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Enhancing your immune system, getting a good night’s sleep, and reducing your anxiety level are just three of the benefits promised to people who use herbs. But while consumers hear about the benefits of herbs, they usually haven’t heard about the potential dangers if surgeons and anesthesiologists don’t know about their use prior to surgery.
The American Society of Anesthesiologists (ASA) in Park Ridge, IL, has issued a warning for patients to tell physicians about the use of herbal medications before surgery. The ASA recommends that a patient stop taking herbal medications two to three weeks before surgery, and if there is not enough time to stop taking the medication, the patient should bring the product in its original container to the hospital or surgery center.
"Seeing the original container gives the pharmacist, surgeon, and anesthesiologist a better chance to identify other ingredients that might produce an interaction with drugs during or after surgery," explains Jessie A. Leak, MD, an associate professor in the department of anesthesia at M.D. Anderson Cancer Center in Houston and a researcher who specializes in the study of herbal medication.
One in three Americans use a botanical or herbal product, and 60% of these do not regularly disclose the use to their physicians, according to Leak. "We are very concerned about the possible effect of some herbal medications on a patient’s outcome," she says. "Consumers don’t realize that natural’ does not equal safe for everyone in every situation."
Because herbal medications and vitamin supplements can be purchased over the counter, pharmacists don’t have the opportunity to spot potential interaction with prescription medication. Some of those interactions can be dangerous if the patient undergoes surgery, Leak says. (See potential interactions, above.)
Some botanicals produce their effect by thinning the blood to increase circulation. If a patient taking one of these botanicals is also taking a drug such as warfarin, the result is excessive bleeding during surgery, says Leak.
Even without warfarin, the patient’s blood may take longer to clot, she says. "If the surgeon knows about the use of the botanical, the patient can discontinue its use several weeks prior to surgery to reduce the risk of bleeding."
Finding out if patients are using herbal medications or vitamin supplements is not a simple task because many are afraid to reveal the use to their physicians, says Paulette Swanson, RN, education coordinator at Lakeview Hospital in Stillwater, MN. "Patients tell us that they don’t reveal their use of herbal medications because physicians don’t ask or because they feel guilty," she says. Patients feel guilt because they don’t want their physicians to think they don’t trust their doctors’ ability to care for them, she adds.
"To help patients feel comfortable discussing their use of alternative medicine, we have to initiate the conversation in a nonthreatening manner," says Swanson. The day-surgery program at her hospital uses a patient admission assessment form that specifically prompts the nurse to ask about alternative medicines as part of the question asking about prescription and over-the-counter medications. (See assessment form, inserted in this issue.)
"Because the nurse is already asking the patient for different types of information, the patient is comfortable giving information about herbal medications," explains Swanson. "If a nurse identifies a patient that is taking more than five medications [including prescription, over-the-counter, herbs, oxygen, or vitamin supplements], a pharmacy consult is requested," she says. "A pharmacy consult is also arranged if the nurse is not familiar with the herb identified by the patient or if the patient doesn’t know why he or she is taking the herb."
Sometimes, just knowing the name of the botanical isn’t enough to enable a physician or pharmacist to evaluate potential interactions, says Leak. "Botanicals are not regulated as a drug by the Food and Drug Administration. They are included in the same category as food," she says.
This classification results in less stringent requirements for the production of botanicals. For example, consider echinacea, which is used to enhance the immune system. Echinacea from one manufacturer may not contain the same amount of echinacea mixed with other ingredients as a second manufacturer, she explains.
If you want to ask patients about use of herbal medications or other alternative medicine treatments, be careful how you address the patient, warns Swanson. Staff cannot be judgmental or skeptical, and can’t offer advice regarding the effectiveness of treatments, she says. "It is also important that your surgery staff is aware of potential interactions."
Most importantly, says Swanson, "You must convey the idea that it is OK to integrate alternative medicine with traditional medicine in order to make the patient feel comfortable enough to give you the information. Not only do we have to ask the patient about herbs, but we have to make them want to answer."
O’Hara MA, Kiefer D, Farrell K, et al. A review of 12 commonly used medicinal herbs. Arch Fam Med 1998; 7:523-536.