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CME

Use of Herbal Supplements and Vitamins in
Plastic Surgery: A Practical Review
George Broughton, II,
Learning Objectives: After studying this article, the participant should be able
M.D., Ph.D., Col., M.C., to: 1. Explain what governmental regulations control the labeling and distri-
U.S.A. bution of herbal supplements. 2. List the more commonly used supplements and
Melissa A. Crosby, M.D. their reported benefits. 3. List the possible postoperative complications from
Jayne Coleman, M.D. consumption of the more commonly used herbal supplements. 4. Explain the
Rod J. Rohrich, M.D. preoperative management of patients using herbal supplements. 5. Know ad-
Dallas, Texas ditional 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. (Plast. Reconstr. Surg. 119: 48e, 2007.)

W
idely used today, herbal medicine dates listic. It is based on the complementary forces yin
back thousands of years and started in and yang. When yin and yang are in balance, the
India and China. Chinese medicine person is healthy; illness occurs when there is
dates back approximately 4000 years and is ho- imbalance between the two forces. The Chinese
evaluate the interactions between the environ-
From the Department of Plastic Surgery, Nancy L & Perry ment (food, air, and drink) and the body
Bass Advanced Wound Healing Laboratory, and the De- (waste). The cause (and treatment) of the im-
partment of Anesthesia, University of Texas Southwestern balance is determined by examining the tongue,
Medical Center.
iris, and pulse. Treatment is usually a mixture of
Received for publication December 16, 2005; accepted Feb-
ruary 9, 2006. herbs, massage, and acupuncture.1
The opinions or assertions contained herein are the private In India, Ayurvedic medicine dates back to
views of the author and are not to be construed as official or 3000 BC. Ayurvedic medicine combines physio-
as reflecting the views of the Department of the Army or the logic and holistic philosophies. It is based on the
Department of Defense. concept that the human body, like the universe,
Copyright ©2007 by the American Society of Plastic Surgeons is composed of five energy elements: earth, wa-
DOI: 10.1097/01.prs.0000252661.72071.8d ter, fire, air, and space. Interaction of these ele-

48e www.PRSJournal.com

to 97 percent of the U. potency.5 A recent survey and Education Act of 1994 places the burden of of 163 health food retail stores in the United States product safety assurance on the manufacturer. taking one or more herbal medications along with prevent. Echinacea pallida. although combinations of herbs on the market. or cure a disease continue “to be re- their prescription medicine. folk remedies. saw palmetto (Serenoa repens).7 It is estimated that up to 32 plain how herbal manufacturers can sidestep U. Complementary manufacturing. ministration put forth the “Regulations on State- cinium macrocarpon). or commonly take herbs (23.13 In the United States. Congress expanded the government’s inter- tic practice of herbal medicine. Siberian ginseng be of concern. Astonishingly. more prevalent among white. female patients more ease is “any deviation from.6 Current movements suggest ments Made for Dietary Supplements Concerning St. and three malas (waste ical use between age groups. health claims. 1998. Treatment is then tients stop herbal medications 2 weeks before personalized to these findings.8.S.S. and Native Americans had a significant medicine was becoming more common and in impact on botanical remedies in the United 1992 established the Office of Alternative Medi- States.8 Drug.10 Unbelievably. Congress recognized that alternative Chinese. the revealed that the top 10 selling herbs are echina.6 percent versus 19.4 est by establishing the National Center of Com- THE PROBLEM plementary and Alternative Medicine to deter- mine the effectiveness of these therapies and Complementary and alternative medicine is support research in alternative medicine. with a minority in the med. valerian the Effects of the Product on the Structure or (Valeriana officinalis). herbal therapy began in the colonial days as folk medicine. Individual herbs can- There are more than 20. self-help groups. and the U. educated. Food and tritional literature. There rarely taught in U. treat. and others.” The definition of dis- Among surgical patients. 70 garded as drugs and have to meet the safety and percent of patients do not reveal the use of these effectiveness standards for drugs under the Food.11. percent). American Panax quinquefolius). the ma.12 Herbal use is products). Food and Drug Administration main- jority of published information about herbal tains for the pharmaceutical industry. and purity and alternative medicine includes herbal reme. Women The Government’s Responsibility would brew botanicals in the home. and feverfew (Tanacetum Function of the Body” to address these concerns.12 The American Society of made by an elaborate system of examinations of Anesthesiologists recommends that all surgical pa- physical and mental findings. Safety and health claim practices continued to cies). All diseases are attributed to an im. population takes herbal Food and Drug Administration drug regulations: remedies on a regular basis.S.Volume 119. a group of cine through the National Institutes of Health. if the U. In the nineteenth century.S. chi. aloe (Aloe spe. are not held to the same standards and regulations megavitamins. Herbal remedies ropractic manipulation. impairment of. loba).6 ex- top 10 herbal agents. Herbal medicine use has increased may be. Phased tri- remedies can be located in the nursing and nu.3 surgery. responsibility of proving that a product is unsafe. Food and Drug Ad- (Eleutherococcus senticosus). hospitals. nacea angustifolia). dietary supplements that on a weekly basis. parthenium) are likely soon to be listed among the Concerning these regulations. although the U.2. Food and Drug Adminis- canadensis). and balance among the three doshas. that the U.S. U. Diagnosis is wealthy individuals. and one in five patients report expressly or implicitly claim to diagnose. Although the Dietary Supplement Health 380 percent from 1990 to 1997. supplements to their health care providers. massage. ginkgo (Ginkgo bi. Sabar et al.S. of compounding herbal preparations when com- dies. medical schools and generally are several important differences regarding the not practiced in U. Food and Drug Administration assumes the cea (Echinacea purpurea. pared with other medications.S.9 One in seven pa- tients report taking at least one herbal supplement under the proposal. and Echi.000 herbal medicines not be patented. garlic. ma huang (Ephedra sinica). and Cosmetic Act.S. Europeans. The U.5 scientific data to consumers. In physicians known as Eclectics adopted the holis. Drug Administration can “suggest” provision of ical literature. als are not required. ginseng (Asian Panax ginseng and tration has reason to believe that an herb is unsafe.2 interruption of the normal structure or func- 49e . John’s wort (Hypericum perforatum). Number 3 • Herbal Supplements and Vitamins ments gives rise to the three doshas (forces). and cranberry (Vac.11 and there is no difference in botan- seven dhatus (tissues). goldenseal (Hydrastis Therefore.S. it can remove the drug from the market. relaxation techniques.S.

The most common Overview reason given for taking herbal supplements is to Arnica has been used topically for centuries improve general health (16 percent). cure. rosis.12 This description epitomizes the majority of aesthetic patients and. on the market today. . at least one person in the operating It has been shown that herbal use is more room should have practical knowledge of herbal prevalent among white. Nearly all (86 percent) prospective. angina pectoris.9 percent). Boiron Arnica Montana Cream and Gel.8 percent that in- or more signs or symptoms .16 These concerns sure. and antiseptic cited “herbals are natural” as the most common properties. and 8 disallowing the statement “decreases blood pres.4 percent that affect blood allows the claim “promotes vascular health” while pressure.” In response to the regulations. Eighteen common herbs used frequently by sur- A general survey14 of adults on herbal medi. their children with herbs.13 A survey Synonyms for and Products Containing of surgical patients revealed that patients admitted Arnica to taking herbal medicines that had coagulation Leopard’s bane. Fifteen percent of adults treated postoperative complications. cardiovascular effects (20 percent). it is a concern that plastic surgeons cannot them would be beyond the scope of this article.4 percent with cardiac effects. 32 percent answered all questions correctly. there are many potential compli. and many other unproven cent used an herbal remedy “sometimes” to applications. depending on which form of it was scription medications. and friends (14 percent) were mountain climbers to relieve sore muscles and the most common sources of herbal remedy in. cations that the surgeon should know.18 Clearly.3 per person. Arnica has caused severe and 50e . SinEcch. Until that Why Should You Care? time comes. There have been multiple clinical “always” to self-treat before seeking medical care studies exploring the efficacy of arnica in reducing from a physician. Magazines (17 percent). 42.15 Another survey of surgery ingested (homeopathic or nonhomeopathic dos- patients found that during the 2 weeks before ages. organ. sed. Cosmesis Bruise Away Cream.7 bacco. of the body surgery. or A recent survey assessing the knowledge of herbal prevent any disease” and thus is not subject to the supplements by anesthesiologists found that only FDA drug regulations. herbal have prompted some anesthesiologists and sur- manufacturers now add information that their geons to postpone elective surgical procedures. Arnica (Arnica montana) ing the past 12 months. and 22. Vita- ative effects (16.20 preoperative use of herbal supplements will cause Use among Surgical Patients harmful effects. Plastic and Reconstructive Surgery • March 2007 tion of any part. discussing only 1 percent of tients. placebo-controlled trials evaluating respondents believed the herb was helpful or very liposuction and rhytidectomy demonstrated sta- helpful. 7. treat. although there HERBAL SUPPLEMENTS are no comprehensive reports in the literature on With over 20. and Arniflora Gel.” This definition hibit coagulation. .14 tistically significant decreases in postoperative Although there is no clear evidence that the swelling and bruising. Two randomized. Medica. arterioscle- formed their physician of such use. The average number of herbs used was 2. and wealthy medicine and its effects.21 trolytes or diuresis (8. mountain to- effects (40. for myocarditis. 14. percent with sedative effects. Only 50 percent of the population in. in alphabetical order. analgesic. gery patients are discussed.17 product “is not intended to diagnose.7 percent consumed complementary that is manifested by a characteristic set of one and alternative medicines: 19. dangerous.7 percent). No data are available.5 percent). respectively). percent). . individuals. It is the classic homeopathic remedy benefit. all physicians need additional and con- tinued training on herbal medicine. blood pressure effects (32. ignore. Herbal users for its antiinflammatory. or system .000 herbal medicines available herbal supplement use among plastic surgery pa.19. The 18 herbs are listed cine use obtained from three grocery store inter. cardiac insufficiency. .. health food for trauma of various kinds and was often used by stores (16 percent). wolf’s bane. Forty-one per. It has also been used formation.11. and effects on elec. minimize bruising from falls. educated. cepts in northwest Ohio showed that 40 percent of respondents have used an herbal supplement dur.8 percent Adverse Effects of patients reported using herbs that are known to Arnica is thought22 to be either worthless or cause adverse effects when combined with pre.

ginseng. Danggui. Bromelin.27 Quai. Tanggwi (Korean).” based on its use for gynecologic surgery. vitamin C. ropean angelica. cardiotoxicity. head- cytes against tumor cells and by inducing the ache. for cardiovascular condi- ing the impaired immunocytotoxicity of mono. Dang Gui. Bromelain may enhance the antithrombotic Dong quai has been known to prolong pro- activity of such drugs as aspirin. complications. as compared with the Recommendations placebo group. Chinese Danggui.25 Overview Known as Chinese angelica.24.23 Arnica demon. production of distinct cytokines such as tumor Dong quai has multiple coumarin derivatives. and is used primarily for women’s apple plant. Ananase.12 No data are available. Yuan Nan wild Dong Quai.24.29 Bromelain should be stopped 2 tions for the prevention of bruising and swelling weeks before surgery in a select group of patients can probably be safely taken by patients under a taking this supplement with anticoagulants or with physician’s supervision. bromelain has been shown to disorders such as painful dysmenorrhea.21 Bromelain may increase heart rate at creased sun sensitivity with a risk of severe pho- higher doses and should be used cautiously in tosensitivity may occur because of chemicals in 51e . bromelain may increase the risk of en’s ginseng. lated as “the blood”). It re- Overview mains one of the most popular plants in Chinese Bromelain is an extract derived from the pine. and general fatigue/low vitality. Ananas sativus. Concomitant use thrombin time/international normalized ratio of bromelain and amoxicillin or tetracycline has and activated partial thromboplastin time. and Japanese medicine.21 necrosis factor-␣. Synonyms for and Products Containing Synonyms for and Products Containing Dong Quai Bromelain American angelica. wild angelica. Tang and Traumanase. and bleeding.27 bleeding disorders or who are taking anticoagu. arnica should be stopped 2 weeks before surgery and topical arnica (all types) should not be used Dong Quai (Angelica sinensis) on broken skin or during the postoperative period until the wound is completely healed.9 percent of patients Use among Surgical Patients in the perioperative period.Volume 119. infections. without documented bleeding Arnica available in manufactured prepara. European Dong Quai. and rutin resulted tions) are reserved for professionals. It cells and as an inhibitor of platelet aggregation. to suggest that bromelain should not be used by bances. medicine. female plant protease concentrate. Presurgical Precautions and with less inflammation.28 strates the paradox of homeopathic medicine— Presurgical Precautions and the less concentrated the drug. Eu- lainum. Each time the drug is diluted A randomized. and been reported to increase the serum levels of these may interact with the effects of Coumadin. grape seed extract. There are animal data blood pressure.26 Dong quai is taken by 0. That is why the common potencies are onstrated oral supplementation with a nutritional available over the counter in the United States and supplement containing bromelain. the stronger or Recommendations more efficacious it is. and muscle paralysis. tions/high blood pressure. dong quai has been used for thousands of years in traditional Bromelain Chinese. bromeline. In addition. wild Chin Quai. Tang Kwei. root of the Holy Ghost. Use among Surgical Patients and interleukin-8. the very highest potencies (most dilute formula. wom- In theory. Bromeliaceae. Tanggui (Korean).26 is also given for strengthening xue (loosely trans- Bromelain acts as an immunomodulator by rais. Toki Adverse Effects (Japanese).25 in a 17 percent decrease in wound-healing time. Korean. calcium. Danggui-Nian-Tong-Tang (DGNTT). interleukin-6. serious gastrointestinal distur.” Dong quai has been called said to reduce inflammation and swelling after “female ginseng. patients with liver disease. inflammation. Caution is advised in people who have Yungui. interleukin-1␤. Adverse Effects lants. and neuropathic (nerve) pain. postpar- act as a potential immunomodulator of tumor tum weakness. double- by a factor of 10 or 100 or more it becomes more arm crossover study out of our institution dem- potent. Unsupervised ingestion of a history of bleeding disorder or liver disease. Bromelins.30 In- antibiotics. Proteinases found in bromelain are “health conditions. pineapple extract. Brome. large increases in people with heart disease. placebo-controlled. Number 3 • Herbal Supplements and Vitamins fatal poisonings.13.

it is taken to prevent and treat farction (including a hypercoagulable state) were upper respiratory tract infections. rudbeckia. ephedra has before surgery. A recent case report40 described a weightlifter using an ephedra-contain- Overview ing supplement who had experienced an acute Echinacea is used as a natural antibiotic for its myocardial infarction secondary to thrombosis in immunostimulating properties. Herbals That Affect Cytochrome CYP3A4* aforce. Dong quai Ephedra (Ephedra sinica. a volatile oil in dong quai. interactions: A literature review. Echinacin. black Susan. weight loss. sales of echinacea are believed to represent Use among Surgical Patients approximately 10 percent of the dietary supple. 2005). been suspected of creating a hypercoagulable state. or bloating. Ma Huang) preparations may contain high levels of sucrose Overview and should be used cautiously by patients with Ephedra. Bio Trim. and ber.37 Most of the drug– herb interac. laxative effects/diarrhea. black Sampson. Kansas snake root.31 In the United situ. 52e . Metaboloss. In the United ruled out. Med. and female patients. tions. a potent stimulant. Bladderwrack-Dandelion Virtue. †Data derived from Miller. L. States.27 cursor to epinephrine and pseudoepinephrine. Better Body Energy for Life.11 Metabolife 356. burping. purple coneflower. scurvy root. Testosterone Theophylline cea may decrease the effects of cyclosporine and *CYP3A4 is the most abundant of all the P450s in human liver and steroids. Plastic and Reconstructive Surgery • March 2007 dong quai (furocoumarin.7 percent of surgical Biovital Plus. G.37 Other drug– herb interactions in. 158: 2200. kegelblume. (Herbal medicinals: Selected clinical considerations focusing on known or potential drug-herb interac- roids. amiodarone. methotrexate. red sunflower.42 quicker healing for skin and oral wounds and Synonyms for and Products Containing oral/injectable echinacea for vaginal Candida al. Echinacea is also purchased to treat sumed by 18 percent of patients preoperatively. 1998). is the herbal pre- diabetes or glucose intolerance. Echinaguard. Long-term use Presurgical Precautions and should therefore be avoided. vom- iting. and sun hat. interactions. cock-up-hat. Metabo- Synonyms for and Products Containing TRIM. Naturally Ripped. In contrast. AllerPlus. Andro Use among Surgical Patients Heat. and suntan lotions Recommendations that contain dong quai often limit the amount of Because of the risk of significant drug– herb dong quai to less than 1 percent. anorexia. All other possible causes of myocardial in- States and Europe. Echin.32–35 Acceleration. psoralen. dyspepsia. Safrole. Ephedra-containing concoctions are con- ment market.36 There is a theoretical risk Licorice Oral contraceptives for poor wound healing in chronic users. may nacea to inhibit cytochrome CYP3A438 (Table 1). the Topical echinacea juice has been suggested for overweight. John’s wort Cyclosporine snakeroot. patients.27 Digitalis Adverse Effects Inhibits activity Lidocaine Goldenseal Midazolam Long-term use (8 weeks) is associated with Echinacea Nifedipine immunosuppression. Echinacea can potentiate the toxicity of is involved in the metabolism of many environmental toxicants and barbiturates. Naturatussin Echinacea American coneflower. Dong quai (par. Presurgical Precautions and Components of the herb are known to inhibit the Recommendations complement pathway in vitro. be carcinogenic (cancer-causing). and as a stimulant. The herb is commonly used by the young. Naturafed. nausea. Other uses for ephedra include treatment of Echinacea (Echinacea purpurea. Echinacea angustifolia) hancer. Echinacea respiratory illnesses. patients should stop taking the drug ticularly with prolonged use) is associated with 2 weeks before surgery. Echinacea is taken by 12. drugs. tions of echinacea occur from the ability of echi- gapten). Intern. body building en- pallida. clude potentiation of hepatotoxic effects of ste. AllerClear.39 raising a concern Patients should stop taking the drug 2 weeks for prolonged bleeding. Induces activity Coumadin St. Table 1. Drugs 65: 1239. Indian Common Medications Metabolized Herb and Its Effect by CYP3A4† head.41 genital herpes and radiation-associated toxicity. hedgehog. and Hu et al. comb flower. (Herb-drug and halothane. ketoconazole. Echina. Ephedra bicans infections. solhat. Metabolift. Arch.

27 bound headaches. There are no rebral vascular accident. body odor. has antiplatelet activity. Therma.45 Presurgical Precautions and Recommendations Garlic (Allium sativum) Possible intraoperative complications in- clude interactions with anesthetic gases and re.54 –56 Garlic comes in a raw form and as an herbal tablet. as an antibiotic. this herb have a 10 percent chance of developing ThermoDiet. ce- ficial effect this herb may have). ephedra from store shelves. myocardial infarction. Kwai. arrhythmias. Number 3 • Herbal Supplements and Vitamins 1. Nettle-Reishi Virtue. flirtwort.43 Adverse Coumadin. Feverfew (Tanacetum parthenium) Use among Surgical Patients Overview Garlic is used in up to 7. headache. Power Thin. and cardiomyopathy. panic cycloxygenase51–53 (possibly explaining the bene- attacks. lieves diarrhea. camphor of the poor.21 Feverfew is regarded as garlic.S. Overview fractory hypotension requiring phenylephedrine Commonly used for cooking.21 monoamine oxidase inhibitors. gar- has also been used for arthritis.12 verfew reduces the frequency and severity of mi- graine headaches when taken in small amounts Synonyms for and Products Containing daily. Respa-Herb. and intestinal Bad breath. Fresh garlic has caused rash or skin burns. garlic clove.9 percent of surgical Several clinical trials46 – 48 have shown that fe. and re- ephedra-free at least 2 weeks before surgery. nervousness. a general tonic. ProLab Adverse Effects Stoked. and “blood purifier. and antitussive. cardiovascular medications. and bloating. tranquilizer.31.21 According to a recent study based on data Presurgical Precautions and from the U. Ripped Adverse effects occur most when patients stop Fuel. Drug– herb Feverfew interactions that may occur with garlic include Featherfoil. However. Poison Control Centers and sales Recommendations information. Pro-Ripped Ephedra. it is used to prevent infection preparers handling garlic. Ajoene. Our recommendation is that patients 2003.S. Other side effects in- and reduce swelling from wounds and tooth ex. and midsummer daisy. insomnia. Adverse Effects ation. patients.Volume 119. drug. palpitations.50 and has side effects of ephedra-containing drugs include been shown to inhibit lipoxygenase and tachycardia. allergies. People who abruptly discontinue drene. Allicor. clude hypotension. angina. lowering agent. Thermo Cuts. cramps. and Kyolic. the U. It inhibits platelet mediately stop using them. garlic corns. bachelor’s hypoglycemics. seizures. 53e . lic oil. Ultra Diet Pep. Feverfew garlic. clove eficial effect of feverfew over placebo. analysis49 of five double-blind. patients should be aggregation. most common serious complication from garlic Use among Surgical Patients use is increased bleeding secondary to its anti- No data are available.57–59 Garlic may Synonyms for and Products Containing also prolong the effects of Coumadin. SinuCheck. ran. lipid- ra-containing supplements should be told to im. hypertension. and buttons.27 indigestion. diuretic. taking feverfew. Garlic domized.44 As of December 30. Thermicore. hyperten- published recommendations for stopping this sion. fatigue. antihypertensive.41 Patients taking ephed. The traction. and allergic reactions parasites. SinuClear. Thermic Blast. other gynecologic disorders. but its effectiveness for these ailments are the most common reported side effects of has never been verified. platelet and antithrombotic effects. garlic extract. painful menstru. ephedra accounted for 64 percent of Feverfew has the potential to interact with all reported adverse effects from herbs. Adverse Effects joint pain. featherfew. and Xenadrine a postfeverfew syndrome—symptoms include re- RFA-1.” both in people taking garlic therapy and in food As a wash or rinse. muscle stiffness. Food and Drug Administration should wean off their feverfew over 2 weeks and made a statement that ephedra may present “an then be off it completely for 2 weeks to minimize unreasonable risk of illness or injury” and man- the risk of developing a postfeverfew syndrome dated the removal of all substances containing and bleeding. postnatal bleeding. SnoreStop. controlled trials failed to show any ben. and tension. garlic is also used (not pseudoephedrine). enhances fibrinolytic activity.

however. Overview leading to vitality and longevity. motion sickness. the efficacy of anticonvulsants13 and also interacts ingwer. chosen ninjin. kankyo. and dementia31. five-leaf ginseng. chayenne ginger. gegibre. patients preoperatively. prevention of arterial Synonyms for and Products Containing spasm. tebofortan.63 ginkgo.62 Adverse Effects Use among Surgical Patients Small clinical trials have not demonstrated Ginger is consumed by 2. Japanbaum.41 prolonged bleeding (because of inhibition of Presurgical Precautions and thromboxane synthetase). lia. tanakene. Alzheimer’s disease. vital. five-fin- thromboxane synthetase. Jamaica ginger.60 Presurgical Precautions and Recommendations Ginseng (Panax quinquefolius.63 clude arterial vasodilation. chikusetsu and antioxidant capabilities.60 Overview Ginseng.68 The physiologic ef. sophium.65 supplement at least 36 hours before surgery. postop. shown to decrease blood glucose levels in both Patients also take ginkgo to treat asthma. rheumatoid arthritis. vasan. Salisburia macrophylla. xi cal bleeding.76 Ginkgo can Adverse Effects interact with barbiturate anesthetics. dwarf ginseng.69 Ginkgo also inhibits ginseng.78 uent of Ginkgo biloba. xi shen. Ginseng gregation. angina. type II diabetics and nondiabetics. Ginsenosides have been fore. Japanese Ginger (Zingiber officinale) silver apricot. gan jiang. yakuyo ninzin. temple balm. which may increase surgi.27 spirits. tempeltrae. ginseng radix. It is recommended that patients discontinue Zingiber officinale) its use 1 week before surgery. oriental plum tree. ya chio. causing pro- Possible perioperative complications include longed sedation. ginger root. cerebral insuffi- have also been found to inhibit platelet aggrega- ciency. ginger trips. yang 54e . gers. sore throats.64 hyperglycemia. Salisburia adiantifo- Typical uses of ginger include food prepara. black ginger. Araliaceae (family). Ginseng is consumed by 7. noyer du Japon. maid- enhair tree. Panax Ginseng. yakuyo ninjin. cystectomy have been reported. has gained popularity for its alleged ability to protect the body from stress.77 Ginsenosides colds. gin. and to dispel evil yin-guo. tebonin.71–75 Ginkgo also cochin ginger. kung sun shu. kew tree. a constit- tion and enhance fibrinolysis. peripheral vascular disease. Allheilkraut.60 Ginkgo Arbre aux quarante écus. five cases of spontaneous hemor- Synonyms for and Products Containing rhage (four cerebral. and yin-hsing.4 percent of surgical fects of ginkgo extracts have been reported to in.11 continue its use 7 days before surgery to prevent Synonyms for and Products Containing possible bleeding complications. and Recommendations prolonged prothrombin time if taken with Patients should be advised to cease taking this Coumadin. valverde.60. gingembre.67 Ginkolide B. tion. reduction of blood viscosity/erythrocyte ag. patients. and race ginger. tramisal. lowers a patient’s seizure threshold and decreases gerall. one hyphema) and one case of Ginger postoperative bleeding after a laparoscopic chole- African ginger. The pharmaco- Ginkgo biloba (maidenhair tree) and its leaf ex- logic effects and properties of ginseng are heter- tracts are commonly used to improve circulation. relief of respiratory ailments. there- known as ginsenosides.66 ogenous and related to the active constituents memory. most commonly of the Asian or Ginkgo (Ginkgo biloba) American species. ginger power BP. erative nausea and vomiting.61. Plastic and Reconstructive Surgery • March 2007 Presurgical Precautions and Use among Surgical Patients Recommendations Ginkgo is taken by 8. and eye problems. silver apricot.70 yang shen. salisburia. antagonism of platelet-activating factor. LI 1370. was found to inhibit platelet- activating factor and presumably is the cause of the Use among Surgical Patients herb’s antiplatelet activities.6 percent of surgical bleeding complications with the consumption of patients preoperatively.27 with monamine oxidase inhibitors. tanakan.6 percent of surgical Patients taking garlic supplements should dis. pei Overview kuo. pei-wen. Rokan. it is typically used in the elderly population.

eye root. Overview crease the therapeutic effect of Coumadin.27 tion.37 It is also known to inhibit cytochrome glycans. and headaches. and re- of the knee.85 Presurgical Precautions and Recommendations Use among Surgical Patients Because goldenseal inhibits cytochrome No data are available.81 dians who used the plant to improve digestion as a bitter tonic and to treat ulcers. Number 3 • Herbal Supplements and Vitamins shen yeh-shan-seng.79 Ginseng is known to de. Dia. stabilize collagen and elastin. CYP3A4. and has chemopreventive daily (tablets or capsules) has been well tolerated effects in patients with cancer. Glucosamine is commonly taken with spiratory failure. tachycardia. grape seed extract has been reported to re- Presurgical Precautions and duce inflammation. Goldenseal root has acquired a con- Ginseng has been studied to determine whether siderable reputation as a natural antibiotic and as it improves postoperative nausea and vomiting. glucosamine may proanthocyanidin content. Adverse Effects Ginseng may cause insomnia.82 There is a case report of a patient disorders. In a 3-year study and several seed extract provides two to five times better pro- short-term trials.83 Other Goldenseal is consumed by 1. and she had been taking ginseng Use among Surgical Patients along with other herbs and medications. Maxi GS. Caution is advised in bioflavonoid that acts as a strong antioxidant. An infusion of the Presurgical Precautions and root was used as a soothing rinse for eye and skin Recommendations infections. epistaxis. Available evidence from randomized con- CYP3A438 and affects drugs metabolized by the trolled trials supports the use of glucosamine sul- enzyme system (Table 1). cerebral ar- teritis.86 It appears that glucosamine does not combination.Volume 119.11 include digitalis84 and monoamine oxidase inhibi. GS-500. the number of adverse events in tection against oxidative tissue damage as com- patients taking glucosamine was no different from pared with vitamins C and E singly and in placebo. pro- patients with bleeding disorders and in those tak. eye balm.21 Grape Seed Adverse Effects Overview Glucosamine may increase insulin resistance Grape seed is extracted from red and purple and consequently affect glucose tolerance. yuan-seng.89 55e . hypoglycemia. Glucosamine Complex. yuansheng. Goldenseal (Hydrastis canadensis) hypertension. In addi- ing drugs that may increase the risk of bleeding. ground raspberry.21 Adverse Effects Overview Goldenseal is known to cause sodium deple- Glucosamine is an amino monosaccharide tion and may potentiate the effects of other found in chitin. jaundice root. Goldenseal. Synonyms for and Products Containing tors. and NAG. glycoproteins. tecting DNA from harmful free radicals. and need to be stopped until the evening before sur- zhuzishen. yellow root.80 and Goldenseal is a Native American medicinal paradoxically inhibits platelet adhesiveness and plant introduced to early settlers by Cherokee In- antagonizes platelet-activating factor. undergoing reoperation for postoperative bleeding after a mastectomy. Recommendations act as a natural antihistamine. grapes and purported as having health benefits betics should use glucosamine supplements under based on its antioxidant action found in its active medical advisement. Indian tur- meric. and glycosamino- diuretics. Proanthocyanidin is a increase the risk of bleeding. Other side effects in- fate in the treatment of osteoarthritis. and protect and Glucosamine at a dose of 500 mg three times heal connective tissue. Patients should stop taking ginseng 2 weeks Goldenseal before surgery. particularly clude gastrointestinal upset.38 patients should stop taking this drug 2 Synonyms for and Products Containing weeks before surgery. nervousness. Glucosamine Sulfate and Indian paint.4 percent of sur- medications that can cause herb– drug interactions gical patients. with a remedy for various gastric and genitourinary mixed results. Glucosamine Sulfate Aflexa. grape for 30 to 90 days. In theory.87 chondroitin sulfate (a glycosaminoglycan derived from articular cartilage). Nature’s Blend Glucosamine.88 Reportedly.27 gery.

wurzelstock. which is known to heal stomach ulcers. glycyr- rhizin. The first discovery of the health ben- 56e . fied by diuretic use. Kava kava is taken by 1. intoxicating pepper. vegetables. the U. Presurgical Precautions and The glycyrrhizin in licorice also appears to be ef- Recommendations fective against viruses such as hepatitis B. kawa. as with any supplement. which may be magni- kava. injuries. headache. effects.2 percent of surgical and sweetwood.S. headaches. The side effects disappear been associated with liver-related injuries— after the drug is discontinued. ever. In Asian medicine. and licoricidin—are antiinflammatory. liquorice. licorice preparations should not be used comatose. Food and Drug Ad.21 patients. influ- None.31. lic- Ava.13 Licorice Use among Surgical Patients Black sugar. 50 g of licorice root daily) for an “extended period tation. ication for Parkinson’s disease should not take this drug. when ministration has received a report of a previously taken in high dosages (⬎20 g of licorice extract or healthy young woman who required liver transplan. Opc extract is a proven treatment for stomach ulcers. the root has also been used for boils. surgery. Licorice Opc (Oligomeric Proanthocyanidins). and human immunodeficiency virus by en- hancing the immune system’s T-cell count and Kava Kava (Piper methysticum) stimulating interferon.63 Adverse Effects Synonyms for and Products Containing Licorice is known to cause hypertension. cirrhosis. and grape seed extract. Overview Synonyms for and Products Containing Licorice root has long been known for its abil- Grape Seed ity to soothe respiratory inflammation. ava pepper.” it will lead to adverse effects listed above.11 (kava potentiates ␥-aminobutyric acid) and mus- Synonyms for and Products Containing cle relaxant properties.91 A man tak. coumarin. Grape seed extract appears safe overall. dehydration. and liver failure—in Presurgical Precautions and over 25 reports of adverse events in other coun.21 The extract also seems to have a beneficial effect Adverse Effects on viral infections of the liver. likely to produce any side effects. enza. 85. licorice root.8 percent of surgical Kava kava is typically used for its antianxiety patients. eye diseases.38 It is sometimes barbiturate anesthetics13 and has been shown in accompanied by fatigue. in addition to several reports of liver-related of time. However. sakau.95 Licorice inhibits CYP3A4 in vitro and may Adverse Effects affect the metabolism of drugs (Table 1) metab- Kava kava can prolong the anesthetic effects of olized through this cytochrome. licorice is un- the United States. supplement. Plastic and Reconstructive Surgery • March 2007 Use among Surgical Patients Licorice (Glycyrrhiza glabra) No data are available. Other ingredients—including glabridin. and myalgias. Licorice inhibits platelet aggregation and contains hibition of thromboxane synthesis. adequate scientific diarrhea. and has resulted in cardiac tonga. Because of the possibility of these side ing kava kava with alprazolam became semi. sore throat.93. vitro to cause platelet dysfunction through in. Patients should stop taking kava kava 2 weeks canola oil. and green leafy before surgery. Recommendations tries. flaxseed oil.92 Kava kava– containing products have longer than 6 weeks. Patients taking levodopa-based med. Licorice contains glycyr- beneficial and adverse effects associated with this rhetic acid. walnuts. and sodium retention. ar- Kava Kava rhythmias.94 Omega-3 Fatty Acids Presurgical Precautions and Overview Recommendations Omega-3 fatty acids are found in various fish.90 arrest. kava kava. kew.21 Use among Surgical Patients Overview Licorice is taken by 0. and yanggona. how. rauschpfeffer. sweetroot.21 including hepatitis.90 Kava kava also has an antagonistic effect Patients should stop taking licorice 2 weeks before on dopamine. Four patients required liver transplants. In addition. and studies have not been performed to delineate the swelling from infections. In At recommended dosage levels. orice causes hypokalemia. awa.

drug– herb interactions with phenylephrine. dwarf palm.87 enoic acid (EPA. corancillo surgery. it is used for symptoms operative sedation. halibut oil. Arecaceae (fam- cular disease. ily). reduction of blood clots.3 percent of surgical patients induce the activity of hepatic cytochrome use saw palmetto. Johns wort has also been (breaking down of blood clots). fish extract. Number 3 • Herbal Supplements and Vitamins efits of omega-3 fatty acids was made in the 1970s.102 Fish oils and dopamine reuptake by neurons105 and has appear to decrease platelet aggregation and pro. Presurgical Precautions and Recommendations Use among Surgical Patients Because of the ability of omega-3 fatty acids to St. and Recommendations long chain polyunsaturated fatty acids. nor- linolenic acid.13 The active ingre- Use among Surgical Patients dients or the mechanism by which they act are not No data are available. epinephrine. though not considered the standard of care in the however. balm-of-warrior’s wound. dendlu.27 Because of the risk of postoperative bleeding. omega-3 fatty acid supplements 2 weeks before balsana. Synonyms for and Products Containing Saw when scientists discovered that the Eskimos living Palmetto in Greenland had fewer occurrences of cardiovas.13 sociated with cardiovascular collapse on induc- Use among Surgical Patients tion of anesthesia. and prevention of breast cancer. American dwarf palm tree. alpha. C20:5n-3). and may reduce shown to induce the cytochrome P450 pathway. bossant. ine.12 The majority of patients using CYP3A4108 and reduce the efficacy of cyclospor- saw palmetto are male. 57e .98 –100 Very large intakes of fish oil/ omega-3 fatty acids (“Eskimo” amounts) may Overview increase the risk of hemorrhagic (bleeding) St. John’s Wort (Hypericum perforatum) at lower doses. amiloride. acids may increase the risk of bleeding. John’s wort is taken by up to 4. Coumadin. and psoriasis. patients should use surgical patients.-linolenic acid (ALA. fuga daemonum. Eisenblut. John’s Wort taking 3 g or more per day should stop taking Amber touch-and-heal. flor de Sao Joa.96 Reported physiologic effects saw palmetto berryserenoa. eicosapenta. litus. although there is little evidence of significant bleeding risk St.12 caution taking supplements containing omega-3 Synonyms for and Products Containing fatty acids before surgical intervention.107 St. C18:3n-3). John’s wort is used to treat depression and stroke.96. oral contraceptives. doco. Stro- of omega-3 fatty acids include reduction of cho.101 High doses have also been associated anxiety by inhibiting serotonin.106 St. and Zwegpalme. John’s wort is known to Approximately 2. cod liver oil. mycin D.97 tress. diabetes mel.5 percent of reduce blood clot formation.103 altering the metabolism of many drugs metabo- lized through this pathway. Blutkraut. been found to be as efficacious as monoamine long bleeding time and increase fibrinolysis oxidase inhibitors. gen. bassant. date. cold water fish. and actino- sahexaenoic acid (DHA. devil’s scorge. well defined. and witcher’s herb.27 Saw Palmetto (Serenoa repens. alleviation of fatigue and Saw palmetto can cause occasional gastric dis- depression. propanolol. Patients St. tachycardia. decreased in. there are theoretical #945. it is the most popular herbal treat. and angina. There has been one report of severe Synonyms for and Products Containing intraoperative bleeding in a patient taking saw Omega-3 Fatty Acids palmetto. cabbage palm. von Willebrand factor. fish oil fatty acids. Al. be more severe when combined with narcotics. there have been no reports of this to United States. goatweed hartheu.Volume 119. Adverse Effects patients should stop taking the drug 2 weeks be- Intake of 3 g/day or greater of omega-3 fatty fore surgery. Sabal serrulata) Adverse Effects Overview Potential side effects include prolonged post- Popular in Europe. norepinephrine. digitalis.15 Long-term use of the herb has been as- ment for this condition.104 In addition. WS 1473. rheumatoid arthritis. fish liver oil. This tranquilizing effect may associated with benign prostatic hypertrophy. C22:6n-3).27 lesterol. with nosebleed and blood in the urine. fish Presurgical Precautions and body oil. Serona repens. Adverse Effects flammation and pain. Elusan Prostate.

red blood cell production. setwall. Use among Surgical Patients Valerian root is taken by 2. nervous system depressants. Table 2 pro- Valerian root is used commonly for its sedative vides a brief overview of some recently identified and hypnotic properties in patients with insomnia. it is prudent that hypericin has been described. St. retinal. and E are discussed.12 Overview Synonyms for and Products Containing Vitamin A is a generic term for a large number Valerian Root of related compounds including retinol. Vita- muscle relaxation through interactions with min A plays a role in vision. Many commonly encountered supplements tients using antidepressants containing serotonin have the potential to interact with prescription and by those taking monoamine oxidase inhibi. identified through case-by-case reporting. retinoic acid. tamins A. and acute hepatitis. because of the lack of content Valerian Root (Valeriana officinalis) consistency in marketed products.54 3 weeks before an elective operative procedure. 58e . John’s wort 2 mends that all herbal medications be stopped 2 to weeks before surgery. and central by exerting its effects by inhibiting serotonin. Many supplements and vitamins may be stopped later.116 Be- doxycycline.113 Multiple preparations are available (a dried herb. restlessness.21 in gene transcription. gene tran- ␥-aminobutyric acid receptors. It has been recommended that American Society of Anesthesiologists recom- patients discontinue all use of St. In addition. common supplement– drug interactions.114 teract the negative effects of chronic corticoste- Long-term consumption of valerian root by one roid use and irradiation. Beta-carotene and other Adverse Effects carotenoids are found in various plants that ulti- The herb may cause excessive sedation and mately are converted to retinol in the body. impact on surgical patient care are discussed. growth.109 –111 midazolam.105 Caution should be exercised by pa. VITAMINS ous extract. neurons. Vi- cations. and verted to retinoic acid in the body and plays a role vandal root. Plastic and Reconstructive Surgery • March 2007 indinavir.1 percent12 to 51 percent11 of preop- sumably secondary to withdrawal.37 symptoms.5 percent of surgical Vitamin A (Retinoic Acid) patients. Be- tients. However.13 Additional embryologic development. and the herb Only the vitamins that may have a significant is commonly combined with other herbal medi. tobacco root.93. Johns wort has also been shown to induce Few studies exist examining these interactions. re. and specifically retinoids such as cause of the lack of consensus on the interaction tretinoin used by many plastic surgery patients between herbal supplements and anesthetics. the cytochrome P450 pathway. immunity. and dopamine reuptake by taking the drug 2 weeks before surgery. an aque. Presurgical Precautions and Presurgical Precautions and Recommendations Recommendations St. blurred vision.115 Administra. interactions. and tion of benzodiazepines will reverse the patient’s lidocaine. patients should stop norepinephrine. theophylline. Concomitant use scription.117 and less commonly as an anxiolytic. or an ethanol extract13). report the use of herbal supplements with one or ported photosensitivity related to the compound more prescription medications. erative patients report taking vitamins.94. B12. capon’s tail. John’s wort (Hypericum perforatum) is used Because valerian root may potentiate sedative by many patients to treat depression and anxiety effects of barbiturates. medications and anesthetics used during surgery. midazolam and lidocaine) metabolized cause 16 percent of adults in the United States through this pathway (Table 1). anesthetics. pre. we support this Overview recommendation for our patients. and with barbiturates is contraindicated.119 –122 patient resulted in delirium and cardiac failure Use among Surgical Patients during emergence from general anesthesia. altering the me. All-heal. and other retinoids. Retinal is con- Amantilla. the should be avoided. tors.112 Patients taking plastic surgeons be aware of some of the most other photosensitizing agents such as tetracycline. high doses of side effects include gastric distress. and the majority of this information has been tabolism of many drugs (most notably in our pa. heliotrope. Garden heliotrope. C. From 15.118 Brief. vitamin A may improve wound healing and coun- excitability.

SSRIs.. MAO. serotonin selective reuptake inhibitors. cyanocobalaminum.123 Vitamin A.Volume 119.4 mg/day for adults and adolescents aged 14 hemorrhage. bedumil. Z. Anacobin. international normalized ratio. meats. Palmi. Bedoz. tremulousness. Synonyms for and Products Containing such as fish. Herb-drug interactions: A literature review. acetylsalicylic acid. and Cyomin. is 2. Decreased plasma levels cyclosporine. nonsteroidal antiinflammatory drugs. Number 3 • Herbal Supplements and Vitamins Table 2.21 Overview Adverse Effects Vitamin B12 is an essential water-soluble vita. 700 ␮g/day (2300 IU) for women]. B complex vitamin. cobalamin. The elderly emy of Sciences to prevent deficiencies in vitamin are the most at risk for deficiency. John’s wort SSRIs/MAO inhibitors Central serotonin excess Oral contraceptives Altered menstrual bleeding Loperamide Acute delirium episode Warfarin Decreased INR Digoxin. BP. Vitamin B12 is bound to Adverse Effects the protein in food. retinaldehyde. hydroxocobal- couraged from taking such high doses unless un. Adapted from Hu. and ur- min that is commonly found in a variety of foods ticaria have been reported. Yang. Hydrochloric acid in the stom- Recommended dietary allowance levels for vi. Itching. ach releases B12 from protein during digestion. Patients exceeding the recommended di. monoamine oxidase. The human body stores several years’ worth nyl acetate. shellfish. Institute for Medicine of the National Acad. and dairy products. proteins. B complex.118 From 15. other B vitamins in a vitamin B complex formu- beta-carotene oleovitamin A. of vitamin B12. cobamin. tamin A oral intake have been established by the Once released. retinyl palmitate. cyanocobalamin. indinavir. Tox. idrossocobalamina. estrogen Ginseng Alcohol Increased blood concentrations Warfarin Decreased INR Phenelzine Insomnia. cycobemin. Drugs 65: 1239. Al- phamin. ASA.27 vitamin is extremely rare. Cyanoject. etary allowance (⬎5000 IU/day) should be dis. der the supervision of a physician. reti. P. Vitamin B12 (20 ␮m/ 59e .27 (from decreased intrinsic factor production) and vitamin A is generally considered nontoxic. and is absorbed into the bloodstream.124 The recommended dietary allowances icity has been shown to result in liver damage.. Crys- Vitamin B12 (Cyanocobalamin) tamine. rash. cobalamins. amin. so nutritional deficiency of this tate-A. Recommendations Synonyms for and Products Containing Patients taking their recommended daily dose Vitamin B12 of vitamin A do not need to stop taking it before B-12. See text for detailed explanation. Excess in strict vegetarians who do not consume animal dosing may lead to acute or chronic toxicity. lation.1 percent12 to 51 percent11 of preop- Presurgical Precautions and erative patients report taking vitamins. hydroxocobalaminum. headache. 2005. axerophtholum. X. et al. Ho. At recommended doses [900 ␮g/day (3000 IU) B12deficiency is seen with pernicious anemia for men. Supplement–Drug Interactions Supplement Drug Interaction Garlic Warfarin Increased INR Chlorpropamide Hypoglycemia ASA/NSAIDs Potentiate antiplatelet effects Antihypertensives Potentiate effects Ginkgo biloba Warfarin/ASA Bleeding Anticonvulsants Decrease effectiveness Thiazide diuretics Increase BP Trazodone Coma Digoxin Increased plasma levels St. blood pressure.. vitadurin. surgery. Vitamin A Vitamin B12 is frequently used in combination with Antixerophthalmic vitamin. Aquasol A. B12 complexes with intrinsic factor U. and excess amounts can years and older. C. NSAIDs. mania Echinacea No known No known Kava Alprazolam Coma Feverfew ASA/anticoagulants Potentiate effects INR. and Solatene. and coma. amitriptyline. Cryst. Cobex. transitory exanthema. hydroxocobemine. Cobolin-M. lead to increased risk of congenital disabilities in Use among Surgical Patients pregnant women. theophylline. methylcobalamin.S.

tients taking vitamin C versus placebo. Vitamin effects on the common cold. cre. ascorbic E deficiency (which is rare).138.125 talose C-1000. ing.131–133 Patients not necessarily have to stop their intake during the deficient of these vitamins might be at increased perioperative period.1 percent12 to 51 percent11 of preop. A all individuals in the general population.127–130 Hyperhomocysteinemia is thought to Recommendations be responsible for accelerated atherosclerosis and Patients taking vitamin C supplementation do venous thromboembolic disease.134. Dosing and daily allowance rec- of the neurotransmitter norepinephrine. Ca. clinical trials have shown minimal mg of ␣-tocopherol equivalents ⫽ 1. Vitamin E has been From 15. proven medicinal uses of vitamin E supplementa- tamic acid. calcium ascorbate. From 15. It is thought in people with conditions aggravated by acid load- that this may have been caused by an accumula. there are no clearly acid. The tolerable upper intake level is reported Peripheral vascular thrombosis has been reported. C-500-GR. aside from the treatment of vitamin Antiscorbutic vitamin.1 percent12 to 51 percent11 of preop- Ce-Vi-Sol. with glucose 6-phosphate dehydrogenase defi- cantly lower in patients with venous thrombotic ciency. Cevalin. tion of homocysteine. ascorbyl palmitate. erative patients report taking vitamins. Vitamin E exists in eight differ- Vitamin C is required for the synthesis of col. and albumin concentrations in 101 con. E supplements are available in natural or synthetic tamin C has been shown to have no significant forms. There is ongoing research in numerous diseases. cevi.135 In addition. hemolysis (red blood cell destruction) in patients Serum vitamin B12 concentrations were signifi. or in international units. folate. Vitamin C products in the particularly in cancer and heart disease. and supplement labels may use. C-Gram. to be 2000 mg/day as reported by the Institute of Presurgical Precautions and Medicine. Dull-C. merous health conditions.”137 High recent study126 measured vitamin B12.140.141 United States include Ascorbicap. ascorbate.126. tiple adverse effects. Vita-C. controlled. doses of vitamin C have been associated with mul- atinine. however.5 IU. Vitamin E (Tocopherol) Overview Vitamin C (Ascorbic Acid) Vitamin E is a fat-soluble vitamin with antiox- Overview idant properties. However. the letter “d” (for example. The natural forms are usually labeled with effect on outcome between terminal cancer pa. matched for age and sex. dl-alpha-tocopherol). which food prevent the common cold. risk of flap failure for similar reasons (specula- tion). ent forms. iso-ascorbic acid. 60e . High doses of vitamin C should be avoided disease than in the control subjects. such as cirrhosis.136 whereas synthetic forms are labeled “dl” (for ex- Use among Surgical Patients ample. tivitamin formulations. Cevi-Bid. Use among Surgical Patients con. gout. ll-C. Ce. Upper tolerable intake levels “repre- Recommendations sent the maximum intake of a nutrient that is likely Vitamin B12 taken at the recommended dose to pose no risk of adverse health effects in almost does not need to be stopped before surgery. of which ␣-tocopherol is the most active lagen and plays an important role in the synthesis form in humans. Vitamin ommendations for vitamin E are often provided in C is also an effective antioxidant and has been ␣-tocopherol equivalents to account for the dif- shown to be able to regenerate other antioxidants ferent biological activities of the various forms of such as vitamin E. proposed for the prevention or treatment of nu- erative patients report taking vitamins.27 Symptoms may persist for up to 4 months after the Adverse Effects supplement is stopped and may require treatment The recommended daily intake of vitamin C is with systemic corticosteroids and topical therapy. Vitamin C is often taken to vitamin E. d-gamma-tocopherol). often based on its an- Synonyms for and Products Containing tioxidant properties and as a free radical scaven- Vitamin C ger. vi.139 intimal thickening and induce a hyperthrombotic Presurgical Precautions and state. Vitamin C is included in thousands of mul. and sodium ascor. Large doses may precipitate and 101 control subjects. Plastic and Reconstructive Surgery • March 2007 day) and pyridoxine (80 mg/day) have been nadian products include Proflavanol C and Revi- associated with cases of rosacea fulminans. which is believed to cause or paroxysmal nocturnal hemoglobinuria. particularly at doses greater secutive patients with venous thrombotic disease than 2000 mg/day. tion beyond the recommended daily allowance. and Flavorcee. 60 mg. renal tubular acidosis. 1 double-blind. bate. For conversion. Ce-Vi-Sol. Cetane.

Pheryl-E. ginkgo biloba. were of mixed quality. John’s wort. absorption function spite the fact that one-quarter of adults reported Metastatic calcifications using an herbal product to treat an illness last year. Vitamin E Dry. manufacturers mortality risk difference in high-dosage vitamin E are not obligated to guarantee the quality or trials was 39 per 10. Aquasol E. and Vitamin E St. clusions have been criticized by some experts be. vitamins. As with any public market. including vitamin and dent clotting factors (particularly in patients with herbal supplementation. Bent and Ko150 report that of the 10 most Vitamin B12 Prevents anemia Rash commonly used herbs in the United States in 2001. In addition. others have not ob- served a greater incidence of bleeding. Amino. and As consumers and health care providers. the burden was Recent evidence suggests that regular use of placed on the U. Webber Vitamin The Dietary Supplement Health and Educa- E. Potential Positive and Negative Effects of Common Vitamins those taking drugs that may increase the risk of bleeding. Annual synthesis Vitamin D Bone formation/ Anorexia sales of dietary supplements in the United States mineralization Nausea/vomiting are approaching $6 billion. red blood cells. Vitamin plements” and exempted them from the safety E MTC. Number 3 • Herbal Supplements and Vitamins Synonyms for and Products Containing only for garlic.143–145 In studies of vitamin E. saw palmetto. tocotrienol. Vitamin E-d-Alpha. central nervous statistically significant evidence of efficacy exists system. gastrointestinal. Total E. tion Act of 1994 classified herbs as “dietary sup- pha. and minerals have been used synthesis for centuries not only to supplement the diet but Norepinephrine also to treat illness and improve health. further the benefits and risks of presently available Opti-E.Volume 119. Aquasol E. E Mixed. dietary supplements. ability. Vitamin Positive Negative Presurgical Precautions and Vitamin A Vision Liver toxicity Recommendations Immunity Bleeding Development Birth defects Patients should discontinue high doses of vita.27 prescription and other over-the-counter medica- Adverse Effects tions must fulfill. Nutr-E-Sol. Aquasol E. the buyer yses) of the results of prior smaller studies that must beware. quantity of herbal substance in their products. GI.151 Therefore. We must inquire about over- aggregation and antagonism of vitamin K– depen.147.S. tocopherol. Alph-E. Vita Plus E. Vitamin E Antioxidant Anticoagulant Wound healing DISCUSSION Vitamin C Antioxidant Kidney stones Collagen GI distress Herbs. additional research is needed to define enol concentrate. E-Pherol. Aquavit-E.149 Caution is advised in patients with bleeding disorders and in Table 3.142 These con. 61e . As demonstrated by this systematic Spondyvit. E-Complex-600. Food and Drug Administration high-dose vitamin E supplements (400 IU/day or to prove a supplement unsafe before its removal greater) may increase the risk of death (all-cause from store shelves.146 Increased risk not always mean it is safe. of bleeding when used with warfarin (Coumadin) has been noted. CNS. review. De. High doses have a responsibility to educate ourselves and our of vitamin E (⬎400 IU/day) might increase the patients about the risks and potential benefits of risk of bleeding because of inhibition of platelet such supplements. we often in patients with chronic illnesses. Vitamin E-dl Al. with variable results. Liquid and efficacy requirements and regulations that E. particularly member that because something is “natural” does when used in humans with aspirin. tocotri. in our preoperative in- vitamin K deficiency). and an average of 1000 Intestinal Ca2⫹ Impaired renal new products are being developed each year. the-counter medications. we must re- and gum bleeding has been observed. Until more stringent regulations exist a small increase in the rate of hemorrhagic stroke and further research is performed. Liqui-E. Skin metabolism difficulties als exists to support the efficacy of the majority of Erythropoiesis Nerve injury the herbal supplements available to the public. In (decreased sensation) addition.21. tocopheryl succinate.148 However. and Dry E. RBC. resulting in the problem of batch-to-batch vari- cause they are based on recalculations (meta-anal. Vitamin B6 CNS Balance limited evidence from randomized controlled tri. RBC production min E (⬎400 IU/day) 2 to 3 weeks before surgery.000 persons). terviews.

Plastic and Reconstructive Surgery • March 2007 To adequately cover such a vast topic in one Additional Resources setting is impossible. cirrhosis. blood pressure. assist in educating ourselves and our patients.info. vm. Supplements: http://dietary-supplements. upper respiratory infection. Potential Positive and Negative Effects of Common Supplements Supplement Positive Negative Arnica Antiinflammatory ? Increased bleeding Analgesic Antiseptic Decreases bruising Bromelain Antiinflammatory Platelet inhibitor Immunity Platelet inhibitor Wound healing Dong quai Gynecologic disorders Bleeding Photosensitivity Gastrointestinal problems Echinacea Antibiotic Immunosuppression (long-term use) Wound healing Drug interactions (inhibits cytochrome P450) Ephedra Stimulant Hypertension Decongestant Tachycardia Appetite suppressor Palpitations Irritability Feverfew Migraine headaches Bleeding Postfeverfew syndrome (when stopped abruptly) Garlic Decreases BP ? Increased bleeding Antithrombotic Antihyperlipidemic Ginger Relief of URI Bleeding Relief of sore throat Interacts with Coumadin Arthritis Hyperglycemia Motion sickness Ginkgo biloba Antioxidant Vasodilation Anticoagulant Drug interactions [lowers seizure threshold.gov/ herbal supplements and vitamins. prolonged sedation (barbiturates)] Ginseng Hypoglycemic Anticoagulant Anticoagulant Hypoglycemia Stress relief Hypertension Tachycardia Glucosamine sulfate Arthritis Unknown Goldenseal Dyspepsia Drug interactions (inhibits cytochrome P450) Antibiotic Grape seed extract Antioxidant Unknown Antihistamine Chemo protective Wound healing Kava kava Antianxiety Prolong anesthesia Muscle relaxant Liver injury (hepatitis. we have U. MAO. liver failure) Licorice Respiratory inflammation Increased bleeding (inhibits platelet aggregation) Dyspepsia Drug interactions (inhibits cytochrome P450) Omega-3 fatty acids Reduce cholesterol Anticoagulant Anticoagulant Antiinflammatory Saw palmetto Benign prostatic hypertrophy ? Increased bleeding St. interacts Vasodilation with MOA inhibitors. John’s wort Antidepressant Photosensitivity Inducing cytochrome P450 Valerian root Sedative Potentiates sedation BP.cfsan.S. 62e . monoamine oxidase. we hope to PDR for Herbal Medicines have provided those in practice a brief guide to commonly encountered dietary supplements that National Institutes of Health Office of Dietary we have seen consumed by our patient population. Food and Drug Administration Center for provided a brief list of additional resources to Food Safety and Applied Nutrition: www. Tables 3 and 4 summarize the above-mentioned nih. Below. In this discussion.gov Table 4. URI.fda.

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