This is a subject of real importance, and the belated wake up call is timely. Unfortunately, much of the new literature is inappropriate to the real clinical context, because it often based upon unproven extrapolations from test tube studies or purely speculative interactions because of the general lack of data. It is invariably presented by individuals who lack specific training either in the complexities of natural product chemistry (a subject long since dropped from standard pharmacy and pharmacology courses) or lack experience in the clinical use of natural remedies, and are who can only speculate upon on the from a narrow perspective. For Naturopathic physicians, clinical herbalists and other similar practitioners of complementary and alternative medicine (CAM), the importance of potential interactions between herbs and supplements with drugs has long been considered a important part of clinical assessment and natural therapeutics. But for MD's and healthcare professionals working within the framework of standard practice medicine, there has been a sudden awakening to the fact that there is a large and important area of information about natural remedies and their potential interactions which is not available in standard medical curricula, and has not been the subject of systematic study. Fortunately, the emerging framework of "Integrative Medicine", which seeks to combine CAM with modern biomedical practice without violating the basics tenets of either (a tendency that is arguably at this time more a mind-set among some medical professionals rather than an institutional reality) has begun to produce solid informational tools to guide health professionals through the complexities of the multidisciplinary area of interactions in terms of everyday clinical reality rather than alarmist speculation.
In the case of surgical procedures, the area of natural remedies potentially interacting with perioperative procedures has also become a topic of current debate. Some valuable patient survey information has become available which gives us a sense of the growing importance of these concerns. In the Journal of the Association of Operating Room Nurses (Jan 99), JM Murphy discussed cases of patients who had been taking herbs prior to surgery and how this had influenced the course of events, particularly the postponing of the procedure. She emphasized the importance of the perioperative team members asking patients about their use of herbal remedies during assessments of medication use. McLeskey et al found that 170 of 979 (17.4%) of presurgical patients admitted taking herbal products when questioned. The median age for both the herb users and non-users was 62 years. Of the patients taking herbs, 55% took only one product, 45% took multiple products. In decreasing order, the most commonly utilized herbs among this group were: Gingko biloba (32.4%), garlic (26.5%), ginger (26.5%), ginseng and St. John's Wort (14%). The most commonly used nutritional supplements were glucosamine sulfate (17%), chromium picolinate (17%) and chondroitin sulfate (12%). In October, 1999, in light of the increasing use of the use of natural products by patients, John B. Neeld, Jr, MD, President of the American Society of Anesthesiologists reiterated statements he first made in the spring of 1999, in which he suggested that patients should stop taking herbal medications at least 2 to 3 weeks before surgery. Neeld and others have specifically cautioned against feverfew potentially affecting PT time and increasing risk of bleeding, and St. John's Wort and Kava-kava prolonging the sedative effect of anesthesia due to a presumed MAOI-like action. While each of these warnings may have some anecdotal or theoretical foundation, no clinical research, published case reports or substantive pharmacological analysis has confirmed these claims of adverse effects or interactions. Pending further research leading to the establishment and adoption of formal protocols supported by clinical studies, the following recommendations should be considered by nursing staff involved in peri-operative care:
PRE-OPERATIVE
1. Audit all dietary supplements and herbal remedies taken on a regular basis by the patient, It is well known that patients are sometimes fearful of disclosing supplement use to physicians, and the role of nursing personnel and pharmacists in gathering information undisclosed to physicians may be important.
1.1 Audits should include supplement product brand name, a technical description of the contents using proper botanical names for herbs rather than common names. For example there are many different kinds of "ginseng". The best method is to ask the patient to bring the package or container and transcribe the details from the label.
1.2 The dose, in terms of amount, frequency and history of usage should be noted. The form of the remedy should be noted. For example, 300mg of dried St John's Wort herb is very different from 300mg of standardized extract of St John's Wort. 2. The supplement audit should then be checked against an "amber /red alert" list of "potentially serious interactors". This list should compiled from a reliable database of interaction information by medical team members. *** The two primary areas of pre-operative concern are interactions affecting blood coagulation and other hematological parameters and interactions with anesthetics that may affect sensitivity to sedation or recovery times. (Examples of herbs common affecting coagulation are garlic, ginkgo, ginger, and cayenne. Herbs that may affect the CNS include valerian, kava kava and St John's Wort. Herbs such as Milk thistle which act on the liver may alter the rate of clearance of CNS anesthetic agents like diazepam)
3. If a potential interaction is discovered the matter should be referred to perioperative medical team members and an assessment made as to whether the scheduled procedure should be postponed for a period while the supplement is withdrawn from use. This may involve additional testing of INR/PT times.
POST-OPERATIVELY
In the post-operative area, natural remedies have been shown to be more of positive benefit than to cause negative effects.
1. Recovery: It has been shown that preoperative consumption of capsules counting one gram dried ginger root can reduced nausea and vomiting during recovery. Ginger also has anticoagulant effects, but a single pre-operative dose is unlikely to alter coagulation
2. Healing: Several folk and natural remedies are considered to speed the healing process, reduce bruising and soreness and minimize scar formation. Some of these agents such as Arnica her are not suitable for internal use in high doses.
3. Pain medication: Post operative patients discharged with pain medication prescriptions should be advised about possible additive interactions with natural agents acting on the CNS that may be consumed to enhance sleep, reduce anxiety or help pain relief.
4, Convalescence: Several natural remedies have been shown to improve convalescence, notably the ginseng family. One authoritative reference system to provide interaction information on natural substances in the form of an easy to use, comprehensive and well-documented database. put together by a team of naturopathic physicians, medical herbalists, pharmacists, and medical doctors is Interactions™, the IBIS Guide to Drug-Herb and Drug-Nutrient Interactions™. With Interactions™, a physician, pharmacist or patient can quickly and accurately retrieve information on a desired drug, herb, or supplement. Interactions™ makes it easy to find the information on each topic from several different starting points. A user can choose a topic from lists of drugs, herbs, nutritional supplements, drug classes, or herb groups. Drugs are listed by brand name, generic name, or drug class and a reference database of these names is provided. Alternatively, a powerful search facility can be used to enter and locate the name of a substance or agent to find all entries on its interactions in the program. Once a desired topic has been selected, the program immediately presents a summary outlining the therapeutic uses for the substance and an overview of known and potential interactions. From there it is easy to access more detailed interaction information for each drug, herb or nutrient combination by clicking on the "Interactions" option. In this section, Interactions™ provides detailed information on each potential drug-nutrient or drug-herb interaction for the chosen substance, including key information on research, doses and mechanisms of action. Physicians and pharmacists will find that each entry is formatted for quick review and written in a thorough, practical style designed for sharing with patients. Essays on individual drugs and nutrients include a chemical formula drawing while color photos brighten each herb article. The monographs vary in length from several paragraphs to many pages depending upon the complexity of the interactions of the particular substance. In addition, each herb entry also includes a "Clinical" section describing the properties, therapeutic uses, typical dosages, and any known toxicities or side effects for that herb. Finally, the sources of information for each substance are cited throughout the text and meticulously documented under the "References" section of each entry. The reference section provides comprehensive bibliographic data and offers abstracts for the most relevant journal articles. Interactions™ is available on CD-ROM (Windows and MacOS) and is being licensed to select websites. It is produced by Integrative Medical Arts of Beaverton, Oregon. You can learn more by calling 503.628.0319, sending email to Interactions@IBISmedical.com, or visiting http://www.IBISmedical.com.