.
صفحه 49:
ياه
Used to support overall health and
boost the immune system.
May also be used to increase
stamina, promote a sense of well-
being, control blood pressure, and
lower blood glucose levels.
Excessive use may cause
hypertension, and CNS stimulation.
صفحه 50:
Ginseng
effects.
May cause hypoglycemia in patients
taking insulin or oral diabetic agents.
» Monitor blood glucose levels closely
in patients who have been taking
ginseng.
>» May increase warfarin’s anticlotting
effect.
صفحه 51:
Guarana
سس )سس
as a CNS stimulant. ۱71660 «
> Contains a high concentration of
caffeine and is found in many
antifatigue products.
® If taken in combination with SNS
can cause cardiac arrest.
® May also decrease cerebral blood
flow
صفحه 52:
۲ baplientions
Patients are reluctant to reveal
their use of dietary supplements
to their health care providers.
’ Caregivers should be aware of
the many potential interactions
with patients undergoing
anesthesia or moderate sedation.
صفحه 53:
ما تست
Make sure to get an accurate,
nonjudgmental, and thorough
history of all medication use.
® Encourage the patient to discuss
their use of herbals.
This screening should be a routine
part of all preanesthetia screening.
صفحه 54:
® This screening should take place
far enough in advance to allow for
discontinuation of potentially
dangerous interactions.
® Patients should discontinue their
herbal preparations at least two
to three weeks before surgery.
صفحه 55:
Safe, effective care requires awareness of
all your patients’ use of herbal
supplements and knowledge of their
potential interactions with anesthestics
and drugs used during moderate sedation.
* Include all medications when reviewing
your patients’ meds before their
procedure.