CAPSAICIN
General Info
Capsaicin is the active ingredient in the extract of hot peppers. It is
most concentrated in the rib or membrane, less in the seeds, least in
the flesh. Capsaicin for medicinal use comes from Capsicum fructescens,
a species of the cayenne pepper. Mechanism
of Action
Capsaicin depletes substance P in afferent type C sensory nerve fibers
and affects only proprioception. Unlike other treatments for neuropathy,
such as local anesthetics, opiates, anti-seizure medications or tricyclic
antidepressants, capsaicin specifically treats pain without impairing
other aspects of the nervous system. In incomplete depletion of substance
P from suboptimal use, it may cause parodoxical increase of pain.
Uses
Post-herpetic neuralgia, post-mastectomy pain, hemodialysis-associated
pruritus, psoriatic itching and pain, painful neuropathies, especially
diabetic neuropathy, and other superficial neuropathies.
Doses
Creams of varying potency from 0.01% and
0.075% applied 4-5 times daily for at least four weeks. Because of local
side effects, it is advisable to start with low potency creams and increasing
in potency as tolerated. Less frequent application, such as once or twice
daily, can actually lead to increased pain. Older patients, especially
those with long-standing post-herpetic neuralgia, may require several
years of therapy and may even need lifelong treatment.Capsaicin is also
available as fresh and dried peppers, capsules, tablets, and tinctures.
Precautions
Because of potential respiratory toxicity, avoid concentrations greater
than 0.1%. Higher concentrations are also more likely to cause local chemical
irritation. Wear gloves during applications, avoiding contact with eyes
and mucous membranes; do not use on open abrasions and open wounds.
Formulation
Approved for external application, capsaicin is also available as tablets,
capsules and tinctures.
Capsaicin
and Dyspepsia
In a small trial in Italy (Dr. Mauro Bortolotti et al, University of Bologna),
30 patients with functional dyspepsia were randomized on daily capsules
of 2.5 g of red pepper or placebo. The capsaicin content (trans-8-methyl-N-vanillyl-6-nonenamide)
was 0.7 mg/g of red pepper power. After 3 weeks, upper gastrointestinal
symptoms of epigastric pain, fullness, nausea and early satiety were all
significantly reduced in the capsaicin group and not in the placebo group.
The mechanism of action is believed to be the desensitization of gastric
nociceptive C fibers, which carry pain sensations to the central nervous
system. (NEJM.346[12]:947-48,2002) Clinical Capsules. Internal Medicine News. May15,2002 |
CHAMOMILE
Matricaria recutita
Uses
(1) As a sedative, antispasmodic, and antiseptic. (2) For peptic
ulcers; mucous membrane and anogenital inflammation. (3) To promote
wound healing.
Caution
Use with caution in patients taking other
sedating medications because of possible excessive excessive sedation,
drowsiness, loss of coordination, and trouble driving or operating machinery.
An active ingredient in chamomile is coumarin.
ANTICOAGULATION CONCERNS
It is unknown whether chamomile affects
coagulation and if there is significant interaction between chamomile
and warfarin.
Monitor chamomile use in patients also taking warfarin.
|
ECHINACEA
Echinacea purpurea
General Info
A perennial American wildflower
belonging to the daisy family, found in the Plains states. Different
parts of the plant contain different chemicals; e.g., isobutylamides
are in the roots of augustifolia and purpurea; cichoric acid is in the
above-ground parts of purpurea.
Mechanism of
Action
Stimulation of phagocytosis by macrophages; inhibition of hyaluronidase;
increase fibroblast number and properdin levels and possible increase
of interferon production.
Uses
An immunostimulant used to prevent or treat the common cold and flu.
Topically for stings, bites, wounds, burns. In Europe, available for
parenteral use.
Studies
There has been controversy with echinacea use, with some studies showing
benefit while other show none. From a meta-analysis of 14 published,
randomized and placebo controlled trials, users of echinacea suuplements
reduced their odds of developing the common cold by more than half.
In those who have caught a cold, echinacea supplements cut a mean of
1.4 days from the duration of illness.
Prophylactic use of echinacea reduced
the incidence of naturally occurring colds by 65%, compared with placebo.
Dose
900 mg (180 drops) of an ethanolic extract
of E. Purpurea roots significantly reduced the severity and duration
of symptoms of flu-like infections. 450 mg (90 drops) were no more effective
than placebo.
Caution
Possible reactions in
those with a history of allergy to the daisy family. No documented drug interactions. Patients receiving immunosuppressives
(cyclosporine) should be monitored for decreased effectiveness when
used with echinacea. Also, long-term use of Ecchinacea may cause immunosuppression.
Should not be used in patients with autoimmune diseases or progressive
systemic diseases as: SLE, TB or MS. German Commission E monograph states
that "the metabolic condition in diabetes can decline upon parenteral
application." Some products may be adulterated with another similar
herb, Parthenium intergrifolium L, which has no pharmacologic activity.
PREOPERATIVE SURGICAL CONCERNS
Use for more than
8 weeks raises concerns for postoperative immunosuppression which may
theoretically cause postsurgical complications, including impaired wound
healing and opportunistic infections. There is also concern for hepatotoxicity.
|
EPHEDRA
Ephedra sinica,
Ephedra intermedia, Ephedra equisetina, Ephedra distachya
General Info
A naturally occurring
substance in the Chinese herbal Ma-Huang. Ephedrine constitutes
30 to 90 percent of the alkaloids of Ephedra species. Ephedrine alkaloids
are amphetamine-like compounds with powerful stimulant effects on the
heart and nervous system, increasing the heart rate and blood pressure,
decreasing the appetite and providing an sense of energy-boosting.
Uses
Ephedra (Ma-Huang) is found in many herbal weight-loss products and
has been called the "hebal fen-phen," promoted in some weight
loss clinics as the alternative to fenfluramine (Pondimin) and dexfenfluramine
(Redux), prescription anorexiants recently removed from the U.S. market.
Ephedrine containing products are also
marketed as decongestants, bronchodilators, stimulants and energy-boosters.
As a stimulant, it has been marketed as an ergogenic drug for enhancement
of athletic performance and body building efforts. It has also been
available as "herbal ecstasy" with its ability to induce euphoria,
heighten awareness and sexual sensations.
Caution
Available evidence show a significant
and unreasonable risk of illness and injury from dietary supplements
containing ephedra. Adverse reactions are
insomnia, nervousness, tremor, headaches, hypertension, seizures, arrhythmias,
heart attack, stroke and death. Should
not be used with MAOIs (monoamine oxidase inhibitors, ie, phenelzine,
tranylcypromine), cardiac glycosides, and antiarrhythmic agents. FDA
warnings have been issued because of its causative relationship with
hypertension, seizures, and death. It should not be used in patients
with a history of hypertension, heart disease, arrhythmias, glaucoma
or stroke. Although dosage limit has been suggested at 8 mg every 6
hours (24 mg per day) for ephedra alkaloids, serious side effects may
occur at much lower doses (4-20 mg per day).
An NIH report concluded that ephedra
is associated with higher risks of mild-to-moderate side effects such
as heart palpitations, psychiatric and upper gastrointestinal effects
and symptoms of autonomic hyperactivity (tremors and insomnia).
While
ephedra-products make up less than 1% of all dietary supplement sales,
these products account for 64% of adverse events associated with dietary
supplements.
PREOPERATIVE SURGICAL CONCERNS
Patients on ephedra who are later
on halothane anesthesia may be a higher risk for ventricular arrhythmias.
There is also concern for hypersensitivity myocarditis. Ephedra should
be discontinued at 24 - 48 hours before surgery.
|
FEVERFEW
Tanacetum parthenium
Uses
Treatment of migraine headaches, fever, and menstrual problems. It is
thought to work by decreasing the production of prostaglandins through
a mechanism different from NSAIDs.
Caution
Unknown interaction with aspirin or NSAIDs.
ANTICOAGULATION CONCERNS
It appears to inhibit platelet activity and should be used with caution
by patients receiving anticoagulant therapy (eg. warfarin, dicoumarol,
heparin).
|
GARLIC
Allium sativum
Uses
Lowers total cholesterol, LDL, triglyceride
levels, and blood pressure, and raises HDL cholesterol levels. It is
reported to have antibacterial, antifungal, antithrombotic, hypoglycemic,
antiinflammatory, and anticancer activity.
Cautions
When garlic is used in combination with other lipid-lowering agents
(eg, atorvastatin [Lipitor], fluvastatin [Lescol], pravastatin [Pravachol],
simvastatin [Zocor], gemfibrozil [Lopid], fenofibrate [Tricor], niacin
[Niaspan], hypoglycemic agents (eg, insulin, glyburide, glipizide, troglitazone
[Rezulin], glimeripide [Amaryl], chlorpropamide [Diabenese], tolbutamide
[Orinase], or antihypertensive agents, their effects may be increased.
ANTICOAGULATION CONCERNS
Garlic can also be used to decrease
platelet aggregation; thus, combined use with anticoagulants may increase
the risk of bleeding. Isolated reports have suggested that garlic may
increase international normalized rations (INRs). However, none of these
potential drug interactions has been adequately documented.
PREOPERATIVE SURGICAL CONCERNS
The potential for irreversible inhibition
of platelet aggregration warrants stopping its use at least 7 daqys
prior to surgery, especially if postoperative bleeding is of particular
concern or if other platelet inhibitors are used.
|
GINGER
Zingiber officinale
Uses
Used mostly for motion sickness as an
antiemetic / antinauseant. Also used as an antispasmodic and antiinflammatory
agent. In a controlled trial in the U.S. with college students as the
subjects, compared with placebo and diphenhydramine, ginger was most
effective for reducing experimentally induced motion sickness (students
were spun in a chair). Fifty percent of the subjects who ingested ginger
remained in the chair for 6 minutes, but none treated with either placebo
or diphenhydramine was able to do so. In Germany, ginger was approved
for use in motion sickness and as a digestive aid.
Caution
ANTICOAGULATION CONCERNS
Ginger may decrease thromboxane production
and cause prolong bleeding time and platelet inhibition. Therefore,
should be used with caution by patients receiving anticoagulant therapy.
|
GINKGO BILOBA
Active Ingredients
Flavone glycosides have antioxidant properties:
terpenoids (ginkgolides) improve circulation; bilobalides have neuroprotective
properties.
It alters vasoregulation, modulates neurotransmitter and receptor activity
and inhibits PAF (platelet activating factor).
Uses
Ginkgo is promoted to treat Alzheimer's disease and dementia, improve
memory and cognitive function, cerebral and peripheral blood flow (claudication),
tinnitus and vertigo.
Caution
Some Ginkgo products may contain a neurotoxin
(Ginkgo toxin) that might increase the risk of seizures. Caution is
advised in patients requiring anticonvulsant therapy (eg, carbamazepine,
phenytoin, phenobarbital) or agents that might lower the seizure threshold
(eg, amitriptyline, imipramine, molindone [Moban], promethazine [Phenergan],
tramadol [Ultram], maprotiline [Ludiomil], bupropion [Wellbutrin, Zyban]).
ANTICOAGULATION CONCERNS
Ginkgo therapy has been associated
with decreased platelet aggregation and spontaneous bleeding, and should
be used with caution by patients receiving anticoagulants, vitamin E,
aspirin, NSAIDs and other drugs or herbal medicinals with antiplatelet
or anticoagulant effects. A case of spontaneous bilateral subdural hematoma
has been attributed to ginkgo us.
PREOPERATIVE SURGICAL CONCERNS
The effect on PAF and platelet aggregation
may contribute to perioperative bleeding. Ginkgo use should be discontinued
at least 16 hours before surgery.
|
GINSENG
Uses
The most controversial of herbs, it has
claimed benefit for just about every human ailment with little scientific
evidence to support its myriad of claims. It has touted as an "adaptogen"
(to build up vitality and resistance to stress) and as an aphrodisiac.
There are claims on lowering total and LDL cholesterol levels. Some
ingredients raise blood pressure, and some lower it. Unfortunately,
as in many herbals claiming medicinal benefits, there is no quality
control and many preparations contain little or no ginseng. One study
looked at 10 'ginseng' products and found 7 contained no ginseng at
all. A study analyzed 54 ginseng products; 60% contained less than the
therapeutically effective levels, and an astounding 20% contained no
active ingredient. In another study, on 18 quality of life measures,
ginseng was equivalent to placebo; four quality of lilfe measures improved,
but clinical relevance was nonexistent.
Caution
Nervousness and excitation can occur in the first few days of intake.
Overuse can cause headache, epistaxis, insomnia, and palpitations. Because
of ginseng's unpredictable effect on BP, hypertensive patients should
be cautioned of its use. Estrogenic effects can cause vaginal bleeding
and mastalgia; patients on hormonal therapy should avoid its use. Ginseng
can also adversely interact with monoamine oxidase inhibitor phenelzine.
In general, patients should be discouraged from using ginseng for longer
than 3 months.
ANTICOAGULATION CONCERNS
Probably has an interaction with warfarin.
Patients on warfarin and dietary supplements containing this herb should
be closely monitored for a possible interaction.
PREOPERATIVE SURGICAL CONCERNS
May have an irreversible effect on
platelets and should be discontinued at least 7 days before surgery.
|
GOSSYPOL
It is associated with renal loss of potassium, resulting in hypokalemia.
Avoid intercurrent use of gossypol with hydrochlorothiazide or
furosemide or digoxin. |
GLUCOSAMINE and CHONDROITIN
Uses
Both components of the cartilage matrix, have been touted as pain relievers
as well as agents that might actually slow the progression of osteoarthritis.
Studies show glucosamine stimulates the cartilage cells to synthesize
glycosaminoglycans and proteoglycan ground substance. For the past three
decades, it has been thought to be beneficial for osteoarthritis. However
studies to support this were lacking - until recently. Studies using glucosamine
sulfate, 1500 mg day, suggest a beneficial effect on arthritis of the
knee, hip, and back. A study showed a slight but significant increase
in joint space and less progression of OA of the knees, with improvement
in scores of pain and physical function. Glucosamine sulfate seems to
be more effective, faster acting and provides far more impressive results
and greater overall benefit than chondroitin. Recent studies have
shown that glucosamine does not adversely affect blood sugar control.
Dose
Glucosamine: 1500 mg daily in 3 divided
doses; chondroitin sulfate, 800 to 1,600 mg daily, the lower dosing given
to patients under 120 pounds.
Caution
Glucosamine is derived from oysters and the chitin of crab shells and
chondroitin is derived from shark cartilage and bovine trachea. Because
of the nature of these sources, allergic reactions are possible. |
HAWTHORNE
Crataegus laevigata,
Crataegus monogyna, Crataegus pinnatifida
Uses
Hawthorne is used to treat heart disease, angina, hypertension, and
sleep disorders. High doses of hawthorne can cause depression of the
CNS and hypotension.
Caution
Should be used with caution in patients receiving antihypertensive medications
and other drugs reported to cause depression of the CNS (eg, antihistamines,
tricyclic antidepressants, anticonvulsants, benzodiazepines, antipsychotics).
|
KAVA
Piper methysticum
Uses
Kava kava is used to treat sleep disorders, anxiety, and menopausal
symptoms. In the U.S., the anxious and the insomniacs spent more than
$50 million on variety of kava products: drinks and teas, capsules and
candies.
Caution
When used with other sedative agents (eg, benzodiazepines, antihistamines,
anticonvulsants, tricyclic antidepressants, antipsychotics), it may
cause excessive sedation, drowsiness, loss of coordination, and trouble
driving or operating machinery. Kava dermopathy has been reported with
the use of kava as a traditional South Pacific beverage.
An alert
has been issued because of recent increasing reports of severe liver
damage in kava users with one patient needing a liver transplant. Patients
who have liver disease or who consume moderate amounts of alcohol should
avoid use of kava. Users should avoid daily use of more than four weeks.
The recommended dose is 60 to 120 mg of the active ingredient, kavalactone.
ANTICOAGULATION CONCERNS
A specific kavalactone, kawain, appears
to decrease thromboxane 2 production and inhibit cyclo-oxygenase, indicating
that kava may have significant inhibitory effect on platelet aggregation.
PREOPERATIVE SURGICAL CONCERNS
It has hypnotic and sedating effects
and should be discontinued at least 24 hours before surgery.
|
KELP
Its prolonged use is associated with hyperthyroidism; should be considered
a possible etiology of atrial fibrillation with patients with apparent
lone AF. Discourage use of kelp with amiodarone. |
LIQUORICE
Glycyrrhiza glabra,
Glycyrrhiza uralensis
Uses
Liquorice is used as an antiinflammatory agent and for the treatment
of peptic ulcers. This liquorice is not, however, found in most candy
that is labeled as "licorice."
Caution
Liquorice has mineralocorticoid properties
and may cause pseudoaldosteronism with sodium and water retention and
hypokalemia. Therefore, liquorice may decrease the effectiveness of
antihypertensive agents and diuretics. In addition, it may increase
the risk of hypokalemia when used with non-potassium sparing diuretics
(eg, chlorothiazide [Diuril], furosemide [Lasix], bumetanide [Bumex],
torsemide [Demadex], metolazone [Zaroxolyn]). The effects of digoxin
(Lanoxin) and other digitalis glycosides can be increased if the liquorice
does cause hypokalemia. With low potassium, digitoxicity may occur with
therapeutic digoxin levels.
|
MELATONIN
Mel, Melatonex
General Info
Pineal gland hormone whose synthesis / secretion is controlled by the
prevailing light-dark environment, via the hypothalamic suprachiasmatic
nuclei (SCN). It is synthesized from serotonin. Nocturnal secretion
of melatonin and its main metabolite 6-sulphatoxy melatonin (6-hydroxy
melatonin sulfate) is highest in young children and falls with age.
In the US, synthetic melatonin is sold
over-the-counter as a "food supplement" because it is naturally
found in small amounts in some foods (e.g., bananas and rice). Like
other supplements sold in the US market before October 15, 1994, melatonin
was exempted from federal drug laws and was considered as a food supplement
by the Dietary Supplement Health and Education Act of 1994. There are
no natural extract versions of melatonin currently available. The US
retail market for melatonin is estimated at $200-350 million annually.
Some studies have suggested melatonin
may enhance immune response by increasing IL production by T-helper
cells and free radical scavenging.
Uses
Although melatonin has been studied for cyclic mood disorders, sexual
maturation and reproduction, its main use is for "jet lag"
and as a sleep aid. Studies supports the use of melatonin for short-term
treatment of jet lag. Caution must be exercised since melatonin is a
recombinant human hormone, and the safety of long-term use has not been
evaluated. A recommended jet lag protocol is: 0.3 mg synthetic melatonin
tablets: (1) For eastward travel, take preflight melatonin in the late
afternoon of departure and take post-flight melatonin for four days
after arrival at local bedtime. (2) For westward flights, take melatonin
at local bedtime for four days after arriving with a second smaller
dose if there is early morning awakening. It should not be taken for
more than one month at a time and not more than 0.5 mg per day, as long-term
studies are not yet available. ·
Adverse Effects
Sleepiness, impaired libido, mild depression at greater doses. Nausea,
headache, nightmares. Possible decreased alertness and reproductive
effects. Drug interactions with beta-blockers, CNS depressants, androgens
and estrogens, SSRIs and MAOIs.
RECOMMENDATIONS
Use only synthetic melatonin and start with the lowest possible dose
(available as 0.3, 1.5, 3.5, 10 mg) 1-2 hours before bedtime.
CAUTION
Do not use during pregnancy, lactation,
in children, or if trying to conceive. Do not use if a patient has immune-system
cancers. Do not use if a patient is on any drug that may interact with
melatonin.
|
PHYTOESTROGENS
General info
Phytoestrogens are nonsteroidal
plant compounds resembling estradiol (E2), with both estrogenic and anti-estrogenic
activities. They are found in many fruits, vegetables and grains, but
leguminous seeds are especially rich in these compounds.
There are 3 main classes of phytoestrogens:
flavanoids, coumestans, and resorcyclic acid lactones. Isoflavones have
the most potent hormonal-like activity and an extensive range of biological
activities in the body. More than 1,100 isoflavanoids are known, exclusively
found in leguminous seeds such as soybeans, chickpeas, lentils and beans.
The most important isoflavones are genistein, daidzein, glycetin, formonetin,
and biochanin. Soybeans, besides being an excellent sourse of isoflavones,
is also rich in daidzein and genistein.
Ipriflavone
(7-isopropoxyisoflavone) is a synthetic isoflavone derivative used in
several countries in Europe, in particular Italy, and in Japan, for prevention
and treatment of osteoporosis. In the US, ipriflavone (IP) is available
as a dietary supplement.
Uses
Phytoestrogens are used to treat the symptoms of menopause. Phytoestrogens
(eg, coumestrol, genistein, daidzein, biochanin A, formononetin) can be
found in foods such as soy, lentils, broad beans, chick-peas, and red
clover, as well as nonprescription products (eg, Promensil).
Recent studY: Phytoestrogen supplements
for the treatment of hot flashes: The Isoflavone Clover Extract (ICE)
Study: a randomized controlled trial. JAMA.2003;290:207-214. A randomized
controlled trial of 252 menopausal women, aged 5-60, with about 35 hot
flashes per week, using Promensil (82 mg/d of isoflavones) and Rimostil
( 57 mg/d of total isoflavones) showed no clinical effect on hot flashes
and other menopause symptoms compared to placebo.
Doses
Isoflavone consumption in Eastern countries is in the order of 20-150
mg/d (average 40 mg/d), as compared with 2-5 mg/d in Western countries.
In adults consuming 50 mg/d total isoflavones (such as found in traditional
Japanese diet) a plasma isoflavone concentration of 50-800 ng/ml may be
achieved, far exceeding normal plasma estradiol concentrations (40-80
pg/ml).
Persons with risk factors for osteoporosis
should consume about 14 servings of soy protein per week. This would provide
an average of approximately 16-20 g of soy protein/d with 32-40 mg of
isoflavones/d. Persons with osteoporosis should consume 21 servings of
soy protein per week, which would yield about 24-30 g of soy protein and
48-60 mg of isoflavones daily.
The average dose recommendation of isoflavone
dietary supplements is 40 mg/d of aglycone isoflavones. Doses of 40-160
mg/d have been used in humans with a favorable side effect profile. The
usual dose of IP (ipriflavone) is 200 mg tid.
CAUTION
Some of the phytoestrogens do have significant activity at the estrogen
receptors. When phytoestrogens are used in combination with estrogen-containing
products, the risk of estrogen-related side effects (eg, nausea, bloating,
breast fullness or tenderness) may be increased. Isoflavone dietary supplements
should be avoided in pregnancy and lactation.There are concerns with the
use of high doses of isoflavones by patients with hormone-sensitive cancers.
Until use in cancer patients is more carefully evaluated, concentrated
supplements should be taken with caution. It is unknown if phytoestrogens
will decrease the effectiveness of tamoxifen (Nolvadex) or raloxifene
(Evista). |
SAW PALMETTO
Serenoa repens
USES
Saw palmetto is used for the treatment
of benign prostatic hypertrophy and as a diuretic and urinary antiseptic.
It appears to inhibit both dihydrotestosterone binding at the androgen
receptors and 5-alpha-reductase activity on testosterone.
CAUTION
Whether saw palmetto can increase or decrease the effectiveness of doxazosin
(Cardura), terazosin (Hytrin), and finasteride (Proscar) is unknown. |
ST. JOHN'S WORT
Hypericum perforatum
Uses
The mechanism of action of St. John's wort has not been fully established
but likely is involved with inhibition of serotonin, norepinephrine
and dopamine reuptake. St. John's wort also utilizes the cytochrome
P450 system which affects the metabolism of more than 50% of all drugs.
It also inhibits GI absorption, including the P-glycoprotein enzyme
system with wide-reaching effects. It is used for the treatment of anxiety,
depression, and sleep disorders.
Caution
It is commonly stated to be a MAOI and a selective serotonin reuptake
inhibitor. If the MAOI properties were significant, we should have seen
reports of elevated blood pressure in patients concomitantly receiving
decongestants, Ma Huang, and other sympathomimetic products. However,
caution should be used if the patient is taking St. John's wort and
a sympathomimetic agent or other MAOIs (eg, phenelzine [Nardil], selegiline
[Carbex, Eldepryl], furazolidine [Furoxone]), especially in patients
with hypertension or arrhythmias.
The risk of serotonin
syndrome may be increased when St. John's wort is used in combination
with other serotonergic agents: tricyclic antidepressants, SSRIs (Prozac,
Paxil, Zoloft), lithium, dextrometorphan. The serotonin syndrome is
a hyperserotinergic condition that can have very dangerous side effects.
Signs and symptoms of serotonin syndrome may include euphoria, drowsiness,
sustained rapid muscle contraction and relaxation in the ankle, causing
abnormal movements of the foot; clumsiness, restlessness; dizziness;
sweating, muscle twitching, rigidity, high body temperature; mental
status changes, including confusion and hypomania; shivering, diarrhea,
and loss of consciousness.
St.
John's wort has had documented interactions with cyclosporine, amitriptyline,
digoxin, indinavir (49 % to 99% reduction in serum drug levels), warfarin,
phenprocoumon, theophylline, oral contraceptives, SSRIs, and loperamide.
In addition, St. John's wort may increase the risk of photosensitivity
reactions when used with other photosensitizing agents (eg, tetracycline,
doxycycline, fluoroquinolones, interferons, felbamate [Felbatol], griseofulvin,
isoretinoin [Accutane], porfimer [Photofrin]).
PREOPERATIVE SURGICAL CONCERNS
May increase the metabolism of drugs
utilized in perioperative care, including cyclosporine, midazolam, lidocaine,
and calcium channel blockers. Use should be discontinued at least 5
days before surgery.
|
VALERIAN
Valeriana officinalis
General Info
A traditional herbal sleep remedy.
Chemical constituents are sesquiterpenes of the volatile oil (valerenic
acid), iridoids (valepotriates), furanofuran lignans, free amino acids,
and alkaloids. The sesquiterpine components are believed to be responsible
for its biologic effects. Studies have suggested direct sedative effects
(valepotriattes, valeric acid) and interaction with neurotransmitters
such as GABA.
As a food supplement, it is not subjected
to regulatory control beyond labeling requirements. FDA classifies valerian
as GRAS.
Has
the characteristic odor of dirty socks.
Uses
Anxiolytic, sedative, and tranquilizer.
It appears to be a safe sedative/hypnotic choice for mild to moderate
insomniacs wihtout the hangover-sleepiness of benzodiazepines. It is
also used for mild anxiety; however supporting data is limited.
Although with poorly defined effects
on GABA neurotransmission, it may attenuate benzodiazepine withdrawal
symptoms.
Side Effects
Some patients report mild headache
(occasionally migraine-type) or gastrointestinal disturbances (usually
nausea) with valerian use. There have been at least five reports of
hepatotoxicity; these were not dose related and were considered idiosyncratic
(Drug Saf. 17[5]:342-56, 1997). There has been one case report of a
withdrawal syndrome similar to that seen with benzodiazepines in a man
who used high doses of the herb for many years (JAMA 280[18]:1566-67,
1998).
Long-term safety studies have not yet
been done with valerian. In theory, valerian could interact with barbiturates,
benzodiazepines, opiates, or alcohol.
A report of an overdose of valerian with
40-50 capsules (20 times the recommended dose) resulted in mydriasis,
fatigue, abdominal cramping, chest tightness, lightheadedness, and foot-hand
tremor that resolved in 24 hours. Lab tests, including liver funtion
tests, were normal.
Caution
No significant herbal/drug interactions with valerian have been reported.
It may potentiate the sedative effects of barbiturates, anesthetics
and CNS depressants.
Although not synergistic with alcohol, concomitant use is not recommended.
Withdrawal may occur with sudden cessation after high-dosage long-term
use.
Use in pregnancy is not recommended.
Label
caution: In one label
testing of 17 valerian products, only 9 products passed. Four had no
detectable level of expected valerinic acid, another four had about
half of claimed amounts. Extract products fared much better than root
powder source.
Doses
and Recommendations
Use 300-600 mg one hour before bedtime
for insomnia, bid for anxiety. Must contain 0.5% essential oil (valerenic
acid).
For use as dried herbal valerain root,
2 to 3 g is soaked in one cup of hot water for 10-15 minutes and ingested
1/2 to 2 hours before bedtime.
PREOPERATIVE SURGICAL CONCERNS
Valerian produces dose-dependent sedation
and hypnosis and can potentiate the sedative effects of anesthetics
and adjuvants such as midazolam. Taper use over several weeks before
surgery as sudden discontinuation may result in a benzodiazepine-like
withdrawal.
|
