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Nutritional Supplements Perioperative Implications for Eye Surgery Page 2

St. John’s Wort (Hypericum perforatum)

Active ingredient: Hyperforin is the most metabolically active ingredient currently recognized. However, the herbal is usually defined by hypericin, which was previously thought to be the most active ingredient; it is bioactive in vitro. 13 The half-life of various metabolites ranges from 9 to 43 hours. 58


Mechanism & Benefits: St. John’s wort is used for mild to moderate depression; itinhibits serotonin, norepinephrine, and dopamine reuptake in vitro but not in vivo in usual amounts. Use with or without a serotonin-reuptake inhibitor may create a central serotonin excess syndrome. 69, 70It induces cytochrome enzymes (especially CYP450 3A) and P-glycoprotein; this, then, increases the elimination of drugs and affects 50% of drugs in the marketplace.  Therefore, St. John’s wort decreases the blood levels of cyclosporine, all currently marketed HIV protease inhibitors, warfarin, lidocaine, calcium channel blockers, digoxin, imatinib, theophylline, simvastatin, tetracycline, and serotonin receptor antagonists. 71, 72 It may only take two weeks of oral use of St. John’s wort to cause a doubled clearance of alprazolam. 73


Potential Side Effects & Precautions: St. John’s wort can lower the blood levels of cyclosporine and induce rejection; it can also lower the blood levels of antiretroviral drugs and lead to loss of virologic response. Concomitant antidepressant use has been associated with hypertension, serotonin syndrome, or lack of effect. 69 Serotonin syndrome is characterized by headache, gastrointestinal upset, motor restlessness, autonomic and mental status changes. 41 St. John’s wort decreases the efficacy of sildenafil so that increased amounts of sildenafil are prescribed; there has also been break-through bleeding, which affects the use of oral contraceptives and has been associated with pregnancy. 12 It also affects estradiol, and desogestrel.  

St. John’s wort rarely causes skin photosensitivity; however, it carries the potential for eye phototoxicity since there is uptake in the lens and growth inhibition of retinal pigment epithelial and choroidal endothelial cells in an animal study. 74 The dose of hypericum used in animal studies is 20 to 30 times the human dose for mild to moderate depression. 73

Valerian (Valerina officinalis)
Active Ingredient: Many identified but two main categories: volatile oil containing valerianic acid and iridoids.
Mechanism & Benefits: valerianic acid increases GABA secretion and inhibits breakdown. 75
Potential Side Effects & Precautions:Increased sedation with concomitant benzodiazepines may occur and adverse interactions may occur with tricyclic antidepressants. 12 

 

Yohimbe
Active Ingredient(s): various alkaloids including yohimbe and tannins.
Mechanism & Benefits: It may be a monoamine oxidase inhibitor as well as a pressor agent; it blocks presynaptic alpha2-adrenergic receptors and decreases outflow of blood from the penis. 76
Potential Side Effects & Precautions: Adverse interactions may occur in patients with hypertension, or those taking monoamine oxidase inhibitors. 25 Yohimbe may increase the risk of intraoperative hemodynamic instability. 3 An allergic dermatitis with eosinophilia has been reported and a lupus-like syndrome. 76 In moderate doses, yohimbe may increase systolic blood pressure in patients with orthostatic hypotension secondary to primary autonomic failure. 34

 

Information for Patients

The following material is excerpted from An FDA Guide to Dietary Supplements. 15
  • A healthy diet with a variety of fresh fruits and vegetables will have many overall benefits and may also contain many of the antioxidant vitamins and minerals.
  • Consumers who use dietary supplements should always read product labels, follow directions, and heed all warnings.
  • To help protect themselves, consumers should:
    • Look for ingredients in products with the U.S.P. notation that indicates that the manufacturer followed standards established by the United States Pharmacopeia.
    • Realize that the label term “natural” doesn’t guarantee that a product is safe.
  • Supplement users who suffer a serious harmful effect or illness that they think is related to supplement use should call a doctor or other health care provider.
  • If shoppers find dietary supplements with labels stating or implying the product can help diagnose, treat, cure, or prevent a disease, they should realize the product is being marketed illegally as a drug and as such has not been evaluated for safety or effectiveness.
  • The majority of supplement manufacturers are responsible and careful.  But as with all products on the market, consumers need to be discriminating.  FDA and industry have important roles to play, but consumers must take responsibility, too.
 

Conclusions

The effects of herbals are diverse and can be adverse. Their use is disseminated throughout the population and merits observation. Yet patients do not readily offer information about nutritional supplement use to their physicians.  If a surgical procedure is contemplated or untoward event occurs, it is important for the physician to ask the patient about any use of alternative medications. This will allow the patient and physician to discuss any potential for adverse interactions and plan for any discontinuation of the supplement before surgery.

The cost of using herbal supplements can be significant and is seldom covered by health insurance.  The quality of supplements can vary by manufacturer and absorption can be affected by a variety of dietary factors. 77 Pesticides, herbicides, and other ingredients may contaminate herbal products. 77

This assessment is not meant to cover every potential side effect that a nutritional supplement may cause but the ones of most importance to the physician-patient team. This assessment does not contain information on herbs used in other healing traditions, such as in Chinese medicine. Although this information will be updated periodically, it may not be complete on a specific supplement or problem. Health-related information changes frequently and therefore information contained in this assessment may be outdated, incomplete or incorrect. Very few randomized controlled clinical trials exist for the use of nutritional supplements. Much of the material in this assessment is drawn from studies of small series of patients and anecdotal information. Much of the material in print merits further scientific validation and verification. The Food and Drug Administration has not evaluated statements made about products.

The material in this complementary therapy assessment has not been reviewed or approved by the Board of Trustees of the American Academy of Ophthalmology and does not in any way constitute a guideline or policy of the American Academy of Ophthalmology. This material has been developed by the American Academy of Ophthalmology to inform its members.

 

Development of Complementary Therapy Assessments

Complementary, or alternative therapies, are a growing part of health care in America.  Americans spend an estimated $14 billion a year on alternative treatments.  Mainstream medicine is recognizing a need to learn more about alternative therapies and determine their true value. Most medical schools in the United States offer courses in alternative therapies. The editors of the Journal of the American Medical Association announced that publishing research on alternative therapies will be one of its priorities. The National Institutes of Health National Center for Complementary and Alternative Medicine has broadly defined complementary and alternative medicine as those treatments and health care practices not taught widely in medical schools, not generally used in hospitals, and not usually reimbursed by medical insurance companies. More scrutiny and scientific objectivity is being applied to determine whether evidence supporting their effectiveness exists.

In the fall of 1998, the Board of Trustees appointed a Task Force on Complementary Therapy to evaluate complementary therapies in eye care and develop an opinion on their safety and effectiveness, based on available scientific evidence, in order to inform ophthalmologists and their patients. A scientifically grounded analysis of the data will help ophthalmologists and patients evaluate the research and thus make more rational decisions on appropriate treatment choices.

The Academy believes that complementary therapies should be evaluated similarly to traditional medicine: evidence of safety, efficacy, and effectiveness should be demonstrated. 78-80 Many therapies used in conventional medical practice also have not been as rigorously tested as they should be. Given the large numbers of patients affected and the health care expenditures involved it is important that data and scientific information be used to base all treatment recommendations. In this way, we can encourage high-quality, rigorous research on complementary therapies. 81, 82

 

Adverse Event Reporting

To further our understanding of the impact that nutritional supplement use has on patient health and well-being, Pamela S. Chavis, MD, has established a monitoring process to collect information about adverse events related to nutritional supplement use. A reporting form is included with the assessment and may be sent to the FAX number on the form.

MedWatch, the FDA Safety Information and Adverse Event Reporting Program, also collects information about adverse events related to dietary supplements. Reports to MedWatch are voluntary and can be made by phone (1-800-FDA-1088), fax (1-800-FDA-0178), or on the Internet (http://www.fda.gov/medwatch/report.htm).

 

Additional Resources

An 8 ½ inch by 11inch information poster on nutritional supplements for office use can be downloaded in PDF format for printing in black and white or color. Pamela S. Chavis, MD, and Mary Beatty-Brooks produced the poster for the McGuire Veterans’ Administration Medical Center in Richmond, VA.

The American Society of Anesthesiologists (http://www.asahq.org/) has helpful information for patients and physicians about dietary supplement use and anesthesia.   
Additional Internet resources include:
•     NIH Office of Dietary Supplements available at http://ods.od.nih.gov
•     FDA Consumer Information available at http://www.cfsan.fda.gov/~dms/ds-info.html
•     Federal Trade Commission available at http://www.ftc.gov/ 
•     USDA Agricultural Research Service Phytochemical and Ethnobotanical Databases at http://www.ars-grin.gov/duke/
•     The National Eye Institute at http://www.nei.nih.gov 

 

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