Safety issues with herbal medicine

Use of Herbal Supplements and Vitamins in Plastic Surgery: A Practical Review

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Explain what governmental regulations control the labeling and distribution of herbal supplements. 2. List the more commonly used supplements and their reported benefits. 3. List the possible postoperative complications from consumption of the more commonly used herbal supplements. 4. Explain the preoperative management of patients using herbal supplements. 5. Know additional resources to consult when unanswered questions arise.

BACKGROUND

The American public spends over $5 billion per year on herbal supplements, and approximately 20 percent of all Americans use prescription medications concurrently with herbal supplements. As the number of people who take alternative medicines rises, there is growing awareness among health care providers of the need to become educated and to educate their patients on the effects that such supplementation may have on their health. As plastic surgeons, we have an added responsibility to become informed because of potential adverse interactions with other medications and anesthesia in the elective surgical patient.

METHODS

Literature regarding commonly encountered herbal supplements and vitamins was reviewed and summarized to include reported indications for use and potential adverse effects and interactions specific to the perioperative patient.

RESULTS

Abundant literature exists regarding herbal supplementation, but very little scientific evidence exists to advocate the use of the majority of supplements available on the market. In addition, little is known about the positive and negative interactions that these supplements are capable of producing, and those interactions that are known are based on case reports.

CONCLUSIONS

With the lack of quality scientific studies to support the efficacy of most herbal products available and the limited regulation of these products by the government, health care providers are faced with a significant public health dilemma. This article provides a brief overview of information published on commonly encountered herbal supplements and vitamins taken by plastic surgery patients.

Perceptions of natural health products among patients attending a memory clinic

This study compared patient and caregiver perceptions of natural health products (NHPs) and conventional medications in a memory clinic population. A total of 620 mildly cognitively impaired patients and their caregivers participated in interviews enquiring about their perceptions of NHPs in 4 areas: (1) disclosure of NHP usage information to health care professionals, (2) safety and benefits of NHPs, (3) safety and benefits of conventional medications, and (4) physician knowledge about NHPs. Differences in responses between NHP users and nonusers and between patients and caregivers were examined. A total of 51.8% of subjects were current NHP users, with vitamin E, ginkgo biloba, and glucosamine being the most commonly used products. Multivariate analysis of variance showed that NHP use significantly influenced participant interview responses (Pillai's trace, F[4, 613] = 3.488, P = .008), while interviewee (patient or caregiver; Pillai's trace, F[8, 1228] = 1.499, P = .153) and gender (Pillai's trace, F[4, 615] = 0.528, P = .715) did not. Subsequent univariate tests showed that NHP users were significantly more likely to endorse the effectiveness and safety of NHPs compared with nonusers (F[1, 616] = 7.826, P = .005). Careful questioning during visits with health care providers and better counseling may be necessary to reduce the potential for adverse events and NHP-drug interactions.

In vitro interactions of water-soluble garlic components with human cytochromes p450

Eight water-soluble components of aged garlic extract were evaluated to assess their potential to inhibit the activity of human cytochrome-P450 (CYP) enzymes. The in vitro model consisted of human liver microsomes with index reactions chosen to profile the activity of the following six CYP isoforms: CYP1A2, 2B6, 2C9, 2C19, 2D6, and 3A. With only 2 exceptions, none of the 8 garlic components produced >50% inhibition even at high concentrations (100 micromol/L). S-methyl-L-cysteine and S-allyl-L-cysteine at 100 micromol/L produced modest inhibition of CYP3A, reducing activity to 20-40% of control. However available clinical evidence does not indicate CYP3A inhibition in vivo. The findings suggest that drug interactions involving inhibition of CYP3A enzymes by aged garlic extract are very unlikely.

Herb and supplement use in the US adult population

BACKGROUND

Research on the scope of use and factors associated with herbal medicine use is limited.

OBJECTIVES

The aims of this work were to assess national usage patterns, reasons for use, and the perceived efficacy of herbal products and dietary supplements.

METHODS

This was a secondary analysis of the complementary and alternative medicine (CAM) supplement to the 2002 National Health Interview Survey (NHIS), conducted by the National Center for Health Statistics (NCHS). Participants were asked whether they had used natural herbs for their own health and treatment. Those who responded yes were compared with those who responded no. Supplement users were asked whether they had used any of 36 specific herbs or nonherbal dietary supplements (eg, glucosamine, fish oil, bee pollen), how important the use of CAM treatment was to them, whether they had seen a CAM provider, and whether they had informed a conventional medical provider about their use. NCHS weights, derived from Decennial Census data, were used to calculate national prevalence estimates. Group comparisons of herbal use were conducted with the Wald x(2) test.

RESULTS

A total of 31,044 adults participated in the 2002 NHIS CAM survey; 632 were omitted from analyses due to incomplete information. In all, 5787 adults said they had used herbs or supplements during the previous 12 months, of whom 57.3% said they used these products to treat specific conditions. Based on these responses, an estimated approximately 38.2 million adults in the United States used herbs and supplements in 2002. More than half of all users said that herbs and natural products were important to their health and well-being. Use rates were higher for women than men (21.0% vs 16.7%; P < 0.001); adults aged 45 to 64 years (P < 0.001 vs other age groups); those of multiple races (32.2%), Asians (24.6%), or American Indians or Alaskan natives (21.9%) rather than whites (19.1%) or blacks (14.3%) (effect of race, P < 0.001); residents of the western United States (effect of region, P < 0.001), and college graduates (25.3% vs 10.4% among those who did not graduate high school; effect of education, P < 0.001). Only 33.4% told a conventional health care provider about their herb or supplement use use.

CONCLUSION

Herb and natural supplement use was widespread in the US adult population in 2002, according to data from the NHIS CAM survey, despite the fact that few participants informed their conventional health care providers about such use.

Hepatotoxicity of NONI juice: Report of two cases

AIM: NONI juice (Morinda citrifolia) is an increasingly popular wellness drink claimed to be beneficial for many illnesses. No overt toxicity has been reported to date. We present two cases of novel hepatotoxicity of NONI juice. Causality of liver injury by NONI juice was asses-sed. Routine laboratory tests and transjugular or percutaneous liver biopsy were performed. The first patient underwent successful liver transplantation while the second patient recovered spontaneously after cessation of NONI juice. A 29-year-old man with previous toxic hepatitis associated with small doses of paracetamol developed sub-acute hepatic failure following consumption of 1.5 L NONI juice over 3 wk necessitating urgent liver transplantation. A 62-year-old woman without evidence of previous liver disease developed an episode of self-limited acute hepatitis following consumption of 2 L NONI juice for over 3 mo. The most likely hepatotoxic components of Morinda citrifolia were anthraquinones. Physicians should be aware of potential hepatotoxicity of NONI juice.

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.

Preliminary studies on Campomanesia xanthocarpa (Berg.) and Cuphea carthagenensis (Jacq.) J.F. Macbr. aqueous extract: weight control and biochemical parameters

An infusion of Campomanesia xanthocarpa Berg. (Myrtaceae) leaves (Guabiroba) and the herb Cuphea carthagenensis (Jacq.) J.F. Macbr. (Lythraceae) (Sete-sangrias) is traditionally used in the South of Brazil to treat high levels of cholesterol and triglycerides. The effects of the aqueous extracts of these herbs were investigated in rats fed on a high calorie diet. Chronic treatment with the Guabiroba aqueous extract induced a significant reduction in weight gain in the rats, compared to the control group. Also, biochemical analysis showed that this treatment reduced the glycemia, while no effects on lipidic levels were observed. The biochemical analysis of the animals treated with Sete-sangrias aqueous extract showed no effect on glucose and triglyceride levels, while chronic treatment with the Sete-sangrias aqueous extract induced a significant reduction in plasma cholesterol in rats.

Cytokine production by non-adherent mouse splenocyte cultures to Echinacea extracts

BACKGROUND

Echinacea is commonly used in oral dosage as an immune stimulant to increase resistance to viral, bacterial and fungal infections of the upper respiratory tract. It has been suggested that Echinacea is able to stimulate innate immune responses, including those regulated by macrophages and natural killer cells. Indeed, macrophages respond to purified polysaccharide and alkylamide preparations. However, the mechanisms for stimulation of cells responsible for adaptive immunity have not been fully elucidated for other molecules present in Echinacea purpurea preparations.

METHODS

Adherent and non-adherent mouse splenocyte populations were incubated in vitro with Echinacea, or with water or alcohol soluble Echinacea extract preparations. Supernatants were collected at 48-h post-incubation, and tested by standard ELISA for presence of secreted cytokines and proinflammatory mediators.

RESULTS

Whole splenocyte populations were capable of producing significant amounts IL-6 (1014 pg/ml) in response to Echinacea preparations. The response was primarily contained towards products isolated to the water extract preparation; no IL-6 was produced upon challenge with the alcohol extract. The IL-6 response was produced by the non-adherent cellular population, which made 4912 pg/ml IL-6 when treated with water soluble extract at 1 mg/ml. Likewise, the water soluble extract of Echinacea was able to stimulate non-adherent splenocyte populations to produce TNF-alpha (2082 pg/ml), IL-10 (892 pg/ml) and MIP-1alpha (6486 pg/ml) from non-adherent splenocytes, but only significant concentrations of TNF-alpha and MIP-1alpha mediators were produced from adherent populations at similar dose concentrations. Neither population of splenocytes was capable of stimulating significant production of IFN-gamma, IL-2 or IL-12 to any preparation of Echinacea examined.

CONCLUSIONS

The immune stimulatory ability of components contained within E. purpurea extracts offer insight into possible therapeutic potential of this product to regulate non-adherent lymphocytes in immune responses and activation events.

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.

Anaphylactic reaction to a dietary supplement containing willow bark

OBJECTIVE

To report a case of anaphylaxis resulting from the use of a willow bark-containing dietary supplement in a patient with a history of an aspirin allergy.

CASE SUMMARY

A 25-year-old white woman presented to the emergency department of a community teaching hospital with anaphylaxis requiring epinephrine, diphenhydramine, methylprednisolone, and volume resuscitation to which she responded favorably. Medication history revealed that she had ingested 2 capsules of Stacker 2 (NVE Pharmaceuticals, Newton, NJ), a dietary supplement promoted for weight loss, prior to experiencing her initial symptoms. Among other active ingredients, this product contains willow bark. Of significance is that this patient also reported a history of allergy to acetylsalicylic acid. No other causes for anaphylaxis were identified. She continued to receive routine supportive care and the remaining hospital course was uncomplicated.

DISCUSSION

Dietary supplements, including herbal products, are used by many individuals who consider them to be inherently safe despite limited regulatory oversight by the Food and Drug Administration. While there may be value to specific botanical ingredients, a potential for adverse effects also exists. The popular product consumed by our patient is used for weight loss and contains willow bark, a source of salicylates. Based on the Naranjo probability scale, it is probable that this case of anaphylaxis was due to this dietary supplement.

CONCLUSIONS

The use of any willow bark-containing dietary supplement may present a risk of anaphylactic reaction to patients with a history of allergy to salicylates. Clinicians need to recognize the potential for adverse effects from dietary supplements.

Dietary supplements and functional foods: 2 sides of a coin?

Dietary supplements are used by more than one-half of the adult US population. In contrast to pharmaceuticals, dietary supplements may be sold in the United States with little regulation other than listing of ingredients and the potential health benefits. By contrast, herbal products in Germany are carefully regulated by the same standards as drugs, and efforts are under way to standardize their regulation in the entire European Union. Most herbal users do not inform their physicians that they are taking these supplements, and most physicians do not inquire. Although some herbal products have clinically proven benefits, it is increasingly apparent that many contain potentially toxic substances, particularly in relation to interactions with drugs. Hence, it is essential that practicing physicians develop a working knowledge of herbals-specifically, about claims for their usage and potential or proven efficacies and toxicities-and that they incorporate such knowledge into the evaluation and management of their patients. By contrast, functional foods-integral components of the diet that are understood to contribute added health benefits-are the subject of intense and widespread research in food and nutritional science. Examples include many polyphenolic substances, carotenoids, soy isoflavones, fish oils, and components of nuts that possess antioxidant and other properties that decrease the risk of vascular diseases and cancer. Practicing physicians are advised to stay abreast of these emerging findings in order to best advise their patients on the value of health-promoting diets in disease prevention.

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.

Survey of the use of complementary medicines and therapies in children with asthma

OBJECTIVE

To survey the frequency of use of complementary medicines (CM) and complementary therapies (CT) in asthmatic children.

METHODOLOGY

A 3-month survey of asthmatic inpatients and outpatients of a teaching hospital respiratory paediatrician was undertaken. Parents answered a structured questionnaire about their past and present usage and opinions of CM and CT. Parents and the physician independently assessed overall asthma control. 'Users' and 'non-users' of CM and CT were compared for characteristics of asthma, usage of conventional medications and parental demographics.

RESULTS

One hundred and seventy-four children with 331 parents were enrolled in the study. All of the children were on bronchodilators and 150 (86.2%) were on disodium cromoglycate or inhaled steroids. Control was assessed by a physician as good in 95 children (54.6%), fair in 65 (37.4%) and poor or very poor in 13 (7.5%). Ninety (51.7%) of the children had used at least one CM in their lifetime. Out of the 145 preparations used, 90 (62.1%) were in current use. Vitamins and minerals (53.2%) and herbal preparations (29%) were used most commonly. Only 47.8% of parents had told their doctors about the use of CM. Costs ranged from $A2-$A200 (median $A10) per month. Forty-three (24.7%) of the children had been taken to an alternative practitioner at a cost of $A25-$A400 (median $A40) per month. Users of CM and CT were significantly more likely than non-users to have persistent asthma (P < 0.02), be on high-dose inhaled or oral steroids (P < 0.05), to have poor or very poor control of symptoms (P < 0.04), and more frequent doctor visits (P < 0.05). They also had more adverse reactions to relieving bronchodilators (P < 0.02) and were significantly older than non-users (P < 0.02). The most common reasons for using CM and CT were dissatisfaction with conventional therapies and concerns about steroid side-effects.

CONCLUSIONS

Health professionals should be aware of the high rates of usage of CM and CT in asthmatic children and of parental attitudes to conventional and alternative therapies.

Evaluation of the use of complementary and alternative medicine in the largest United States-Mexico border city

STUDY OBJECTIVE

To evaluate the use of complementary and alternative medicine (CAM) in the El Paso, Texas, region.

DESIGN

Prospective observational study conducted from April-October 2000.

SETTING

Several hospitals and clinics.

SUBJECTS

Five hundred forty-seven participants.

INTERVENTION

Semi-structured interview with a bilingual questionnaire.

MEASUREMENTS AND MAIN RESULTS

Complementary and alternative medicine was used in 77% of our population. The most common CAM providers were massage therapists (19.4%) and herbalists (12.4%). The most common herbal or home remedies were chamomile (13.1%) and aloe vera (8.5%). The most common nutritional or commercial products were multivitamins (16%), ginseng (3.6%), and ginkgo biloba (2.8%). We identified 599 CAM usages that could result in drug interactions, disease interactions, or adverse reactions.

CONCLUSIONS

A wide range of CAM use was documented in this study. Our results indicate that Hispanics in this area use CAM at a higher rate than national trends. Many of these therapies can adversely affect a variety of disease states and drug therapies.

Seizure activity and unresponsiveness after hydroxycut ingestion

A 22-year-old man was hospitalized after unexplained seizure-like activity and unresponsiveness. A urine toxicology screen was negative for salicylates, acetaminophen, alcohol, and drugs of abuse. Medical history was insignificant with the exception of recent (within 2 wks) ingestion of Hydroxycut is a dietary supplement purported to be energy enhancing, muscle building, and fat burning. The agent contains ephedra alkaloids and caffeine, which are both central nervous system stimulants; the etiology of seizure was attributed to their consumption. Due to a significant number of reported adverse events, the United States Food and Drug Administration (FDA) proposed regulations for dietary supplements containing ephedra alkaloids and requested an independent review of case reports linked to these products. Because herbal products are not subject to the same rigorous FDA regulations required for prescription and over-the-counter products, consumers unknowingly risk adverse effects when taking these products. Questioning patients about consumption of herbal products should be part of routine medical visits.

Drug interactions update: drugs, herbs, and oral anticoagulation

Management of warfarin drug interactions is often complicated by lack of information regarding interactions with new drugs and with herbal medicinals. The pharmaceutical industry has increased both the number and quality of drug interaction studies prior to marketing new agents. Interactions may still occur in patients, however, despite negative pre-marketing studies in healthy volunteers. The clinical significance and intensity of warfarin interactions with prescription drugs (e.g., celecoxib, proton pump inhibitors, and selective serotonin reuptake inhibitors) can often be predicted on the basis of known metabolic characteristics of the drugs and warfarin enantiomers. Drug interactions with herbal medicinals are much more difficult to characterize and predict because of the lack of federal regulations regarding safety, efficacy, and manufacturing standards. Published case reports of interactions between warfarin and even the most widely used herbal medicinals are limited. Practitioners are encouraged to report such interactions through the FDA MedWatch program.

The anti-inflammatory natural product parthenolide from the medicinal herb Feverfew directly binds to and inhibits IkappaB kinase

BACKGROUND

Biologically active natural products continue to be useful in the exploration and control of intracellular signaling processes. For example, the sesquiterpene lactone parthenolide from the anti-inflammatory medicinal herb Feverfew (Tanacetum parthenium) appears to inhibit the pro-inflammatory signaling pathway. Parthenolide's direct molecular target, however, remains unknown. We set out to identify the molecular mechanisms of parthenolide's anti-inflammatory activity.

RESULTS

A parthenolide affinity reagent was synthesized and shown to bind directly to and inhibit IkappaB kinase beta (IKKbeta), the kinase subunit known to play a critical role in cytokine-mediated signaling. Mutation of cysteine 179 in the activation loop of IKKbeta abolished sensitivity towards parthenolide. Moreover, we showed that parthenolide's in vitro and in vivo anti-inflammatory activity is mediated through the alpha-methylene gamma-lactone moiety shared by other sesquiterpene lactones.

CONCLUSIONS

In recent years, the multi-subunit IKK complex has been shown to be responsible for cytokine-mediated stimulation of genes involved in inflammation and as such represents an attractive target for pharmaceutical intervention. Our finding that parthenolide targets this kinase complex provides a possible molecular basis for the anti-inflammatory properties of parthenolide. In addition, these results may be useful in the development of additional anti-inflammatory agents.

Potential interaction between warfarin and boldo-fenugreek

A patient was treated with warfarin for atrial fibrillation. During treatment, an increase in international normalized ratio (INR) and her admission that she was taking a variety of natural products, to include boldo and fenugreek, led us to suspect that some of these natural products could alter the effect of warfarin. When she stopped the culpable products, the INR returned to normal after 1 week. The herb-drug interaction was observed a second time after both products were reintroduced a few days later. The imputability of this interaction to both natural products, as determined by the Naranjo algorithm, suggests a probable association between boldo-fenugreek and increased bleeding time in patients treated with warfarin. No undesirable reaction was reported during telephone discussions with the patient. Nevertheless, we recommend that clinicians treating patients with anticoagulant therapy be vigilant when patients also take herbal agents.

Chinese proprietary medicine in Singapore: regulatory control of toxic heavy metals and undeclared drugs

Traditional Chinese medicine (TCM) is gaining popularity as a form of complementary and alternative medicine. Reports of efficacy of TCM are increasing in numbers. TCM includes both crude Chinese medicinal materials (plants, animal parts and minerals) and Chinese proprietary medicine (CPM) [final dosage forms]. Despite the belief that CPM and herbal remedies are of natural origin, unlike Western medicine, and are hence safe and without many adverse effects, there have been numerous reports of adverse effects associated with herbal remedies. Factors affecting the safety of herbal medicines include intrinsic toxicity, adulteration, substitution, contamination, misidentification, lack of standardisation, incorrect preparation and/or dosage and inappropriate labelling and/or advertising. Hence, new regulations on the control of CPM were enforced in Singapore with effect from 1 September 1999. These include licensing and labelling requirements, as well as control of microbial contamination. This article also reviews reports of excessive toxic heavy metals and undeclared drugs in CPM in Singapore between 1990 and 1997. The names, uses, toxic heavy metal or drug detected and the year of detection are tabulated. Information on the brand or manufacturer's name are provided whenever available. The public and healthcare professionals should be better informed of the basic concept of TCM and its usefulness, as well as the potential adverse effects associated with its use. Greater control over the safety and quality of CPM could be achieved through good manufacturing practice, regulatory control, research, education, reporting usage of Chinese medicine (as in drug history) as well as reporting of adverse events.