Perioperative considerations for the patient on herbal medicines.

Herbal medicines have enormous presence in the United States health care system. There is an increasing trend towards reimbursement of herbal medicines by insurance companies, which further encourage their utilization. Herbs are listed under the "supplement" category by the Food and Drug Administration. The Dietary Supplement and Health Education Act signed into law in October 1994, requires no proof of efficacy, no demonstration of safety, and sets no standards for quality control for the products labeled as "supplements" thereby increasing the risk of adverse effects of these herbs. The United States has experienced an epidemic of over-the-counter "natural" products over the last two decades; but there is little motivation for the manufactures to conduct randomized, placebo-controlled, double-blinded clinical trials to unequivocally prove the safety and efficacy of these drugs. Physicians, irrespective of their specialty, should not underestimate the potential risks associated with the use of herbs as reports indicate that within the last two decades, more than 100 herbogenic deaths have occurred, many serious complications have been reported, patients have required renal dialysis, renal transplantation and hepatic transplantation after taking botanicals. Internists must inquire about the patient's use of herbal products. In addition, the education of each patient regarding the serious, potential drug-herb interactions should be a routine component of preoperative assessment. The American Society of Anesthesiologists (ASA) recommends that all herbal medications should be discontinued 2-3 weeks prior to an elective surgical procedure. If the patient is not sure of the content of the herbal medicine, he/she should be urged to bring the container so that an attempt can be made to review the contents of the preparation. While such an action holds some promise in the elective setting, emergency care should be based on a thorough drug-intake history from the patient or a relative, if possible. Medical research and medical literature in general has not addressed this new group of health supplements, despite the fact that many of these herbs have the potential to cause serious health problems and drug interations. There is a need to conduct scientific clinical trials to study the anesthetic drug responses to commonly used neutraceutical agents.