Herbal therapy: what every facial plastic surgeon must know

Herbal medicine (phytomedicine) uses remedies possessing significant pharmacological activity and, consequently, potential adverse effects and drug interactions. The explosion in sales of herbal therapies has brought many products to the marketplace that do not conform to the standards of safety and efficacy that physicians and patients expect. Unfortunately, few surgeons question patients regarding their use of herbal medicines, and 70% of patients do not reveal their use of herbal medicines to their physicians and pharmacists. All surgeons should question patients about the use of the following common herbal remedies, which may increase the risk of bleeding during surgical procedures: feverfew, garlic, ginger, ginkgo, and Asian ginseng. Physicians should exercise caution in prescribing retinoids or advising skin resurfacing in patients using St John's wort, which poses a risk of photosensitivity reaction. Several herbal medicines, such as aloe vera gel, contain pharmacologically active ingredients that may aid in wound healing. Practitioners who wish to recommend herbal medicines to patients should counsel them that products labeled as supplements have not been evaluated by the US Food and Drug Administration and that no guarantee of product quality can be made.     

The peri-operative implications of herbal medicines

An increasing number of patients are taking herbal medicines such as echinacea, garlic, ginkgo biloba, ginseng, St John's Wort, valerian, ephedra, kava, grapefruit juice and ginger. Although these herbal medications are considered 'natural' products that may have some benefits, adverse effects such as increased bleeding tendencies and drug interactions are associated with their use. Surgeons and anaesthetists may be unaware of their patients' use of these medications because it is common for patients not to disclose their use of this form of medication, and both surgeons and anaesthetists often fail to enquire about their use. Anaesthetists and surgeons must be familiar with the effects of herbal medicines and should specifically enquire about the use of herbal medicines during pre-operative assessment. Currently available data suggest that all herbal medicines should be ceased 2 weeks before surgery.     

A surgeon''s guide to herbal supplements

The use of herbal supplements has steadily increased in the United States over the last decade. Despite the increased awareness of alternative therapies by the government and lay public, many physicians do not ask their patients about their use of these alternative medications. In addition, many physicians are unaware of the possible side effects that may occur when a patient consumes these substances. Considering a number of these supplements have been associated with adverse reactions in the perioperative period, it is important for a surgeon to understand all of the herbs a patient may be taking. The purpose of this article is to discuss the growing trend of herbal use among surgical patients and give the reader some background on the most commonly used herbs.     

Perioperative considerations for the patient on herbal medicines.

Herbal medicines have enormous presence in the United States health care system. There is an increasing trend towards reimbursement of herbal medicines by insurance companies, which further encourage their utilization. Herbs are listed under the "supplement" category by the Food and Drug Administration. The Dietary Supplement and Health Education Act signed into law in October 1994, requires no proof of efficacy, no demonstration of safety, and sets no standards for quality control for the products labeled as "supplements" thereby increasing the risk of adverse effects of these herbs. The United States has experienced an epidemic of over-the-counter "natural" products over the last two decades; but there is little motivation for the manufactures to conduct randomized, placebo-controlled, double-blinded clinical trials to unequivocally prove the safety and efficacy of these drugs. Physicians, irrespective of their specialty, should not underestimate the potential risks associated with the use of herbs as reports indicate that within the last two decades, more than 100 herbogenic deaths have occurred, many serious complications have been reported, patients have required renal dialysis, renal transplantation and hepatic transplantation after taking botanicals. Internists must inquire about the patient's use of herbal products. In addition, the education of each patient regarding the serious, potential drug-herb interactions should be a routine component of preoperative assessment. The American Society of Anesthesiologists (ASA) recommends that all herbal medications should be discontinued 2-3 weeks prior to an elective surgical procedure. If the patient is not sure of the content of the herbal medicine, he/she should be urged to bring the container so that an attempt can be made to review the contents of the preparation. While such an action holds some promise in the elective setting, emergency care should be based on a thorough drug-intake history from the patient or a relative, if possible. Medical research and medical literature in general has not addressed this new group of health supplements, despite the fact that many of these herbs have the potential to cause serious health problems and drug interations. There is a need to conduct scientific clinical trials to study the anesthetic drug responses to commonly used neutraceutical agents.     

The Impact of Herbal Medicines on Dermatologic Surgery

BACKGROUND: In recent years herbal medicines and supplements have become increasingly popular. With their increased popularity, more publications are warning about the potential harmful effects of some of these products. OBJECTIVE: To present scientific evidence of the benefits and surgical risks of herbal products. METHODS: A Medline search and review of the literature was performed. RESULTS: Many herbal medicines are relevant in dermatologic surgery since Ginkgo biloba, garlic, ginger, ginseng, feverfew, and vitamin E may increase the risk of bleeding, and ephedra may potentiate the side effects of epinephrine. CONCLUSION: Dermatologists should be aware of these herbal products and their uses. Many of these products prescribed by alternative medicine physicians or purchased over the counter should be discontinued prior to dermatologic surgery to minimize the risk of surgical complications.     

Asian traditional medicine for erectile dysfunction

Asian cultures have different belief systems and health seeking behaviors and they believe strongly in the holistic approach to medicine and health. Asian traditional medicine emphasizes the importance of prevention of illnesses and development of natural resistance to disease, and thus believes in the promotion of general well-being. Asian traditional medicine predominates in the Asian countries, and it is used for the treatment of various physical and mental illnesses. It has also been used for the treatment of sexual dysfunction, namely erectile dysfunction (ED) in men. However, the majority of research into the safety and efficacy of medicinal plants or herbs are mainly based on animal models and very limited studies on humans, probably due to negative clinical trial results, drug interactions or toxic reactions. It is generally very difficult to identify the actual ingredient of a herbal medication that is effective for the treatment of ED. Various traditional medicines, such as herbal medicine or animal products, which are used for the treatment of ED are discussed in this paper. It is important for physicians treating ED to know about the various traditional medicines and the perception and beliefs of ED sufferers regarding traditional therapies. Physicians should understand the potential associated health risks of various traditional medicines because of possible adverse events, drug interactions, contamination or adulteration of the medicine. Finally, practitioners treating ED should recognize and emulate the emphatic and approachable qualities of traditional therapists.     

Perioperative anesthesia clinical considerations of alternative medicines

The presence of nutraceutical agents in the United States health care system dictates the need for a general understanding of these agents by all physicians and health care providers. Increasing trend toward reimbursement of herbal medicines by the insurance companies and managed care organizations have further encouraged their use. Because herbs are listed under the "supplement" category by the Food and Drug Administration, the Dietary Supplement and Health Education Act establishes no protocol for standardization of the products labeled as "supplements" thereby increasing the risk for adverse effects associated with the use of these products. Moreover, there is little motivation for the manufacturers to conduct randomized, placebo-controlled, double-blinded safety and efficacy trials on these drugs. Reports indicate that within the last 2 decades,more than 100 herbogenic deaths have occurred [100]. Many serious complications have been reported, including renal failure and need for renal or hepatic transplantation after taking nutraceuticals [101-107].The anesthesiologists should have a detailed knowledge and understanding of the potential risks and purported benefits of herbal medicines and should thoroughly inquire about patient's use of herbal products [108- 11 ]. In addition,the education of each patient regarding the serious, potential drug-herb inter-actions should be a routine component of preoperative assessment. The American Society of Anesthesiologists (ASA), suggests that all herbal medications should be discontinued 2 to 3 weeks before an elective surgical procedure. If the patient is not sure of the contents of the herbal medicine, he or she should be urged to bring the container so that the anesthesiologist can review the contents of the herb or preparation. Although this idea holds some promise in the elective-care settings, anesthetic care in emergency settings should be based on a thorough drug-intake history from the patient or a relative, if possible.Unfortunately, the anesthesia literature has not addressed this new group of health supplements, despite many of these drugs having the potential to cause serious health problems and drug-herb interactions. There is a need to conduct additional scientific clinical trials to study the anesthetic responses to commonly used nutraceutical agents.     

Inadequate involvement of nephrologist/dialysis physicians in transplantation: based on the findings of a survey of transplant recipients

The number of kidney transplantations(KTx) performed annually in Japan remains small even after enactment of the "Organ Transplant" law. One of the reasons for this paucity of KTx might be because most nephrologists or dialysis physicians who provide medical care to potential transplant candidates have little knowledge of KTx and are seldom involved in the care of recipients and donors. The extent to which Japanese physicians participate in KTx has not been well studied. We sent questionnaires to the 212 kidney transplant recipients who have received an allograft at Tokyo Women's Medical University and conducted a survey to examine the extent to which nephrologists or dialysis physicians are involved in KTx. There were 149 recipients, consisting of 95 males and 54 females with an average age of 46.5 years, who responded to the questionnaire. Only 23% of the patients had considered KTx before dialysis access placement. Lack of information on KTx was suspected for this delay in considering KTx. In fact, only 18% of patients were informed about KTx by their nephrologists before starting dialysis and as many as 49% did not receive any information at all. Forty-eight percent of the patients were not provided with the information even on registration for a cadaveric transplant list by their physicians. Only 20% of the patients received some information about KTx through their nephrologists. On the other hand, nearly 100% of patients think it is essential for nephrologists or dialysis physicians to provide information on KTx especially before the initiation on dialysis access. In addition, almost all of the patients would prefer nephrologists or a dialysis physician to participate in the care of transplant patients from the stage of preoperative evaluation through the post-transplant follow-up period. In conclusion, nephrologists or dialysis physicians have not provided information on KTx to their patients appropriately and most of the transplant recipients expect them to participate in KTx. Nephrologists and dialysis physicians need fundamental knowledge about KTx so that they can provide appropriate information to patients with end-stage renal disease.     

Gingko biloba: a case report of herbal medicine and bleeding postoperatively from a laparoscopic cholecystectomy

An increasing variety of alternative health care products (defined as "over-the-counter," nonprescribed herbal medicines) are taken by patients for a plethora of reasons. Unfortunately these self-prescribed remedies are seldom considered by the patient to be medications and as a result it has been noted that 70 per cent of patients do not reveal herbal use to their allopathic practitioners or hospital personnel. The rapid growth of this herbal self-therapy has important implications for the practice of surgery. A case of post-laparoscopic cholecystectomy bleeding in a patient taking Gingko biloba is reported. This preparation has been reported to cause spontaneous bleeding and may interact with anticoagulants and antiplatelet agents. Other herbal medicines have also been associated with potential increased bleeding including garlic, feverfew, ginger, and ginseng. It is vital for surgeons to be apprised of all substances ingested by patients, to be cognizant of their potential adverse effects and drug interactions, and to be familiar with their therapeutic modality, all of which will help to optimize therapeutic approaches and improve patient outcome.     

Long-term Management of the Liver Transplant Patient: Recommendations for the Primary Care Doctor

No official document has been published for primary care physicians regarding the management of liver transplant patients. With no official source of reference, primary care physicians often question their care of these patients. The following guidelines have been approved by the American Society of Transplantation and represent the position of the association. The data presented are based on formal review and analysis of published literature in the field and the clinical experience of the authors. These guidelines address drug interactions and side effects of immunosuppressive agents, allograft dysfunction, renal dysfunction, metabolic disorders, preventive medicine, malignancies, disability and productivity in the workforce, issues specific to pregnancy and sexual function, and pediatric patient concerns. These guidelines are intended to provide a bridge between transplant centers and primary care physicians in the long-term management of the liver transplant patient.     

Incorporating patient preferences into orthopaedic practice: should the orthopaedic encounter change?

The issues concerning treatment decision-making are that often options for treatment lead to uncertain outcomes (benefits and risks) at the individual patient level and that both patients and physicians might value these outcomes differently. There are three main approaches commonly used to describe treatment decision-making including paternalistic, shared and informed decision-making. The challenge and responsibility of physicians is to effectively communicate to patients that they should feel welcome to participate in decision-making through whichever approach seems suitable to them. Changes in laws governing the ethics of medical practice mandate a more comprehensive decision-making tactic requiring a two-way flow of information between patient and physician. The key to information exchange lies in evoking patient preferences by informing the patient of the benefits and risks associated with each treatment option. Decision aids have been developed in a variety of forms to facilitate this transfer of information about available treatment alternatives in as unbiased fashion as possible. We believe that treatment options presented should include not only those available by the particular physicians at that institution but also those available at outside institutions and within other healthcare systems. We discuss barriers for physicians who wish to encourage patient participation such as the power differential that exists between patients and physicians, factors related to health policy, and those unique to surgery. We believe that investigation is necessary to understand how the differences between types of medical practices, or even within a medical field, will influence the importance that patients attach to having their values and preferences considered during treatment decision-making and to evaluate how this importance changes as the severity of adverse events associated with treatment outcomes changes. We feel that it is important for physicians and surgeons to begin to think about these issues and how they might investigate potential resolutions for incorporating patient values and sharing their own preferences for treatment options with their patients during the orthopaedic encounter.     

Three cases of posterior reversible encephalopathy syndrome with chronic kidney disease triggered by infection

Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological condition with diverse neurological manifestations. Many clinical factors are known causes of PRES, but only a few cases of PRES have been reported in patients with chronic kidney disease (CKD) and infectious disease. We describe three cases of PRES in patients with CKD triggered by various infectious diseases. Characteristic hyperintense signals on magnetic resonance imaging (MRI) indicating reversible vasogenic brain oedema in various parts of the brain were observed. To explain the pathophysiology of PRES, the hypertension/hyperperfusion and hypoperfusion/vasoconstriction theories have been proposed. Patients with CKD have many complications including uraemia, hypertension, and immunosuppression. Therefore, physicians should recognize that patients with CKD are at high risk of PRES triggered by infectious diseases and promptly diagnose PRES because immediate treatment of the triggers often leads to complete resolution.     

Alternative Medicine and Nephrology Series Editor: Naomi V. Dahl: Herbs and Supplements in Dialysis Patients: Panacea or Poison?

The safety of herbal remedies and supplement use is of particular concern in patients with renal disease, and reliable information is not always easy to find. Predialysis patients may be drawn to complementary and alternative medicine (CAM) because they believe it can help prevent the progression of their renal disease. The purpose of this series of articles on alternative medicine for nephrologists is to address concerns and issues specific to CAM use in dialysis patients and to provide a guide to reliable sources of information. This introductory article emphasizes safety issues with a focus primarily on herbal medicine. Lack of regulation means that patients may not actually be taking what they think they are. Independent laboratory analyses have shown a lack of stated label ingredients and many instances of supplements and traditional remedies being contaminated with pesticides, poisonous plants, heavy metals, or conventional drugs. While certain supplements are always unsafe (carcinogenic, hepatotoxic, glandular extracts), others are specifically contraindicated in renal disease. Supplement use may be especially hazardous in renal disease because of unpredictable pharmacokinetics, drug interactions, negative effects on kidney function, nephrotoxicity, hemodynamic alterations, unpredictable effects on blood pressure or blood glucose, or potentiation of electrolyte abnormalities. There are no data on potential dialyzability of either active compounds, or their potentially active or toxic metabolites. Many supplements contain metal ions and other minerals. Transplant recipients are also at risk from potential unpredictable effects on immune function. Recommendations and information resources are listed.     

Antiplatelet drugs: a review of their pharmacology and management in the perioperative period

In the normal course of the delivery of care, anesthesiologists encounter many patients who are receiving drugs that affect platelet function as a fundamental part of primary and secondary management of atherosclerotic thrombotic disease. There are several antiplatelet drugs available for use in clinical practice and several under investigation. Aspirin and clopidogrel (alone and in combination) have been the most studied and have the most favorable risk-benefit profiles of drugs currently available. Prasugrel was recently approved for patients with acute coronary syndrome undergoing percutaneous interventions. Other drugs such as dipyridamole and cilostazol have not been as extensively investigated. There are several newer investigational drugs such as cangrelor and ticagrelor, but whether they confer significant additional benefits remains to be established. Management of patients who are receiving antiplatelet drugs during the perioperative period requires an understanding of the underlying pathology and rationale for their administration, pharmacology and pharmacokinetics, and drug interactions. Furthermore, the risk and benefit assessment of discontinuing or continuing these drugs should be made bearing in mind the proposed surgery and its inherent risk for bleeding complications as well as decisions relating to appropriate use of general or some form of regional anesthesia. In general, the safest approach to prevent thrombosis seems to be continuation of these drugs throughout the perioperative period except where concerns about perioperative bleeding outweigh those associated with the development of thrombotic occlusion. Knowledge of the pharmacodynamics and pharmacokinetics of antiplatelet drugs may allow practitioners to anticipate difficulties associated with drug withdrawal and administration in the perioperative period including the potential for drug interactions.     

The prevalence and predictors of the use of alternative medicine in presurgical patients in five California hospitals

We measured the prevalence and predictors of the use of alternative medicine supplements in surgical patients by way of a self-administered questionnaire in consecutive patients > or = 18 yr old awaiting elective noncardiac surgery at five San Francisco Bay Area Hospitals. A total of 2560 patients completed the study survey (60% response rate). Of these patients, 39.2% admitted to using some form of alternative medicine supplements, of which herbal medicine was the most common type (67.6%). Of those who admitted to taking alternative medicine supplements, 44.4% did not consult with their primary physicians, and 56.4% did not inform the anesthesiologists before surgery regarding their use of these products; 53% of the patients ceased the use of these products before surgery. Multivariate logistic regression analysis revealed the following variables to be associated with the preoperative use of herbal medicine: female sex (odds radio [OR] 1.42, confidence interval [CI] 1.17-1.72), age 35-49 yr (OR 1.25, CI 1.02-1.53), higher income levels (OR 1.85, CI 1.50-2.27), Caucasian race (OR 1.34, CI 1.07-1.67), higher level of education (OR 1.35, CI 1.10-1.65), problems with sleep (OR 1.32, CI 1.05-1.66), problems with joints or back (OR 1.27, CI 1.04-1.56), allergies (OR 1.48, CI 1.21-1.82), problems with addiction (OR 1.90, CI 1.25-2.89), and a history of general surgery (OR 1.25, CI 1.03-1.52). In contrast, diabetes mellitus (OR 0.55, CI 0.36-0.86) and the use of antithrombotic medications (OR 0.57, CI 0.38-0.87) were associated with decreased odds of the use of herbal medicines. We concluded that the use of alternative medicine supplements by surgical patients is prevalent. Documentation of the use of these products is critical to determine the potential of drug or anesthetic interactions in the perioperative period. IMPLICATIONS: The use of alternative medicine supplements by presurgical patients is prevalent. Documentation of the use of these products is critical to determine the potential of drug or anesthetic interactions in the perioperative period.     

Herbal medicine use by children presenting for ambulatory anesthesia and surgery

BACKGROUND: Herbal medicine use has become increasingly popular throughout the world. Some of these agents may have serious interactions with anesthetic drugs. Children may potentially be more vulnerable to such interactions because of altered drug handling. While the prevalence of herbal medicine use by children with some chronic illnesses has been estimated, the incidence of this in a population of otherwise healthy children admitted for minor ambulatory anesthesia and surgery is currently unknown. METHODS: Parents of 601 children presenting consecutively for ambulatory surgery were asked to complete a questionnaire detailing administration of herbal medicines to their child. RESULTS: This study identified that 6.4% of children were currently taking an herbal preparation; while a further 10.1% had taken an herbal medicine in the past. Echinacea and arnica were the commonest used herbal remedies. A significant number of children had taken agents which may interact with anesthesia and surgery: St John's Wort, valerian, garlic and gingko. Information on herbal medicines was mostly obtained by parents from nonmedical sources. CONCLUSIONS: A total of 16.6% of children had a current or past history of ingestion of herbal medicines. This finding may have implications for the perioperative management of children presenting for day-case surgery.     

Herbal medicines and interactions with anesthetic agents

Herbal medicines have enormous presence world wide. Herbs are listed under the "supplement" category by the food and Drug Administration in the USA. The Dietary Supplement and Health Education Act signed into law in October 1994, requires no proof of efficacy, no demonstration of safety, and sets no standards for quality control for the products labeled as "supplements" thereby increasing the risk of adverse effects as quantities of active agents are unregulated. The United States has experienced an epidemic of over-the-counter "natural" products over the last two decades; but there is little motivation for the manufacturers to conduct randomized, placebo-controlled, double-blinded clinical trials to unequivocally prove the safety and efficacy of these drugs. Physicians must enquire and be aware of herbal/drug interactions. In addition, patient education of the potential interactions should be a routine component of preoperative assessment. The American Society of Anesthesiologists (ASA) recommends that all herbal medications should be discontinued 2-3 weeks prior to an elective surgical procedure. If the patient is not sure of the contents of the herbal medicine, he/she should be urged to bring the container so that an attempt can be made to review the contents of the preparation. While such an action holds some promise in the elective setting, emergency care should be based on a thorough drug-intake history from the patient or a relative, if possible. Medical research and medical literature in general has not addressed this new group of health supplements, despite the fact that many of these herbs have the potential to cause serious health problems and drug interactions. There is a need to conduct scientific clinical trials to study the anesthetic drug responses to commonly used neutraceutical agents.     

The role of the pharmacist in the management of the operating room

Pharmacy services have traditionally consisted of dispensing, provision of drug information and inventory management practices. Pharmacist's impact on the implementation of medication safety standards, drug therapy optimization, and other clinical interventions has been adequately reviewed in settings of general wards and considered as standard practice; however, these activities in the operating room have not become the standard practice. In this article, we reviewed the clinical interventions by pharmacists working in the operating room. The five main duties or obligations required of the pharmacists are appropriate drug management, achieving medical economic benefits, mixing injectable drugs, risk management, and provision of drug information. The major information provided to physicians and nurses is on usage, dosage, stability, incompatibility, pharmacological effects and adverse effects. Physicians and nurses require the drug information provided by the pharmacist in the operating room. Furthermore, their requirement for the stationing of pharmacist is extremely high. It is suggested that these services might be quite important in optimizing drug therapy and preventing adverse effects. Additionally, pharmacist can contribute on rational use of drug, safety management, reduction of works of other medical staff, and also the medical economics through pharmaceutical care in operating room as well as in general wards. It is suggested that stationing pharmacists in the operating room might be indispensable for hospital administration in view of the medication safety and cost reduction.     

Clinical pharmacology of antihypertensive therapy

Adequate control of blood pressure poses challenges for hypertensive patients and their physicians. Success rates of greater than 80% in reducing blood pressure to target values among high-risk hypertensive patients reported by several recent clinical trials argue that effective medications currently are available. Yet, only 34% of hypertensive patients in the United States are at their goal blood pressure according to the most recent national survey. Rational selection of antihypertensive drugs that target both the patient's blood pressure and comorbid conditions coupled with more frequent use of low-dose drug combinations that have additive efficacy and low adverse-effect profiles could improve significantly US blood pressure control rates and have a positive impact on hypertension-related cardiovascular and renal mortality and morbidity. This article reviews the pharmacokinetic and pharmacodynamic principles that underlie the actions of drugs in each of the classes of antihypertensive agents when used alone and in combination, provides practical pharmacologic information about the drugs most frequently prescribed for treatment of hypertension in the outpatient setting, and summarizes the current data influencing the selection of drugs that might be used most effectively in combination for the majority of hypertensive patients whose blood pressures are not controlled adequately by single-drug therapy.