Indian Journal of Anaesthesia 2007;51 (3) : 184-192

Indian Journal of Anaesthesia, June 2007 Special Article

EFFECT OF COMMON HERBAL MEDICINES ON PATIENTS UNDERGOING ANAESTHESIA

Yatindra Kumar Batra 1, Subramanyam Rajeev 2

Summary
Herbal medicines are the oldest known remedies to mankind. Herbs have been used by all cultures throughout history but India has one of the oldest, and most diverse cultural living traditions associated with the use of medicinal plants. The use of these agents may have perioperative implications, which often is a result of various factors. The constituents of these medications may not be adequately described. Conventional agents like steroids, oral hypoglycaemic agent, nonsteroidal anti-inflammatory agents and antihistamines are frequently added to herbal medicines. Toxic materials like arsenic, mercury, lead, etc. have been detected from time to time in some herbs. The use of herbal medicines can result in drug interactions, most of which are less well defined. The interactions that are most important in the perioperative period include sympathomimetic, sedative, and coagulopathic effects. Less than 50% of patients admit to taking these medicines, which compounds the problem. It is imperative that anaesthesiologists obtain a history of herbal medicine use from patients and anticipate the adverse drug interactions. In case of any doubt, it may be prudent to stop these herbal medicines atleast 23 weeks prior to anaesthesia and surgery. Key words Herbal medicines; Anaesthesia; Complications, Drug interactions. of botanicals can seldom be overlooked as 30% of all modern conventional therapeutic agents are derived from plants3 . World Health Organization estimate revealed that up to 80% of the worlds population still depends on herbal medicines. Chronic ailments have made many patients attempt to cure their disease states with the use of self administered herbal medicines. Few of these conditions include diabetes mellitus, malignancy, arthritic conditions, and AIDS. The inclusion of these nutraceuticals in the supplement category has made them easily available as over the counter medicines 2. Alternative medicine has been defined by The National Institute of Health as the following seven fields; alternative systems (e.g. acupuncture, homeopathy and naturopathy), bioelectromagnetism, diet and nutrition (e.g. macrobiotic diets), herbal remedies, manual healing methods (e.g. chiropractic and massage therapy), mind/body interventions (e.g. meditation, hypnosis, biofeedback), and pharmacologic and biologic treatments (e.g.EDTA for chelation therapy) 4. This review is limited to discussion of herbal

Introduction
The oldest prescriptions of hundreds of different botanicals and food in recorded history were found on Babylonian clay tablets and ancient Egyptian papyrus. Plants and herbals have been a part of many traditional healing practices throughout the history of mankind including: Chinese medicine, Ayurveda, a holistic system in the civilization of India, Curanderismo, a Mexican American healing tradition, as well as the practice of western herbalism. Many botanical compounds were the basis of medical pharmacotherapeutics in the U.S. as recently as the 1930s. As the world witnessed an advancement of scientific methods there was demise in the practice of herbology1. The reemerging popularity of nutraceuticals and of herbal products in the late 1990s led to the establishment of various schools for alternative medicine. A recent study specifically designed to evaluate use of these medications during the perioperative period demonstrated that 22% of the preoperative patients report use of herbal medicines and 51%, use of vitamins 2. After all, the contribution

1. MD, FAMS (Professor), 2. MD, Senior Resident, Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India. Correspondence to: - Yatindra Kumar Batra, Professor, Department of Anaesthesia & Intensive Care, Post-graduate Institute of Medical Education & Research, Chandigarh 160012 E mail: ykbatra@glide.net.in Accepted for publication on 20.4.07

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Yatindra Kumar Batra et al. Common herbal medicines and anaesthesia remedies. The pharmacological effects and anaesthetic implications of some of the commonly used herbs are discussed and few others are mentioned in Table 1. Table 1 Commonly used herbs perioperative implications
Name of herb (Bio lo g ical name) Bilbe rr y (Vaccinium uliginosum)

Name of herb (Bio lo g ical name) Milk thistle (Silybum marianum)

Us e s

Pharmac o lo gical effe cts

Per iope rative c once rns

Anaphylaxis Skin

and their
Per iope rative c once rns
Increased

Us e s

Pharmac o lo gical effe cts

Anthocyanidins

Lowers chol- Antioxidant esterol levels Antifibrinolytic Reduces insulin activity resistance Anti Anti cancer inflammatory effects Immunomodulating effects Autoimmune diseases Diabetic neu ropa thy Osteoporosis ARDS Hypertension Elevated serum lipids
Rich

reactions

Neuropsych-

ological events

Ophthalmic problems GI ailments Anti oxidant Anti tumorogenic

boost production of rhodopsin Tannins have anti-inflammatory properties

risk of perioperative bleeding

Primr ose (Primula vulgaris)

Black Cohosh (Actaea racemosa/ Cimicifuga racemosa)

Gynaecological Labour inducing Hepatotoxic disorders effects Contraindicated Musculoskel- Hormonal effects in pregnancy etal effects Emmenagogue and lactation properties Anovulatory effects Gynaecological More toxic than disorders black cohosh
Hepatotoxic Contraindicated

in aminoacids and omega 6 Increases prostaglandins Anti-inflamma tory Antithrombotic

Sedative May

induce seizures in susceptible pa tients

Saw palmetto (Serenoa repens) St Johns wort (Hypericum perforatum)

Benign prostatic hyperplasia

Inhibits

5 alpha reductase

May

exacerbate preexisting heart disease Pancreatitis

Decreased

Blue Cohosh (Caulophyllum thalictroides) Cr anbe rr y (Vaccinium oxycoccus)

in pregnancy and lactation

Minor depression

Serotonin,

norepinephrine reuptake blocker Inhibits CYP

Antibacterial Urinary tract infection

Inhibits

metabo- Increased risk of lism of warfarin perioperative Enhances immune bleeding system Close INR monitoring with warfarin
Direct

efficacy of other drugs Serotonin syndrome Stopped 5 days preoperatively

Ma Huang (Ephedra)

Weight loss Mood enhancer Allergic rhinitis Asthma

and indirect sympathomimmetic actions

Discontinued

24 hr preop Arrhythmias Haemodynamic instability

May

Overview of commonly used traditional Indian herbal medicines

The use of herbal medicine originated in India long back in pre-vedic period. Rigveda and Atharva-veda (5000 years B.C.), the earliest documented ancient Indian knowledge have references on health and diseases. Texts like Charak Samhita and Sushruta Samhita have documented this in about 1000 years B.C. Medicinal herbs have been in use in one form or another, under indigenous systems of medicine like Ayurveda, Sidha and Unani5. More than 3000 plants are recognized for their medicinal value, and are in use in traditional, folk and herbal medicine, representing about 75% of the medicinal needs of the Third World countries6. There are about 7000 firms manufacturing traditional medicines with or without standardization in India, and hence not many Indian products are available in a standard form5 . Another problem of Indian herbal products is adulteration 7 . The common examples which are well known are substitution of the bark of Holarrhena antidysentrica by Wrightia tictoria, and Saraca indica by Trema orientalis8. The storage process of herbal medicines may not be adequate and may pose additional health hazards. It has been reported that the stored drug samples harbour mycotoxin-producing fungi in high frequency. The

Green tea (Camellia sinensis)

Neurodegene- Caffeine and rative disease tannins cause Anti cancer stimulation of Hypolipedemic CNS Source of vitamin K Antioxidant

antagonize actions of warfarin May cause arrhythmias Caution in renal and thyroid diseases Insomnia
Fatal

Golden seal (Hydrastis Canadensis)

Sore eyes GI problems

Potentially

toxic alkaloids (hydrastine and berberine) Strongly inhibits CYP2D6 and CYP3A4/5
Anthraquinones

respiratory failure Interferes with action of heparin. Hypoglycemia

No ni Indian Mulberry (Morinda citrifolia)

Reduces blood sugar Hastens wound healing in diabetics

Hyperkalemia toxin Acute hepatitis Anti-nociceptive Contraindicated effects in pregnancy Anti-inflammatory and lactation effects

Contd.

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Indian Journal of Anaesthesia, June 2007 harvesting practices and high temperature and moisture contents are conducive to fungal invasion and mycotoxin elaboration. Mycotoxins have been found in stored drugs like, roots/rhizomes of Asparagus racemosus, Atropa belladonna, Withania somnifera, Plumbago zelanica, fruits of Emblica officinalis, Terminalia chebula and seeds of Macuna puriens 9. Complete phytochemical investigations of most of the medicinally important herbs of India have not been carried out so far. Various contaminants both in the form of conventional drugs and heavy metals have been detected in herbal preparations (Table 2). Table 2 Common additives to herbal medicines
Conventional drugs C af fe in e Chl o r phe nir am ine Cypr ohe ptadine De xa me thas o ne Di az e p am Dic lo fe nac Dipyr one Ephedrine Fluo c ino nide Hydr oc hlor othiazide Ibuprofen Indo methacin Methyl testosterone Par ac e tamo l Phe nac e tin Phe nfo r min Ph e ny lbut azo ne Pr e dniso lo ne Pr o me t hazi ne The o phylline Heavy metals Aluminum Arsenic Cadmium Copper Lead Mercury Tin Zink

garded as a good example of an herb with synergism and polyvalent action and Ginger (Zingiber officinale) is another example of synergism. In general, the clinical trial data on these preparations is in the embryonic stages, whereas the popularity of these compounds is fueled in part by anecdotal evidence10.

Arjuna (Terminalia arjuna)

Arjuna is grown in most parts of India and has been used in ayurvedic formulations since ancient times. Besides its wide range of medicinal uses, Terminalia arjuna is also planted for shade and ornamental purposes. It has therapeutic application as hypolipidemic, cardiac stimulant, hypotensive, cirrohsis of liver, diuretic, astringent, haemostatic, prostaglandin enhancing, coronary risk modulating properties, protection against NSAIDs induced gastric ulcer and against skin aliments like acne etc. Intraoperative use of intravenous arjuna produced hypotension in anaesthetized dogs. Hypotension was blocked by propranolol but not by atropine or mepyramine maleate, indicating mediation through beta receptors11 . The product literature states Use of Terminalia arjuna has not been associated with any severe adverse effects. However, comprehensive safety studies have not been performed. Safety in young children, pregnant or nursing women, or people with severe liver or kidney disease has not been established.

Chamomile (Matricaria chamomilla)

Chamomile has been used historically for GI discomfort, peptic ulcer disease, paediatric colic, and mild anxiety. The mechanism of action may be through central benzodiazepine receptors. Several trials have noted hypnoticsedative properties and reports of allergic reaction, however no significant toxicity has been noted 12.

Herbal medicines are typically taken as teas, capsules, tablets, or extracts. But depending upon the type and severity of symptoms, some preparations in China are given intravenously or subcutaneously. The mechanism of action of herbal medicine is not well-documented as to whether they act in a synergistic way or by additive effects. Clinical evaluation is also difficult, without knowing the extent to which synergy occurs within the herbal preparations. Some components may function as potentiators without having an intrinsic activity. St. Johns wort (Hypericum perforatum, family Hypericaceae) is often re-

Ma huang (Ephedra)
Ephedra, originally a native in China is grown extensively in India. There are several Ephedra species used, including E equisetina, E sinica, E intermedia, and E geradiana. E. gerardiana in India is found in drier regions of temperate and alpine Himalaya from Kashmir to Sikkim, Chamba, Lahul, Spiti and Ladakh13 . Ephedra is a botanical source of ephedrine alkaloids, Indian ephedra containing 0.28 to 2.79% by weight. Ephedrine was isolated from ephedra by the Japanese chemist Nagai, in 1887. Ephedrine and pseudoephedrine are the most abundant

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Yatindra Kumar Batra et al. Common herbal medicines and anaesthesia constituents; other sympathomimetic alkaloids which are present in ephedra include methylephedrine, norephedrine, methylpseudoephedrine, and norpseudoephedrine. The mechanism of action of these alkaloids includes direct agonism at and adrenergic receptors and indirect agonism by augmenting release of norepinephrine from presynaptic neurons. Clinically, this results in tachycardia, hypertension, diaphoresis, bronchodilation, agitation, and mydriasis with retained light reflex14. The allied benefits of Ephedra are numerous including joint aches, low blood pressure, cold and flu symptoms, edema, enuresis, narcolepsy, asthma, and upper respiratory infections. It has gained immense popularity for the benefits in weight loss and as a drug to enhance sexual performance. It is a drug of abuse with euphoric, stimulant effects and street names like Herbal Ecstasy, Cloud 9 and Ultimate Xphoria. Currently, the use of ephedra is banned by numerous sporting associations. The adverse effects attributed to the consumption of ephedra include nervousness, anxiety, palpitations, headaches, nausea, hypertension, seizures, strokes, myocardial infarction, hyperthermia, and death. Myocardial ischemia and infarction, dysrhythmias, and uncontrolled hypertension have been reported. Chronic use may induce cardiomyopathy. Other adverse events have been reported include palpitations, anxiety, vomiting, syncope, erythroderma, insomnia, headache, psychosis and heat stroke. Ephedra is included in a growing list of herbal products that has been associated with hepatic injury15 . Central nervous system involvement with vascular ischemia, haemorrhage, vasculitis and seizures has also been associated with its use16 . Ephedra is one of the commonly used herbs even by parturients17 . Although the actual incidence of clinically important symptoms during the perioperative period associated with the use of ephedra is not known, a signicant number of perioperative events including hard to control hypertension, causing myocardial infarction and stroke have been reported. Arrhythmias may be observed, particularly with halothane, isoflurane, desflurane and digitalis. Tachyphylaxis may be observed with intraoperative epinephrine18. Patients on chronic therapy tend to have exaggerated intraoperative hypotension due to depletion of peripheral catecholanie stores, which can be controlled with a direct vasoconstrictor (eg, phenylephrine) instead of ephedrine. Concomitant use with phenelzine or other monoamine oxidase inhibitors may result in insomnia, headache, and tremulousness. Use with oxytocin has been shown to cause hypertension. Absolute contra-indications to products containing ephedra include ischemic heart disease, hypertension, cerebrovascular disease, thyroid disease, diabetes, psychiatric disorders, prostamegaly and pregnancy or lactation. The elimination half life of 5.2 hr indicates that ephedra should be discontinued atleast 24 hr before surgery19 .

Ginger (Zingiber offcinale) (Adraka, Sunthi)

Ginger is inuse inIndia sincehistoric times datingat around 400 BC. Ginger has been described as an effective therapy for nausea, vomiting, motion sickness, hyperemesis gravidarum, PONV and vertigo. The mechanism to prevent nausea and vomiting includes actions at both gut and brain. 6-gingerols in ginger can enhance gastrointestinal transport and galanolactone, another active constituent, can act as a competitive antagonist at serotonin 5-HT3 receptors18. It is also used for respiratory ailments. Ginger has been found to cause hyperglycaemia. Ginger is a potent inhibitor of thromboxane synthetase enzyme, which can prolong bleeding time20. The importance of the enzyme inhibition to the anaesthesiologist is that, use of ginger may alter bleeding time, which therefore makes it imperative to avoid ginger in patients on anticoagulants like warfarin and heparin or drugs such as NSAIDs and aspirin. This may also impose special concerns for regional anaesthesia in patients who consume ginger regularly16 .

Garlic (Allivum sativum)

Garlic is one of the most popular herbs in the world and is cultivated in most parts of India. It has been used for several thousand years to flavour food and by Ayurvedic physicians for its medicinal properties. The most active ingredient of garlic is allicin, which contains sulfur and when combined with breakdown products, gives garlic its characteristic smell. Crushing the garlic clove activates the enzyme allinase that converts alliin to allicin. Constituents in garlic can block the cyclooxygenase pathway, preventing the formation of inflammatory prostaglandins21 . The beneficial effects are found to be in conditions like infection, tumours, diabetes, hypertension, hyperlipidaemia and atherosclerosis. There is increasing interest in its antihypertensive and antihypercholesterolaemic activity. Garlic was also administered to provide strength and to increase work capacity. Garlic is prescribed as a diuretic, expectorant, antimicro-

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Indian Journal of Anaesthesia, June 2007 bial, and antidiarrhoeal agent. The adverse effects of garlic include nausea (6%), hypotension (1.3%) and allergy (1.1%) 22 . The use of garlic may have anaesthetic implications by augmenting the effects of warfarin, heparin, nonsteriodal anti-inflammatory drugs (NSAIDs), and aspirin, and may result in an abnormal bleeding time, which can lead to an increased risk for intra-operative or postoperative bleeding. This may also cause concerns for neuraxial anaesthesia. Pharmacokinetic data are unavailable, however, owing to the antiplatelet effect; garlic is discontinued atleast 7 days before surgery18 .

Ginseng (Panax ginseng)

Ginseng is the most expensive and one of the most widely used herbal drugs throughout the world. There are three main subspecies of ginseng: Panax ginseng, Panax quinquefolius and Panax pseudoginseng. Active compound in panax ginseng is Ginsenoside. Ginseng has mild sympathomimetic activity and may interact with monoamine oxidase inhibitors 25. This herb is well known since ancient times, as an aphrodisiac, anti-aging, and energy enhancing tonic. It is a drug of abuse by athletes who consume this to boost their energy levels. Other effects include augmentation of adrenal steroidogenesis and immunomodulation. Ginseng is consumed as a raw herb, powder, or made into ginseng tea20 . Adverse effects may include irritability, insomnia, and GI disturbance in addition to hypoglycaemia, hypertension, nervousness, insomnia and skin rashes. Weak estrogenic potential may predispose to gynaecomastia and vaginal bleeding26. It may predispose to perioperative bleeding by inhibiting platelet aggregation and prolonging activated partial thromboplastin time, probably due to vitamin K antagonism. It may also predispose to hypoglycaemia. Ginseng may interact with oral anticoagulants, antiplatelet agents, corticosteroids, and hypoglycaemic agents 27 . The use of Ginseng may thus have perioperative implications and should be avoided in patients on anticoagulant medications such as warfarin, heparin, NSAIDs and aspirin. The presence of hypertension and its effects like, the occurence of target organ damage, volume depletion, autonomic instability due to long standing disease may be of additional perioperative concern. Monitoring blood glucose is imperative particularly in diabetic patients on oral hypoglycaemic agents or insulin, due to the risk of hypoglycaemia that may be caused with ginseng. Maniac episodes may be precipitated with concomitant MAOI28 . It is one of the popular herbs even among parturients. The antiplatelet effect may cause concerns with neuraxial blockades commonly employed in parturients. Ginseng should be avoided in pregnancy, in children, lactating women, and in patients with cardiovascular disease29 .

Maidenhair tree (Ginkgo biloba)

Ginkgo biloba is grown for its ornamental purpose and as a source of herbal medicine. Ginkgo extract contains several flavonoids, terpenoids and organic acids that are believed to protect vascular walls and nerve cells by acting as free radicals and by inhibiting platelet activating factors. It can decrease erythrocyte aggregation and blood viscosity. Ginkgo (120 mg.day -1) is used to treat cognitive deficits such as Alzheimers disease, multi-infarct dementia, asthma, angina, intermittent claudication, sexual dysfunction and eye ailments. It is also used in peripheral vascular disease due to its property of decreasing blood viscosity and increasing flow. Chinese herbalists use this drug for respiratory infections 19 . The adverse effects of ginkgo are limited to mild gastrointestinal upset and headache. Various ginkgolides, have platelet activating factor (PAF) antagonist properties and mediate the antiplatelet and anti-inflammatory properties. There are several reports of intracranial haemorrhage in patients using ginkgo. In a case report, a healthy 34 yr old man bled unexpectedly (Hb 16.5 to 5.4 g.dl -1) following laparoscopic cholecystectomy, and on further questioning it was found that he was consuming 2 tablets/day of ginkgo 23 . In spite of the cognition enhancing properties, this herb is neurotoxic. Ginkgo biloba is associated with an increased risk of perioperative bleeding due to interactions with aspirin, or any NSAIDs and anticoagulants such as warfarin and heparin, and their coadministration is hence not recommended. Seizures may be precipitated due to reduced efficacy of anticonvulsants, and the risk may be further exaggerated with concomitant tricyclic antidepressants 24 .

Grapefruit juice
Grapefruit juice, is a popular beverage, that may decrease atherosclerotic plaque formation and inhibit cancer cell proliferation. Unlike other citrus fruits this can inhibit CYP3A4 and can alter metabolism of various medications 30.

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Yatindra Kumar Batra et al. Common herbal medicines and anaesthesia

Kava kava (Piper methysticum)

Kava was originally in use in South Pacific, as their ceremonial drink, and is now used for its medicinal values in other parts of the world as well. It is used as an alternative to sedatives and anxiolytics. Kavalactones (also called kava pyrones), the active component of kava, may work by binding to g-aminobutyric acid (GABA) receptor inhibitors. It is used to treat gonorrhea and many skin diseases. In large doses, kava can lead to kava dermopathy, which causes flaking and a yellowing of the skin. Several studies report extrapyramidal-like dystonic reactions and visual disturbances with use of kava. Use of kava with alcohol or other sedatives is contraindicated, as is use in pregnancy and lactation31 . Hepatotoxicity has been recently reported17 . The use of kava may potentiate the effects of benzodiazepines and barbiturates are potentiated. Ethanol can increase the hypnotic effects of kava kava18 .

St. Johns wort (Hypericum perforatum)

St. Johns wort has been used medically since the day of Hippocrates. The therapeutic effects and toxicity of the herb have been implicated to two extensively studied compounds hypericin and hyperforin, which are rich in ripe fruits15. Though traditionally used for mild to moderate depression, it does not have any role in the treatment of major depression. It has found a place in the treatment of various other ailments: anxiety, insomnia, irritability, neurosis, migraines, dyspepsia, gastritis, inflammatory bowel disease, sciatica, pain associated with herpes zoster, trigeminal and other chronic neuralgia, myalgia, and dental extraction. In addition it is used topically in various dermatological conditions. The herb is available in tablet, capsule, or tea form as well as a cream, oil, or liquid tincture32. The most widely accepted premise to describe the molecular basis of its action is on biogenic amine hypothesis. The predominant mechanism of action is serotonin reuptake inhibition, other mechanisms include monoamine oxidase inhibition, interference with melatonin secretion, and uptake of norepinephrine33 . The electroencephalographic changes seen in patients taking St Johns Wort though similar to patients on selective serotonin reuptake inhibitors, the proposed mechanism is different from SSRIs15 . Hypericum extracts suppress the hypothalamic pituitary axis and reduce corticotrophin releasing hormone and interleukin 6 release, thus mitigating depressive symptoms34 . In addi-

tion effects on GABA receptors, cholinergic receptors, inhibition of viral activity, anti inflammatory activity and anti cancer benefits are under investigation. St Johns wort has been shown to induce cytochrome P450 system, particularly CYP 3A4 leading to altered metabolism of co-administered drugs. It can increase the metabolism of drugs like alfentanil, midazolam, lidocaine, calcium channel blockers, indinavir, estradiol, digoxin, oral contraceptives warfarin, theophylline, oral anticoagulants and cyclosporine35. Serotonin syndrome may be precipitated when St. Johns wort is used with conventional antidepressants, necessitating precautionary measures similar to those for patients taking conventional MAO inhibitors. Discontinuing St Johns wort after protracted use may lead to a rebound increase in plasma concentrations of these drugs 16 . Side effects described include dry mouth, dizziness, fatigue, constipation, and nausea. The most prominent adverse effect is photosensitivity, attributed to its hypericin component. Although there have been no reports of adverse effects on cardiac conduction, concomitant use of SSRIs may precipitate serotonergic syndrome, characterized by tremors, hypertonicity, myoclonus, autonomic dysfunction, hallucinosis, hyperthermia, and even death36. Other less common adverse effects include sexual dysfunction, hair loss, elevated thyroid-stimulating hormone, psychotoxic reactions, and reports of hypertension and hypertensive crisis. Seizures have been noted in animals, but there are no human case reports of this. Withdrawal symptoms may be observed after stopping the drug following a high dose therapy. There is no data till date on the treatment of toxicity15 . The use of this herb is popular even among parturients and children. The anaesthesiologist should preoperatively review additional medications or herbs that the patient may be taking. Delayed emergence from anaesthesia (fentanyl, propofol and sevoflurane) and cardiovascular collapse has been reported37 . Concomitant use of sympathomimetic amines, MAOIs and tyramine containing foods (cheese, beer, wine) is not advisable to prevent the occurrence of serotonin syndrome. The drug interactions make it imperative to discontinue St Johns Wort preoperatively in patients awaiting transplant due to the risk of rejection. Patients on warfarin may be at risk for thrombotic complications because typical doses of warfarin may not provide adequate protection. The pharmacokinetic data described in humans with a median elimination half life of 43.1 hr for hypericin suggest that this drug should be discontinued at

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Indian Journal of Anaesthesia, June 2007 least 5 days preoperatively 38. In parturients, the main interactions are with pethidine, used for labor analgesia where it could result in hyperthermia, hypertension, hypotension, rigidity, seizures, and coma. In addition, ephedrine commonly used to treat spinal hypotension, may have an accentuated response because of more neurotransmitter available for release. As St Johns Wort increases uterine tone in animal studies, it is contraindicated in pregnancy. Safety data during lactation is sparse, though mothers have complained of drowsiness or lethargy in newborns exposed to St Johns Wort 39 . Table 4 Toxicity of herbal medicines commonly encountered in anaesthetic practice
Risk of perioperative bleeding Angelica root Arnica Asafetida Borage seed oil Capsicum Chamomile Chondroitin Dong quai Car diov ascular side -e ffec ts Chan su Chaste tea Dong quai Foxglove Garlic Ginkgo Ginseng Goldenseal Guarana Hawthorn berries Kava kava Licorice root Ma huang Mate St johns wort Yohimbe
Water and electrolyte disturbances

H ypo g lyc aemia Angel pearl Bitter melon Devils claw Garlic Ginseng Karela Ma huang Tongyi Zhen qi
Potential for hepatotoxicity

Valerian root (Valeriana officinalis)

Valerian root has been used for centuries as a sedative agent and sleep aid. Similar to kava, action on GABA receptors may be responsible for the sedative effect. Recently, it has been used mainly for other ailments like insomnia, jet lag, migraine headaches, fatigue, and intestinal cramps. Side effects may include headache, excitability, uneasiness, and cardiac disturbances. The use of this drug is not popular among parturients with only about 0.4% consuming this herb. There are reports of liver dysfunction

Evening primrose oil Green tea Fever few Flower Fenugreek Garlic Ginseng Ginkgo Ginger Golden seal Kava kava Kelp Licorice root

Borage seed oil Chaparral Echinacea Germander Licorice root Pyrrolizidine alkaloids Red yeast rice Skullcap Valerian Willow bark
Prolongation of anesthetic effects

Ginseng Green tea Goldenseal Kelp Licorice root Mate Saw palmetto
Hyperglycaemia

Table 3 Herb drug interactions

Bilbe rr y Black Cohosh Cr anbe rr y Ec hinac ea Ephedra Gi ng e r Ginkgo biloba Increased risk of bleeding with warfarin Increases cytotoxicity of doxorubicin and docetaxel Decreases cytotoxicity of cisplatin Profound hypoprothrombinemia and bleeding with warfarin Avoided with known hepatotoxic drugs Contraindicated with MAO inhibitors, central nervous system stimulants Caution with anticoagulant and antiplatelet drugs Increases haemorrhage with NSAIDs, warfarin Decreases efficacy of anticonvulsants

Lovage root Mate Meadow sweet Onion Parsley Passion flower herb Quassia Red clover Willow bark

Kava kava St Johns wort Valerian

Neurological side effects

Chamomile Ginseng Kava kava Passion flower Skullcap St Johns Wort Valerian
Renal adverse effects

Chromium Fenugreek Garlic Ginger Ginseng Glucosamine Nettle Aristolochia fangchi

Sage

Grapefruit juice Inhibits CYP3A4 induced drug metabolism Green tea Kava Primrose oil St Johns Wort Interferes with absorption of alkaline drugs Sedation with benzodiazepines, barbiturates and alcohol May evoke temporal lobe epilepsy Serotonin syndrome with serotonergic reuptake inhibitors and tricyclic antidepressants Decreased efficacy of warfarin, digoxin, theophylline, cyclosporine, anticonvulsants and antiretroviral agents

and these are considered to be idiosyncratic reactions 19 . Valerian root potentiates sedative effects of anaesthetic agents. Sudden abstinence may precipitate withdrawal-type syndrome17 .

Conclusion
Understanding the ingredients and constituents of herbal medicine associated with the use of herbal medicines is important to anaesthesiologists involved in patient care. Asking patients about self-care and treatments used
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Yatindra Kumar Batra et al. Common herbal medicines and anaesthesia outside the hospital is an important part of the patient history. Herbal therapies are very popular for various conditions despite the lack of strong research supporting some of their use. In spite of high degree of interrater observer unreliability, patients are likely to seek to herbal medicines as a means of self-treatment and a way to maintain additional life control41 . It is vital for the anaesthesiologist to have knowledge of the various interactions associated with the use of herbal medicines (Table 3). Many of these agents lead to an increased risk of perioperative bleeding, and toxicity on almost all the systems has been reported (Table 4). When contemplating this extremely complex subject, it is important to remember that Natural does not necessarily mean safe. It is imperative to remember that at this time, much of the available information is anecdotal and future double-blind, placebo-controlled trials are needed. Active ingredients are not consistent between studies making it difficult to extrapolate meaningful data. Patients should be encouraged to discontinue these products well in advance based on the pharmacokinetic data or when in doubt two to three weeks prior to surgery42 .
12. 13. Rotblatt M, Ziment I. Evidence based herbal medicine. Philadelphia: Hanley and Belfus 2002. Porwal MC, Sharma L, Roy PS. Stratification and mapping of Ephedra gerardiana Wall in Poh (Lahul and Spiti) using remote sensing and GIS. Curr Sci 2003;2:84. Gurley BJ, Gardner SF, White LM, et al. Ephedrine pharmacokinetics after the ingestion of nutritional supplements containing Ephedra sinica (ma huang). Ther Drug Monit 1998;20:439 45. Holstege CP, Mitchell K, Barlotta K, R. Brent Furbee, Toxicity and drug interactions associated with herbal products: Ephedra and St. Johns Wort. Med Clin N Am 2005;89:122557. Cheng B, Hung CT, Chiu W. Herbal medicine and anaesthesia. HKMJ 2002;8:123-30. Hodges PJ, Kam PCA. The peri operative implications of herbal medicines. Anaesthesia 2002;57:88999. Skinner CM, Rangasami J. Preoperative use of herbal medicines: a patient survey. Br J Anaesth 2002;89:792-5. Kaye AD, Kucera I, Sabar R. Perioperative anesthesia clinical considerations of alternative medicines. Anesthesiol Clin N Am 2004;22:12539. Backon J. Ginger: inhibition of thromboxane synthetase and stimulation of prostacyclin: relevance for medicine and psychiatry. Med Hypoth 1986;20:2718. Suekawa M, Ishige A, Yuasa K, et al. Pharmacological studies on ginger 1. Pharmacological actions of pungent constituents, [6]gingerol and [6]-shogaol. Pharmacobiodynamics 1984;7:83648. Rivlin RS. Is garlic alternative medicine? J Nutr 2006;136:713S 5S. Fessenden JM, Wittenbern W, Clarke L. Ginkgo Biloba. A case report of herbal medicine and bleeding postoperatively from a laparoscopic cholecystectomy. Am Surg 2001;67:335. Fugh-Berman A. Herbal medicinals selected clinical considerations focusing on known or potential drug-herb interactions. Arch Intern Med 1999;159:1957-8. Dorman T. Herbal medicine and anesthesia. Curr Opin Anaesthesiol 2001;14:667-9. Shah BK. Drugs. News Views 1997, 4: 7. Izzo AA, Ernst E. Interactions between herbal medicines and prescribed dugs: a systematic review. Drugs 2001;61:2163. Jones BD, Runikis AM. Interactions of ginseng with phenelzine. J Clin Psychopharm 1987;7:2012. Miller LG. Herbal medicinals selected clinical considerations focusing on known or potential drug-herb interactions. Arch Intern Med 1998;158:2200 11. Kane GC, Lipsky JJ. Druggrapefruit interactions. Mayo Clinic Proceedings 2000; 75: 93342. Pittler MH, Ernst E. Efficacy of kava extract for treating anxiety: systematic review and meta-analysis. J Clin Psychopharmacol 2000;20:849.

14.

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