ASRA Guidelines for Herbal Supplements - heather stoddard

ASRA Guidelines for Herbal Supplements - heather stoddard

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1. ASRA Guidelines for Herbal Supplements Heather Stoddard, MD, MPH
2. Why is this important? • Spinal Hematoma – a rare but potentially catastrophic complication of spinal or epidural anesthesia that could result in irreversible spinal cord ischemia – Estimated prevalence of 1 in 150,000 with epidural anesthesia and 1 in 220,000 with spinal anesthesia in patients not receiving thromboprophylaxis • Risks factors: increased age (>65yo), female sex, abnormalities of the spine, difficulty during needle or catheter placement, and presence of an underlining coagulopathy • Patients receiving antithrombotic or thrombolytic therapy are at an increased risk for the development of a spinal hematoma
3. Do certain herbal supplements and medications increase the risk of spinal hematomas?
4. Herbal Supplements in the Perioperative Period • Most patients do not volunteer information regarding use of herbal supplements and herbal medications • Mortality and morbidity can potentially be increased in the perioperative period because of polypharmacy and physiological changes that occur with herbal supplements • Despite the widespread use, there are few controlled clinical trials of the efficacy and adverse effects of herbal supplements – One prospective study of more than 600 patients identified increased bleeding in patients who reported taking herbal supplements – More data is needed to evaluate how bleeding risk is influenced when herbal supplements are taken in conjunction with oral anticoagulants or heparins
5. Herbal Supplements the with Greatest Impact on Hemostasis • Garlic: for HLD, HTN, cancer prevention – Inhibition of platelet aggregation and increased fibrinolysis – Time to normal hemostasis after discontinuation – 7d • Gingko: to slow cognitive decline – Inhibition of platelet-activating factor – Time to normal hemostasis after discontinuation – 36hr • Ginseng: to improve general health and cognitive function – Increased PT and PTT in animals; Other diverse effects (hypoglycemia) – Time to normal hemostasis after discontinuation – 24hr • There have been case reports of spontaneous neuraxial bleeding following ingestion of garlic and gingko biloba
6. Other Herbal Supplements That Impact Hemostasis • Saw Palmetto - for urinary and pelvic symptoms; increased risk of bleeding • Black Cohosh – for menopause symptoms; contains small amounts of salicylic acid; theoretical increased risk of bleeding • Chamomile – for anxiety, GI upset; increased risk of bleeding due to phytocoumarins, with additive effects with warfarin • Feverfew – for multiple symptoms; increased risk of bleeding and other additive effects • Fish Oil – for Omega-3 benefits; dose dependent increased risk of bleeding with does >3g/day • Coenzyme Q10 – an antioxidant; decreases response to warfarin • Goldenseal – for GI symptoms; increased risk of thromboembolism with warfarin and heparin • St John’s Wort – for depression; increased activity of CYP34A; increased risk of thromboembolism with warfarin
7. ASRA Guideline as of 2018 • 14.0 Anesthetic Management of the Patient Receiving Herbal Therapy • 14.1 The use of herbal medications does not create a level of risk that will interfere with the performance of neuraxial block. We recommend against the mandatory discontinuation of these medications or avoidance of regional anesthetic techniques in patients in whom these medications have been administered (Grade 1C - Strong recommendation with consensus among experts but based on data from case reports or expert opinion only) • In other words, neuraxial anesthesia should not be withheld from patients who take herbal supplements • It is often recommended that herbal supplements be discontinued in the perioperative period, but there is no reason to support cancelation of a procedure if the patient has not done so
8. References • ASRA Caogs App • Horlocker et al. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy. American Society of Regional Anesthesia. April 2018. DOI: 10.1097/AAP.0000000000000763 • Herbal Supplements. OpenAnesthesia. 2013. Retrieved from https://www.openanesthesia.org/aba_herbal_supplements/