Carl Hendel, MD. 12/2000

Many very popular herbs are drugs. Make no mistake about that. There is a new term, "nutraceutical."This word implies that, although currently considered a nutritional supplement, there are properties similar to pharmaceutical agents. Some commonly used herbs have medically significant effects. These compounds are taken into our bodies and are metabolized, often through the liver, often through pathways that are used to clear other chemicals, drugs, and toxins. Herbs can interact with other herbs, drugs, existing medical conditions, and physiologic systems. In other words, we all need to regard herbal medicines seriously. But, there is a problem, a scientific knowledge gap. Which risks are real and which ones are theoretical?

The motto for the American Society of Anesthesiologists is VIGILANCE. I am delighted that these dedicated medical specialists are leading the way for a better understanding of the risks and hazards of herbal medicines in people undergoing surgery. This is very important, and our scientific medical community must fully support the research necessary to accurately establish facts about the specific actions of many herbs.

Many herbs, including angelica, anise, arnica, asafoetida, bogbean, boldo, capsicum, celery, chamomile, clove, danshen, fenugreek, feverfew, garlic, ginger, gingko, ginseng (Panax), horse chestnut, horseradish, licorice, meadowsweet, prickly ash, onion, papain, passionflower, poplar, quassia, red clover, turmeric, wild carrot, wild lettuce, willow, and others may THEORETICALLY interfere with the clotting of blood. This is a very large list, and many people are taking several of these herbs at the same time. In addition, these same people may be taking vitamin E, another substance that can influence clotting and bleeding.

There have been some anecdotal reports of increased bleeding during surgery. Anesthesiologists, to be as safe as possible, are requesting that people stop their herbs several weeks ahead of scheduled surgery. This makes sense, since it is "better safe than sorry." But do we have the scientific basis for this recommendation? And, what are the implications for emergency surgery, when there are not two weeks to stop the herbs and supplements?

A clinical example might be a 67 year old man, who has some risks for heart attack. His ability to concentrate and think doesn't seem to be as good as when he was younger. He takes gingko to help with mental concentration and takes garlic to help control his cholesterol. He also takes Vitamin E as an anti-oxidant to lower his risk of heart attack and a small aspirin each day to also decrease his cardiac risk. If he were to be in an accident and need emergency surgery, would he be at increased risk for uncontrolled bleeding?

To my knowledge, studies have not been done to determine whether this risk is real or theoretical. I highly recommend that this be done now. It wouldn't be a complicated study to have people take the above regimen and test their blood to see if there are any significant changes in clotting function.

This is only one area of herbal concern. I have already addressed the issue of herbal purity and quality control in another writing. In addition, there are very real concerns about interference and alteration of metabolism of other major drugs. Saint John's Wort, for example, may well lead to treatment failure by interfering with the metabolism of other drugs, including "blood thinners" and heart pills, and may intensify the responses to narcotics and anesthetics. Concerns also exist for kava kava, ma huang and many others.

There is a responsibility on the part of the scientific community to clarify these and other problems related to the proliferation of unregulated and inadequately studied medicines, these nutraceuticals. Only after some good science is done, can physicians act knowledgeably when patients ask for our input and advice regarding the use of supplements and herbs. Some of the information is known and available through some excellent herb and supplement databases, but we really need much more research to separate fact from fiction, theory from practical reality.

It is most likely that herbs and supplements will be a part of our culture for the foreseeable future. Our job is to find a safe and appropriate place for them.