New recommendations proposed for safe use of herbal medications by patients having surgery

A new study gives patients and their physicians specific recommendations for when to stop use of herbal medications prior to surgery. In the July 11, 2001, issue of JAMA, three University of Chicago physicians assess the interactions between herbs, anesthesia and surgery and suggest ways to reduce the associated risks.

Their goal is to provide a framework for physicians "practicing in the current environment of widespread herbal use" and to encourage patients and physicians to discuss the topic openly and in detail prior to surgery.

"While most of these substances appear to be safe for healthy people, for surgical patients they can affect sedation, pain control, bleeding, heart function, metabolism, immunity and recovery in ways that we are just beginning to understand," said study author Chun-Su Yuan, M.D., Ph.D., assistant professor of anesthesia and a member of the Tang Center for Herbal Medicine Research at the University of Chicago.

Studies suggest that as many as one-third of pre-surgical patients take herbal medications, but that many of those patients fail to disclose herbal use during pre-operative assessment, even when prompted. Further, physicians often are unsure what to do with the information.

"Physicians need to specifically ask patients about herbal medication use," said co-author Jonathan Moss, M.D., Ph.D, professor of anesthesia and critical care at the University. "Many patients think of herbal medications not as supplements but as drugs. Other patients may not want to admit to their use to physicians. But in order to optimize patient safety and pain control during and after surgery, we need to know what herbal as well as over-the-counter or prescription drugs each patient takes."

Despite their reputation as "mild" or "natural," herbal medications can speed up or slow down the heart rate, inhibit blood clotting, alter the immune system and change the effects and duration of anesthesia.

The American Society of Anesthesiologists has recognized the potential for adverse reactions and suggests that patients stop taking all herbal medications two weeks before surgery. This advice may be difficult to implement, however, since most preoperative evaluations occur only a few days prior to surgery.

So the Chicago researchers began to search for more targeted recommendations. Although there are more than 1,500 herbal medications sold in the United States, they focused on the eight most common herbs -- echinacea, ephedra, garlic, ginko, ginseng, kava, St. John's wort, and valerian -- which account for 50 percent of all single-herb preparations sold.

The authors found, first of all, a shortage of clinically relevant information. There were no randomized, controlled trials that evaluated the effects of prior herbal medicine use on the period immediately before, during and after surgery.

However, by reviewing the biology of the compounds as well as all studies, case reports, and reviews addressing the safety and pharmacological effects of these eight medications they came up with the following recommendations:

Effects of herbal medications and recommendations for discontinuation of use before surgery
Herb (other names)	Relevant effects	Perioperative concerns	Recommendations
Echinacea	Boosts immunity	Allergic reactions, impairs immune suppressive drugs, can cause immune suppression when taken long-term, could impair wound healing.	Discontinue as far in advance as possible, especially for transplant patients or those with liver dysfunction.
Ephedra (ma huang)	Increases heart rate, increases blood pressure	Risk of heart attack, arrhythmias, stroke, interaction with other drugs, kidney stones.	Discontinue at least 24 hours before surgery.
Garlic (ajo)	Prevents clotting	Risk of bleeding, especially when combined with other drugs that inhibit clotting.	Discontinue at least 7 days before surgery.
Ginko (duck foot, maidenhair, silver apricot)	Prevents clotting	Risk of bleeding, especially when combined with other drugs that inhibit clotting.	Discontinue at least 36 hours before surgery.
Ginseng	Lowers blood glucose, inhibits clotting,	Lowers blood-sugar levels. Increases risk of bleeding. Interferes with warfarin (an anti-clotting drug).	Discontinue at least 7 days before surgery.
Kava (kawa, awa, intoxicating pepper)	Sedates, decreases anxiety	May increase sedative effects of anesthesia. Risks of addiction, tolerance and withdrawal unknown.	Discontinue at least 24 hours before surgery.
St. John's wort (amber, goatweed, Hypericum, klamatheweed)	Inhibits re-uptake of neuro-transmitters (similar to Prozac)	Alters metabolisms of other drugs such as cyclosporin (for transplant patients), warfarin, steroids, protease inhibitors (vs HIV). May interfere with many other drugs.	Discontinue at least 5 days before surgery.
Valerian	Sedates	Could increase effects of sedatives. Long-term use could increase the amount of anesthesia needed. Withdrawal symptoms resemble Valium addiction.	If possible, taper dose weeks before surgery. If not, continue use until surgery. Treat withdrawal symptoms with benzodiazepines.

The authors caution that even this study has many gaps. Because they are regulated as dietary supplements rather than medications, herbal medications do not undergo the safety and efficacy testing required for new drugs. Further, unlike pharmaceuticals, there is no mechanism to track adverse events caused by herbs.

Herbal medications are even more difficult to study because the ingredients tend to vary enormously from maker to maker and even lot to lot. Potency and purity are inconsistent. Product labels are not always accurate.

In fact, Yuan, who studies the effects of ginseng, has had to work closely with a Wisconsin supplier to obtain consistent supplies of that herb for his research. Many physicians remain unaware of potential risks associated with herbal medications or how they interact with other drugs, note the authors. Medical schools are just beginning to teach students about herbal preparations and to study their effects systematically.

"If patients use them--and we know they do--then we need to know what to expect, how to prevent problems, especially during surgery, and how to respond when something goes wrong." added co-author Michael K. Ang-Lee, M.D., senior anesthesia resident at the University of Chicago.

Over Diagnosis – Over Treatment

The Hidden Pitfalls of Cancer Screening

This article by Maryann Napoli, Associate Director, Center for Medical Consumers

appeared in the April 2001 issue of American Journal of Nursing.

This year an estimated 182,800 women will be diagnosed with breast cancer, and about 40,800 will die of the disease. Every time I come across that ubiquitous statistic, I mentally add this missing one: And at least 32,000 women will be treated for a cancer that never would have killed them. The 32,000 figure represents over diagnosis, an under appreciated byproduct of mammography screening. In fact, over diagnosis is the risk of any screening procedure.

Subject a large group of symptom less people to mammography, computed tomographic (CT) scanning, or a Pap smear, and then biopsy the tiny abnormalities identified by these tests identify--in many cases, the cells will look like cancer under the microscope. But most would never have invaded other organs and become life-threatening, even if left untreated. Widespread acceptance of mammography screening, for example, has caused a dramatic increase in the diagnosis of ductal carcinoma in situ, which usually shows up as micro calcifications on a mammogram. Before the advent of mammography screening, this microscopic lesion within the milk duct was rarely seen beyond the autopsy table. Shockingly, DCIS was routinely treated with radical mastectomy in the 1970s when mammography screening first became available. Women were usually told by their

surgeons, "Be grateful your cancer was found early--your life is saved."

Providers now recognize that treating DCIS with a radical mastectomy was a form of therapeutic overkill. But over treatment and uncertainties persist, as most of these lesions are currently treated with lumpectomy plus radiation or simple mastectomy. Research now indicates that about 80% of all DCIS will never become invasive even if left untreated. Hence my 32,000 statistic, which represents 80% of the nearly 40,000 women diagnosed annually with DCIS. No test can accurately distinguish the DCIS that would become invasive; what's more, invasive is not necessarily synonymous with fatal. For example, invasive breast cancer developed in a small percentage of women whose DCIS was treated either with excision plus radiation or excision alone in a large ongoing clinical trial. Thus far, eight-year results from this trial show a breast cancer mortality rate of 1% in both groups. This is the same rate of mortality shown in much longer follow-up studies of women whose DCIS had been treated with mastectomy in the past. What's more, early detection of DCIS provides no advantage, according to 13-year follow-up results from the

Canadian National Breast Screening Study.

Pick a body part--lung, prostate, cervix, thyroid--look hard enough, and you'll find a "precancerous" abnormality. But not always to the benefit of the patient. In the not-so-distant past, precancerous cervical lesions were almost always treated with a hysterectomy because it was assumed that all would eventually become malignant. Now it is known that nine out of ten regress spontaneously. And widely publicized findings from a 1999 study showed increased lung cancer survival due to screening with the spiral CT scan. But this study has yet to prove a reduced rate of lung cancer mortality--the ultimate test of screening's value. Some doctors caution against premature acceptance of lung scanning because it may lead to unnecessary lung surgery; furthermore, the increased survival might be artificially inflated by the inclusion of scan-detected cancers would have never become invasive.

The PSA screening blood test for prostate cancer may be causing more harm than good. The majority of men diagnosed as result have the type of early prostate cancer that is so slow-growing, the majority will die of other causes. Most are treated with either prostatectomy or radiation therapy, each with a substantial rate of impotence and incontinence.

Cancer always kills, we are told, and early detection virtually guarantees cure. Simplistic half-truths--many of them emanating from the American Cancer Society--are at odds with research showing cancer to be heterogeneous, encompassing a broad spectrum of diseases that includes everything from permanently noninvasive to rapidly fatal.

Screening does save lives, but at a far more modest rate than the public has been led to believe. Whenever you find yourself telling your patients to be screened, don't forget to give them the whole story.