Preoperative use of herbal medicines and vitamin supplements

There has been a definite increase in the popularity and use of complementary and alternative medicines, including herbal medicines, in the last ten years. The aim of this study was to determine the prevalence and patterns of use of herbal medicines and vitamin supplements by patients in the preoperative period. A questionnaire was offered to all patients attending the pre-admission clinics at St. Vincent's Hospital and Box Hill Hospital, Melbourne, over an eight-month period in 2002. In all, 1102 questionnaires were completed (91.8% response rate). The prevalence of herbal medicine use was 14.3%, with an average user age of 54.0 years and 61.4% female predominance. The five most popular herbs were Garlic, Evening Primrose, Gingko, St. John's Wort and Echinacea. The commonest reasons for herbal medicine use were acute and chronic medical conditions. 63.2% of patients had self-prescribed. 27.8% of herbal remedy users had informed the hospital doctors and 41.8% had notified their general practitioner The prevalence of vitamin supplement use was 20.4%, with an average user age of 54.8 years and 66.2% female predominance. The five most popular vitamins were multivitamins, followed by vitamin B, C, E and D. The commonest reasons for vitamin use were maintenance of general well-being and health. The use of herbal medicines and vitamin supplements preoperatively by patients is common. Clinicians should endeavour to familiarize themselves with the more popular and significant herbal medications and, as part of the routine preoperative assessment, ask all their patients about their consumption of herbal remedies.     

Consumption of dietary supplements in a liver transplant population.

The extensive use of alternative medicine products, herbal remedies, and vitamins in large doses has reached an all time high in the general public. Some agents are reported and advertised as immune stimulants and may interfere with patients suffering from immune modification, autoimmune diseases, or transplant recipients. In this report, we will present an investigation into the use of herbal remedies and vitamins in our liver transplant population. We performed an investigation using a questionnaire to determine the use of herbal products and vitamins in our liver transplant population. Medical records were reviewed for each liver transplant recipient that admitted to consuming herbal products or vitamins. Information collected included patient demographics, transplant related information, laboratory tests, outcomes, and herbs or vitamin products used. A total of 290 patients completed and returned the questionnaire. We found 156 admitting to taking more than a standard multivitamin and/or an herbal remedy. All patients were treated with steroids for allograft rejection and experienced a recurrence of amino transaminases following the removal of steroids. Further investigation into dietary supplements using a patient questionnaire form revealed that nearly 50% of patients admitted to using vitamins following transplantation, while 19% used herbal remedies combined with vitamins, most admitting to silymarin. One recipient was ingesting colostrum and required admission for the management of allograft rejection, while 5 patients had consumed large amounts of echinacea or CoEnzyme Q-10 and experienced elevations in their transaminases that resolved with discontinuation of the herb. The review also identified 4 patients with primary biliary cirrhosis and with transaminase elevation (mean values of aspartate aminotransferase and alanine aminotransferase levels of 88 and 95, respectively). All recipients were consuming vitamins, in particular high doses of vitamin E (tocopherol), more than 1 gram per day. All of the transplant recipients were instructed to discontinue all vitamin E products and the amino transaminases resolved over the following 30 to 60 days. In conclusion, this information reveals that a significant proportion of our liver transplant recipients consume herbal remedies. The results of this report suggest that transplant teams need to question each recipient about the use of herbal and vitamin remedies and educate them regarding the potential hazards.     

Herbal and homeopathic medication use in pediatric surgical patients

BACKGROUND: Patients who present for surgery may be using herbal or homeopathic preparations; adverse effects of some of these substances include bleeding, cardiovascular changes, and liver dysfunction. Little information is available on the frequency of use in the pediatric surgical population. METHODS: With institutional approval, a survey was conducted to assess the use of vitamins, nutritional supplements, or herbal or homeopathic preparations in children presenting for surgery in five geographically diverse centers in the USA. RESULTS: A total of 894 completed surveys showed that overall, 3.5% of pediatric surgical patients had been given herbal or homeopathic medications in the 2 weeks prior to surgery. Most substances were prescribed by parents. The use of these medications did not differ between children with coexisting diseases and those without; use was also not different among ethnic groups or by residence setting (city, suburban, rural). There was a significant difference between the west coast centers in the study compared with the rest of the country (7.5% of patients in Palo Alto, CA; 5.5% of patients in Seattle, WA; 1.5% of patients in Chicago, IL; and 1.9% in Virginia and Delaware used herbal or homeopathic remedies). The most prevalent substance given to children presenting for elective surgery was Echinacea. CONCLUSIONS: Herbal and homeopathic medications are used by a small percentage of pediatric patients presenting for elective pediatric surgery patients. Use of these substances should be addressed in the preoperative history.     

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.     

The use of herbs and complementary and alternative medicine in pediatric preoperative patients

STUDY OBJECTIVE: To determine the use of herbs and complementary and alternative medicine among a pediatric preoperative population. DESIGN: Prospective, consecutive clinical study and survey questionnaire. SETTING: Children's Hospital pediatric preoperative clinic. MEASUREMENTS AND MAIN RESULTS: A total of 1,100 surveys were distributed to pediatric patients under the age of 18 years during their preoperative visit over an 8-month period. The survey consisted of a questionnaire about the use of herbs and complementary and alternative therapies within 1 year before the anticipated surgery. The patient or legal guardian was asked whether the patient had tried any of the complementary and alternative medical therapies within 1 year before the scheduled surgical procedure. Of 1,021 completed surveys received, 29.5% of these patients indicated they had tried one or more complementary and alternative therapies in the past year before the surgery, and 12.8% of the pediatric patients used herbal remedies before the surgery. CONCLUSIONS: Herbs and complementary and alternative medical therapies are frequently used in pediatric populations. Anesthesiologists need to be aware the usage of various herbal supplements in pediatric patients. It is important then to determine the potential of drug and anesthetic interactions in the perioperative period.     

Preoperative use of herbal medicines: a patient survey

Background. There has been recent concern in the media overthe possible detrimental effects of herbal medicines on theperioperative period. Perceived by the public as ‘natural’and therefore safe, herbal remedies may have led to adverseevents such as myocardial infarction, bleeding, prolonged orinadequate anaesthesia and rejection of transplanted organs.In addition, herbal remedies can interact with many drugs givenin the perioperative period. In this article we summarize thepotential perioperative complications that can occur. Methods. In order to determine the extent of use of herbal medicines,we conducted a survey of patients presenting for anaesthesia.During a 3-month period, patients were directly asked by anaestheticstaff if they were currently self-administering herbal medication. Results. Of 2723 patients, 131 (4.8%) were taking one or moreherbal remedy. In only two cases was this recorded in the patients’notes. Women and patients aged 40–60 yr were mostlikely to be taking a herbal product (P<0.05 and P<0.001respectively). The most commonly used compounds were, in descendingorder, garlic, ginseng, ginkgo, St John’s wort and echinacea. Conclusion. Self-administration of herbal medicines is commonin patients presenting for anaesthesia. Because of the potentialfor side-effects and drug interactions it is important for anaesthetiststo be aware of their use. Br J Anaesth 2002; 89: 792–5     

Anaesthetic preoperative assessment of chronic medications and herbal medicine use: a multicenter survey

Objective

This study was undertaken to quantify the use of chronic medication and herbal remedies in the presurgical population.

Study design

Prospective multicenter survey.

Patients and methods

Adult patients presenting for anaesthesia were directly asked if they were currently using chronic medication or herbal remedies.

Results

Among 1057 patients (age 54 ± 17 yrs, woman 54%, ASA 2 [1–4], 74%) were taking one or more chronic medication. The most commonly used treatments were, in descending order angiotensin-converting enzyme inhibitors and angiotensin-II receptor blockers (15%), beta blockers (11%) and platelet inhibitors (10%). Also, 9% were taking one or more of the following herbal remedies known to interact with the perioperative period: valeriane, ginseng, ginkgo, St John's wort, echinacea and ephedra. Women and patients aged 40-70 yr were most likely to be taking a herbal product (p < 0.001 and p < 0.01 respectively).

Conclusion

Chronic medication and herbal remedies are common in patients presenting for anaesthesia. Because of the potential interactions between anaesthetic drugs or techniques and such medication it is important for anaesthetists to be aware of their use.     

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.     

Phytopharmaka

There is a great enthusiasm for herbal medications with increasing and widespread use among the population in various countries. A certain scepticism towards the use of pharmaceutical drugs may promote the use of herbal medicines such as echinacea, ginger, garlic, ginkgo, cranberry, valerian or St. John's wort even in western countries. Although considered safe among users, adverse effects such as increased bleeding tendencies, hypertension and hepatotoxicity can occur. Physicians should caution patients on the adverse side effects of herbal medicines and interactions between herbal medicines and pharmaceutical drugs, leading to various and uncontrollable deterioration of vital functions in the perioperative period. Although evidence-based data are lacking, anaesthesiologists and surgeons should be familiar with the effects of herbal medicines and should enquire about the use of these agents in the preoperative assessment. Currently available data suggest that herbal medications should be discontinued up to 2 weeks before elective surgery, although no guidelines of scientific societies have yet been published.     

The impact of complementary and alternative treatment modalities on the care of orthopaedic patients

The use of complementary and alternative medicine is widespread and popular with the lay public. Although prevalence of use varies among specific patient populations, complementary and alternative medicine, in particular herbal remedies, are widely marketed and used by orthopaedic patients. Herbal supplements can have a negative impact on the perioperative period and may interact with conventional medicines used to manage chronic conditions. Physician-patient communication often does not include the subject of alternative medicines, leading to underreporting of use. Orthopaedic surgeons should adopt methods to routinely elicit from their patients the use of complementary and alternative medicine and should monitor and counsel patients on potential side effects and drug-herb interactions. Preoperative instructions should include cessation of the use of herbal supplements.     

A survey of Chinese herbal medicine intake amongst preoperative patients in Hong Kong

We have surveyed, by means of a questionnaire, the preoperative use of traditional Chinese medicines in 259 adult Chinese patients admitted to a Hong Kong teaching hospital. The spectrum and use of herbal remedies differed from that reported by Western sources. Of those patients surveyed 90% used Chinese herbs on a regular daily basis in traditional soups and teas while 44% had consulted a traditional Chinese medicine practitioner in the last twelve months prior to admission, but mainly for health promotion (59%) and minor ailments (30%). Only 25% sought advice for their current illness and 13% were taking regular traditional Chinese medicines prior to admission. The ingredients were difficult to identify. Patients with cancer were more likely to use ling zhi (odds ratio 5.4). Female patients with reproductive problems were more likely to visit a traditional Chinese medical practitioner (odds ratio 2.6) and use ginseng (odds ratio 5.1). The anaesthetic implications of preoperative traditional Chinese medicine in keeping with Hong Kong practices need to be investigated, and appropriate anaesthetic guidelines should be developed.     

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.     

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.     

Prevalence and correlates of selected alternative and complementary medicine in adult renal transplant patients

Abstract: Background/Significance: The use of complementary and alternative medicine (CAM) has increased considerably in the general population in recent decades. However, the prevalence of CAM use in renal transplant patients has not yet been assessed. Aim: To determine the prevalence and correlates of CAM use among renal transplant patients (RTX) who are more than one year post transplant. Methods: This secondary data analysis used data from Part 1 of the Supporting Medication Adherence in Renal Transplantation (SMART) study, which tested prevalence, determinants and consequences of non‐adherence regarding immunosuppressive medication in kidney transplant (renal TX) patients. The study’s convenience sample consisted of 356 patients recruited from two Swiss outpatient transplant clinics during their annual examination visits (mean age: 53±13; male: 58%). The use of CAM as well as the specific kind of CAM used was assessed through structured interviews. Assessed CAM use correlates were age, gender, education, depressive symptomatology, comorbidity and smoking status. Relationships between CAM use and candidate correlates were explored using multiple logistic regression. Results: The prevalence of CAM use in this sample of renal TX patients was 11.8%. Most frequently used alternative medicines were Homeopathy (42.9%) and Chinese medicine (23.8%). Two patients used St John’s wort. The percentage of patients using Homeopathy (5.1%) and herbal medicine (2%) was similar to that of the general Swiss population (HO: 6.1% & HM: 2.6%). Significant correlates for CAM use were younger age (p=0.017; OR=0.96; 95%CI=0.93‐0.99) and female gender (p=0.035; OR=2.13; 95%CI=1.05‐4.3). Conclusion: Every eighth renal transplant recipient in this sample used some form of CAM. Of these, some used herbal medicines, of which some are known to interfere with certain immunosuppressive treatment (St John’s wort/Chinese medicines). These findings indicate that it is important for health care providers working in renal TX to assess CAM use.     

Herbal medicine use is frequent in ambulatory surgery patients in Vancouver Canada

PURPOSE: To determine the incidence and nature of herbal medicine use among patients in a busy Canadian surgical day care unit. METHODS: We undertook a prospective survey of 575 patients attending our surgical day care unit. The questionnaire inquired as to basic demographics, herbal medicine use, the name and number of herbal medicines used, reason, whether it was self prescribed or not, and if the patient's family physician was aware of the use. In the second part of the study, 44 anesthesiologists were asked to answer a questionnaire of 27 yes/no questions to determine their knowledge of herbal medicines. RESULTS: Four hundred eighty-five of 575 patients completed the questionnaire (84%). Thirty-four percent of patients surveyed in our unit responded affirmatively to herbal medicine use. Of these, 39% took them on a daily basis. Forty-five different identifiable herbs were being taken in total, with echinacea being the most common. Less than half of the patients told their family physicians that they were using herbal medicines and only one-third of patients were taking them on the advice of their physician. In the assessment of anesthesiologists' knowledge of herbal medicine, only 32% of the questions were answered correctly. CONCLUSION: The incidence of herbal medicine ingestion by patients coming to our unit was higher than previously reported. A large variety of preparations were being taken, many without the knowledge of the patient's family physician. The basic knowledge of anesthesiologists with respect to herbal medicine is limited.     

Current management of patients taking herbal medicines: a survey of anaesthetic practice in the UK

BACKGROUND AND OBJECTIVES: Increasing numbers of patients taking herbal medicine products are presenting for anaesthesia and surgery. Anaesthetists need to consider the perioperative implications of herbal medicines and should, therefore, have some knowledge of this subject. METHODS: A postal questionnaire survey was sent to a random 5% of practising members of the Association of Anaesthetists of Great Britain and Ireland residing in the UK, to identify attitudes, practice and knowledge regarding herbal medicines. RESULTS: From 341 questionnaires there were 221 replies, a 65% response rate. Ninety per cent stated that they seldom or never asked patients about herbal medicine usage, yet 65% felt that there could be potentially harmful effects of herbal medicines in the perioperative period. There was a very poor level of knowledge with respect to the current management of 10 well-known herbal medicines. However, 75% agreed that information about perioperative usage of herbal medicines is important, and 77% felt that herbal medicines should be in the undergraduate medical curriculum. Reading was the usual source of herbal medicine product information. Most (82%) felt their knowledge of herbal medicine products and the implications in patient care were inadequate. CONCLUSIONS: This sample of anaesthetists require education on herbal medicines. Suggestions for remedial action are given.