Rising Use of Herbal Supplements Creates Awareness of Risks During the Perioperative Period

Herbal supplements have been used for thousands of years,¹ and more than half of US adults currently consume herbal or vitamin supplements.^2,3 The global market for nutraceuticals and supplements has steadily grown over the past 2 decades.⁴

Since the COVID- 19 pandemic, global supplement sales surged amid concern for prophylactics and improved immune function.⁴ By March 2020, total sales of vitamins and supplements increased 51.2% in the US, while vitamin sales alone increased by 63% in the UK.⁴ The value of the supplement market is predicted to grow to $60 billion in the US and $200 billion globally by 2025.⁵

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High-quality studies show both the health benefits and harm of dietary supplements.^6,7 Despite health benefits, taking dietary supplements with prescribed medication can result in life-threating adverse events, hospitalizations, and death.⁷

A recent review published in the Journal of Clinical Anesthesia addresses herbal supplement interaction with anesthetic medications administered during surgery. The authors report that 50% to 70% of surgical patients do not disclose use of herbal medications to their physicians and most fail to stop taking them perioperatively.⁸

The World Health Organization defines herbal medicines as “herbs, herbal materials, herbal preparations and finished herbal products that contain as active ingredients parts of plants, other plant materials or combinations thereof” used in traditional and complementary medicine.⁹

Currently, the American Society of Anesthesiologists has no position statement or practice guideline addressing discontinuing herbal supplementation prior to surgery. There is limited research both on the safety and efficacy of herbal supplements and on their uses, pharmacological interactions, and complications during the perioperative period.⁸

Due to lack of robust evidence on interactions between anesthesia and herbal medications, current research only points to potential risks. Unknown complications may still occur. Commonly used herbal supplements posing risk during the perioperative period and the conditions they are used for are listed in Table 1.

Practitioners should be aware of the use of herbal supplements prior to surgery. Absent of strong evidence, unpredictable potential drug interactions may occur. The American Association of Nurse Anesthetists (AANA) guidelines direct patients to stop supplements 2 weeks prior to any surgical procedure involving anesthesia to mitigate adverse effects.⁸ Pharmacists can get involved by counseling patients on when to halt use of supplements, as well as proper use and selection of products.

References

1.Petrovska BB. Historical review of medicinal plants and usage. Pharmacology Reviews, 2012;6(11):1-5.

2. Kantor ED, Rehm CD, Du M, White E, Giovannucci EL. Trends in dietary supplement use among us adults from 1999-2012. JAMA. 2016;316(14):1464-1474.

3.2019 CRN consumer survey on dietary supplements. Council for Responsible Nutrition. Accessed April 24, 2024. https://www.crnusa.org/resources/annual-crn-consumer-survey-dietary-supplements-consumer-intelligence-enhance-business

4.Lordan R. Dietary supplements and nutraceuticals market growth during the coronavirus pandemic - Implications for consumers and regulatory oversight. PharmaNutrition. 2021;18:100282. doi:10.1016/j.phanu.2021.100282

5.Dietary supplements market size worth $194.63 billion by 2025: CAGR 7.8%. Grand View Research. May 2019. Accessed April 24, 2024. https://www.grandviewresearch.com/press-release/global-dietary-supplements-market

6.Cohen PA. The supplement paradox: negligible benefits, robust consumption. JAMA. 2016;316(14):1453-1454.

7.Awortwe C, Makiwane M, Reuter H, Muller C, Louw J, Rosenkranz B. Critical evaluation of causality assessment of herb-drug interactions in patients. Br J Clin Pharmacol. 2018;84(4):679-693.

8.Elvir Lazo OL, White PF, Lee C, et al. Use of herbal medication in the perioperative period: Potential adverse drug interactions. J Clin Anesth. Published online April 12, 2024. doi:10.1016/j.jclinane.2024.111473

9.Rojas P, Jung-Cook H, Ruiz-S´anchez E, Rojas-Tom´e IS, Rojas C, L´opez- Ramírez AM, et al. Historical aspects of herbal use and comparison of current regulations of herbal products between Mexico, Canada and the United States of America. Int J Environ Res Public Health 2022;19(23):15690. https://doi.org/ 10.3390/ijerph192315690.