For many people, the words "natural," "herbal," or "alternative medicine" conjure up images of safety and purity. Products that are available over-the-counter without a doctor's prescription are often believed to be free of any risks. Unfortunately, this perception is inaccurate and may create a false sense of security for consumers who purchase these products-and there are a lot of them. An estimated 60 million people in the United States use herbal remedies and the herbal/dietary supplement market represents a growing multi-billion dollar industry.
Botanics (products made from plant life such as roots, barks, or herbs), as well as vitamin and mineral supplements and conventional over-the-counter medications, are chemically active substances that can have powerful effects on the body. The origins of many modern-day pharmaceutical medications can be traced back to plants. Willow bark, for example, was used over 1,000 years ago to reduce fever and pain. The active ingredient in willow bark, salicin, is a pharmacologic predecessor of a class of drugs called salicylates, one form of which is aspirin. Digitalis, a genus of perennial flowering plants, is a source for cardiac medications such as digoxin.
Like pharmaceutical medications, herbal remedies and dietary supplements often have the potential to cause side effects and interact with other prescription medications. There is a growing number of alarming anecdotal reports from doctors' offices and medical centers around the country-some of which have been reported to the Food and Drug Administration's (FDA's) MedWatch program. Reported adverse events range from insomnia and headache to heart attack and death. Included in a 1993 FDA statement before the Senate Committee on Labor and Human Resources are the herbal ingredients chaparral, comfrey, and ephedra (Ma huang), Vitamins A, B6, niacin, and L-tryptophan (an amino acid), all of which are listed as having possible health hazards. A more recent FDA statement warns consumers against using dietary supplements labeled "plantain" because the product may contain components of the plant Digitalis lanata, which can cause fatal heart reactions.
Unlike prescription or over-the-counter medications, dietary supplements are exempt from the FDA's scrutiny for safety and effectiveness. (For the FDA to be able to remove a supplement from the market, it must prove that it is unsafe and, in most cases, this process occurs only after numerous adverse events are reported.) The Federal Trade Commission (FTC) has issued new guidelines for the advertising of dietary supplements but creative labeling can be misleading.
With the integrity of the product left to the discretion of manufacturers, quality control is highly variable. The amount of active ingredient in each pill or capsule may not be standardized, which means that it may vary from batch to batch delivering unknown dosages; in some cases, tests have shown the specified ingredient to be missing from the product altogether. There are also reports of herbal products being contaminated with substances such as fungicides or lead.
Probably of greatest importance is that manufacturers are not required to understand the way in which herbal and dietary supplements work or what their side effects are before distributing the products in the marketplace. Moreover, the product may contain other active substances-whose mechanisms of action are also unknown. This lack of scientific understanding creates the potential for significant risks, especially to those who are having surgery. Unpredictable interactions may occur with medications and anesthesia, and supplements on their own may interfere with the normal mechanism for blood clotting, causing bleeding that is prolonged or difficult to control.
Prior to surgery, plastic surgeons take careful health histories and advise their patients to temporarily discontinue certain prescription and other over -the-counter medications, as well as certain vitamins. Among them are aspirin, nonsteroidal anti-inflammatory medications (eg: ibuprofen), and Vitamin E, which can cause excessive bleeding. Medications categorized as monoamine oxidase (MAO) inhibitors (eg: the antidepressants Nardil or Parnate) are contraindicated because of their interaction with certain narcotics. If given with the frequently-used pain medication Demerol (meperidine), seizures, coma and death may occur; if given with substances such as dopamine or epinephrine, a hypertensive crisis may result.
When patients do not disclose their use of herbal or other dietary supplements along with the other medications they are taking, because they believe these supplements "don't count," unexpected drug interactions may occur. For example, St. John's Wort, an herb used for mood and sleep disorders, has been found to behave like an (MAO) inhibitor. Gingko biloba, which comes from the Chinese maidenhair tree and is commonly used to enhance memory, has anticoagulation effects that are more potent than Vitamin E. Melatonin, used to induce sleep, is believed to compound the effect of the anesthesia being administered, and Echinacea, used to stimulate the immune system, has been reported to cause liver damage and blood pressure abnormalities when used with general anesthesia.
Dietary supplements do count!
Some plastic surgeons advocate the use of Arnica (from the flower Arnica montana) and Bromelain (an enzyme found in pineapples) to decrease postoperative bruising and swelling. These supplements may be prescribed for the day of surgery and several days after. However, there is no consensus on the benefits of such treatment, and these supplements should be taken only under the guidance of one's surgeon.
Patients are advised against self-medicating in general and should disclose to their surgeon any substance they are taking. This includes vitamins, minerals, herbal or other dietary supplements, as well as all prescription and nonprescription medications. In most cases, the potentially harmful substance should be discontinued 1 to 2 weeks before and after surgery to prevent complications.
Dietary supplements should be taken with caution and only after being fully researched. Potential health benefits may not outweigh the risks and a physician's advice should be obtained before taking most supplements.
