October 2001 Bulletin

Commonly used herb supplements, potential hazards

The AAOS Committee on Complementary and Alternative Medicine (CAM) has compiled the following chart of commonly used herbal supplements and the potential hazards they pose. Some references are on page XX; however, there is very little well-documented information about these potential interactions. Use this chart as a rough guide only. CAM suggests instructing patients to cease using most of these preparations at least two weeks prior to surgical interventions.




Interactions with

Dong Quai

To treat menopausal symptoms, PMS, dysmenorrhea

Enhances bleeding; Hypersensitivity to sunlight



To treat colds, flu, and mild infections, especially upper respiratory infections

Hepatotoxicity; Intestinal upset

Other hepatotoxic drugs; Anabolic steroids; Methotrexate

(Ma Huang, Ephedrine Pseudo-ephedrine)

To treat asthma, cough, and to induce weight loss

Seizures; Adverse cardiovascular events

Cardiac glycosides; General anesthesia; MAO inhibitors; Decongestants, stimulants


To decrease cholesterol and blood clot formation

Enhances bleeding



To relieve nausea

Enhances bleeding; CNS depression; Hypotension; Cardiac Arrhythmia; Hypoglycemia

Anticoagulants; Enhances the effects of barbiturates; Antihypertensives; Cardiac drugs; Hypoglycemic drugs

Ginkgo Biloba

To improve circulation, especially to brain; For memory loss, dizziness, and headache

Enhances bleeding; Cramps, muscle spasms



To increase energy and reduce stress

Enhances bleeding; Tachycardia and hypertension; Mania

Anticoagulants; Stimulants; Antihypertensives; Antidepressants/ Pheneizine; Digoxin; Potentiates the effects of corticosteroids and estrogens


Used as a mild antibiotic to treat sore throats and upper respiratory infections

Increases fluid retention; Hypertension; Nausea; Nervousness

Diuretics; Antihypertensives

Kava Kava

To treat anxiety, nervousness, and insomnia

Upset stomach; Allergic skin reaction, yellow discoloration of skin

Potentiates the effects of antidepressants, barbiturates, and benzodiazepines; Skeletal muscle relaxants; Anesthetics


To treat hepatitis and peptic ulcers

Hypertension; Hypokalemia; Edema

Antihypertensives; Potentiates the effects of corticosteroids

(S-adenosyl- L-methionine)

To treat depression or osteoarthritis

Mimics serotonin; Nausea, upset stomach

Drugs that can increase or mimic serotonin, such as antidepressants

St. John’s Wort

To treat mild depression, anxiety, seasonal affective disorder

Enhances bleeding

Anticoagulants; Antidepressants; Decreases the effectiveness of cyclosporine, antiviral drugs; Digoxin; Dextrometorphan; Prolongs the effects of general anesthetics; MAO inhibitors


To treat insomnia, anxiety

Sedation; Digestion Problems

Potentiates the effects of barbiturates


Dong Quai

Page RL, Lawrence JD Potentiation of Warfarin by dong quai. Pharmacotherapy 1999;19:870-6


See DM, Broumand N, Sahl L, Tilles JG In vitro effects of echinacea and ginseng on natural killer and antibody-dependent cell cytotoxicity in healthy subjects and chronic fatigue syndrome or acquired immunodeficiency syndrome patients. Immunopharmacology 1997;35:229-235

Ephedra/Ma Huang

Haller CA, Benowitz NL Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids. N Engl J Med 2000;343:1833-1838

Powell T, Hsu FF, Turk J, Hruska K Ma-huang strikes again: ephedrine nephrolithiasis. Am J Kidney Dis 1998;32:153-159

White LM, Gardner SF, Gurley BJ, Marx MA, Wang PL, Estes M Pharmacokinetics and cardiovascular effects of ma-huang (Ephedra sinica) in normotensive adults. J Clin Pharmacol 1997 Feb;37(2):116-22


Srivastava KC Evidence for the mechanism by which garlic inhibits platelet aggregation. Prostaglandins Leukot Med 1986 Jun;22(3):313-21

Apitz-Castro R, Escalante J, Vargas R, Jain MK Ajoene, the antiplatelet principle of garlic, synergistically potentiates the antiaggregatory action of prostacyclin, forskolin, indomethacin and dypiridamole on human platelets. Thromb Res 1986;42:303-311

Silagy CA, Neil HA A meta-analysis of the effect of garlic on blood pressure. J Hypertens 1994 Apr;12(4):463-8


Phillips S, Ruggier R, Hutchinson SE Zingiber officinale (ginger)–an antiemetic for day case surgery. Anaesthesia 1993 Dec;48(12):1118

Gingko Biloba

Le Bars PL, Katz MM, Berman N, Itil TM, Freedman AM, Schatzberg AF A placebo-controlled, double-blind, randomized trial of an extract of Ginkgo biloba for dementia: North American EGb Study Group. JAMA 1997;278:1327-1332

Oken BS, Storzbach DM, Kaye JA The efficacy of Ginkgo biloba on cognitive function in Alzheimer disease. Arch Neurol 1998;55:1409-1415


Janetzky K, Morreale AP Probable interaction between warfarin and ginseng. Am J Health Syst Pharm 1997;54:692-693


Rehman J, Dillow JM, Carter SM, Chou J, Le B, Maisel AS Increased production of antigen-specific immunoglobulins G and M following in vivo treatment with the medicinal plants Echinacea angustifolia and Hydrastis canadensis. Immunol Lett 1999 Jun 1;68(2-3):391-5

Kava Kava

Pittler MH, Ernst E Efficacy of kava extract for treating anxiety: systematic review and meta-analysis. J Clin Psychopharmacol 2000 Feb;20(1):84-9

Jappe U, Franke I, Reinhold D, Gollnick HPM Sebotropic drug reaction resulting from kava kava extract therapy: A new entitity? J Amer Acad Dermatol 1998; 38:104—6


Fujisawa Y, Sakamoto M, Matsushita M, Fujita T, Nishioka K Glycyrrhizin inhibits the lytic pathway of complement–possible mechanism of its anti-inflammatory effect on liver cells in viral hepatitis Microbiol Immunol 2000; 44(9):799-804


Fava M, Giannelli A, Rapisarda V, Patralia A, Guaraldi GP Rapidity of onset of the antidepressant effect of parenteral S-adenosyl-L-methionine Psychiatry Res 1995 Apr 28;56(3):295-7

St. John’s Wort

Gaster B, Holroyd J St John’s wort for depression: a systematic review. Arch Intern Med 2000;160:152-156

Shelton RC, Keller MB, Gelenberg A, et al Effectiveness of St John’s wort in major depression. JAMA 2001;285:1978-1986

Lantz MS, Buchalter E, Giambanco V St. John’s wort and antidepressant drug interactions in the elderly. J Geriatr Psychiatry Neurol 1999;12:7-10


Donath F, Quispe S, Diefenbach K, Maurer A, Fietze I, Roots I Critical evaluation of the effect of valerian extract on sleep structure and sleep quality Pharmacopsychiatry 2000 Mar;33(2):47-53

Other recommended journal articles regarding herbal supplements.

Ang-Lee MK, Moss J, Yuan C Herbal Medicines and Perioperative Care JAMA 2001;286: 208-216

Kaye AD, Clarke RC, Sabar R, et al Herbal medications: current trends in anesthesiology practice—a hospital survey. J Clin Anesth 2000;12:468-471

Eisenberg DM, Davis RB, Ettner SL, et al Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up study. JAMA 1998;280:1569-1575

Blendon RJ, DesRoches CM, Benson JM, Brodie M, Altman DE American’s views on the use and regulation of dietary supplements. Arch Intern Med 2001;161:805-810

Miller LG Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions. Arch Intern Med 1998 Nov 9;158(20):2200-11

Klepser TB, Klepser ME Unsafe and potentially safe herbal therapies. Am J Health Syst Pharm 1999 Jan 15;56(2):125-38

Hensrud DD, Engle DD, Scheitel SM Underreporting the use of dietary supplements and nonprescription medications among patients undergoing a periodic health examination. Mayo Clin Proc 1999;74:443-447

Anesthesiologists warn: if you’re taking herbal products, tell your doctor before surgery.

Full text of DSHEA at HealthWorld Online http://www.healthy.net/public/legal-lg/fedregs/S784_ENR.HTM

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