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Inicio Colombian Journal of Anesthesiology Dietary supplements and the anesthesiologist: Research results and state of the ...
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Vol. 42. Núm. 2.
Páginas 90-99 (Abril - Junio 2014)
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Vol. 42. Núm. 2.
Páginas 90-99 (Abril - Junio 2014)
Scientific and Technological Research
DOI: 10.1016/j.rcae.2014.02.004
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Dietary supplements and the anesthesiologist: Research results and state of the art
Los suplementos dietéticos y el anestesiólogo: resultados de investigación y estado del arte
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Silvana Franco Ruiza,b,??
Autor para correspondencia
silvanafrancor@gmail.com

Corresponding author at: Calle 121 # 15ª-14, Bogotá, Colombia.
, Patricia González Maldonadob,c
a Surgeon, Universidad de Caldas, Specialist in Epimediology Universidad del Rosario
b Member of the Anestecoop Education Committee, Medellín, Antioquia, Colombia
c Surgeon, Universidad Nacional de Colombia, Specialist in Anesthesiology and Resuscitation, Universidad Nuestra Señora del Rosario, Pediatric Anesthesia Visiting Staff, Hospital Federico Gómez, Universidad Nacional Autónoma de México, Specialist in Service Anesthesiologist, Universidad de La Sabana Clinic, Anesthesiologist, National Police Hospital, Anesthesiologist, Clínica Palermo, Bogotá, Colombia
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Tablas (5)
Table 1. Common uses of various substances.
Table 2. Socio-demographic characteristics of individuals who use dietary supplements.
Table 3. Reasons for consuming dietary supplements.
Table 4. Commonly used supplements, adverse effects and interactions.
Table 5. Evidence-based recommendations for the use of some dietary supplements.
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Abstract
Background

There is a growing worldwide trend towards the consumption of nutritional supplements. Patients scheduled for surgery who are users of dietary supplements run the risk of interactions between these substances and drugs used in the perioperative period.

Objectives

To conduct a socio-demographic characterization, and determine the prevalence of nutritional supplement use in people taken to surgery; to offer a reference guideline for use during pre-anesthetic consultation.

Methods

The research team conducted an observational descriptive and cross-sectional study of patients presenting to the pre-anesthetic consultation in thirteen cities; 1130 patients were asked about the use of these substances.

Results

The prevalence of use was 20.7%, higher among females at 62.8%, compared to males; consumption in people over 41 years was 63.2%; self-medication in 72.8%; increased consumption with age; in middle and high socioeconomic brackets, consumption was 63%; the higher the education, the higher the consumption; 36.6% plan to continue consumption despite the surgical procedure.

Conclusions

The high rate of consumption of nutritional supplements in patients about to undergo surgery, possible drug interactions, and adverse effects of perioperative consumption of some herbs should trigger an alarm in the anesthesiologist performing the pre-anesthetic consultation; it is necessary to include this in the interview and act accordingly. We recommend always asking to see product packaging.

Keywords:
Prevalence
Anesthesia
Diet Therapy
Patients
Surgical Procedures
Operative
Resumen
Introducción

Hay una creciente tendencia mundial hacia el consumo de suplementos nutricionales. Los pacientes que consumen dichas sustancias y que van a ser llevados a cirugía tienen un riesgo potencial de presentar interacciones medicamentosas entre estas sustancias y los medicamentos del período perioperatorio.

Objetivos

Realizar una caracterización sociodemográfica y determinar la prevalencia del consumo de suplementos nutricionales en personas que van a ser llevadas a cirugía; además, servir como guía de consulta para tomar conductas en la consulta preanestésica.

Metodología

Se llevó a cabo un estudio observacional descriptivo de corte transversal, con pacientes que se presentaban a la consulta preanestésica, en 13 ciudades del país. A 1.130 pacientes se les interrogó acerca del consumo de estas sustancias.

Resultados

La prevalencia de consumo fue de un 20,7%, siendo mayor en el sexo femenino, con un 62,8%, frente al sexo masculino; el consumo en personas mayores de 41 años fue del 63,2%; se automedicaron un 72,8%; a mayor edad, mayor consumo; entre los estratos medio y alto el consumo fue del 63%; a mayor nivel educativo, más consumo; el 36,6% piensan seguir consumiendo a pesar del procedimiento.

Conclusiones

El alto índice de consumo de suplementos nutricionales en pacientes que van a someterse a una cirugía, las posibles interacciones con los medicamentos del perioperatorio y los efectos adversos de algunas hierbas medicinales deben poner en alerta el anestesiólogo que realiza la consulta preanestésica; es necesario incluir este tema en el interrogatorio y tomar conductas al respecto. Es aconsejable solicitar los empaques de los productos que consume.

Palabras clave:
Prevalencia
Anestesia
Dietoterapia
Pacientes
Procedimientos Quirúrgicos Operativos
Texto completo
Introduction

Technological developments in medicine at the present time occur at dizzying speed and research brings about amazing breakthroughs year after year regarding new therapies for a broad range of diseases.

Notwithstanding, a growing number of people resort to alternative, non-conventional practices such as acupuncture, homeopathy, herbal therapies and dietary supplements used as nutritional add-ons to their normal diets.1

This has come about because people want to have better control over their health. In contrast with medications, dietary supplements are not subject to rigorous evaluations before they reach the market.2 One out of every six patients takes some type of dietary supplement concomitantly with medications prescribed by their physicians. All kinds of supplements are found in drugstores, supermarkets, local stores, etc., and patients are now able to find abundant information on the web. However, most of them fail to mention the use of these substances to their physicians, placing their life at risk as a result of potential interactions. It is estimated that 70% of patients fail to inform their physician3 and many of them even take mixes of drugs and nutritional supplements containing substances with unknown side effects that might interact with perioperative medications and result in adverse events.4

Many companies promote herbal medications as dietary supplements. It is estimated that this is a 19 billion-dollar industry and that almost half of the Americans take daily supplements, only some of which have proven efficacy.5 According to a report published in 2009 in the United States regarding consumer trust in dietary supplements, 84% of people trust the quality, safety and efficacy claims of these products.6Table 1 shows the common uses of various substances.

Table 1.

Common uses of various substances.

Supplement  Common uses 
Garlic  Lowers cholesterol and blood pressure, antibacterial, antifungal, reduces the probability of thrombus formation, prevents diabetes 
Cranberry  Urinary tract infections 
Mary's thistle  Cirrhosis, dyspepsia, liver disorders 
Indian chestnut  Hemorrhoids, chronic venous insufficiency 
Black Cohosh  Dysmenorrhea Menopause symptoms 
Dandelion  Anorexia, reduced appetite, flatulence, fluid retention, biliary stones, muscle pain 
Dong quai  Irregular menses, amenorrhea, menopause 
Echinacea  Prevention and treatment of bacterial, viral and fungal infections 
Elder  Upper respiratory tract disease 
Ephedra  Increases energy, reduces appetite, bronchodilator 
Spirulina  Malnutrition, diabetes, leukoplasia, weight loss 
Hawthorn  Heart failure 
Euphrasia  Topical use for ear ache, ocular inflammatory disorders 
Ginseng  Treatment of hemoptysis, gastric disorders, vomiting, protection against stress, counteracts weakness 
Ginseng, American  Improves mental performance 
Ginseng, Chinese  Bronchitis, erectile dysfunction, immune modulation, stimulates sexual drive 
Gingko  Treatment for cognitive disorders, peripheral vascular disease, vertigo and tinnitus, depression, memory loss, dementia, and claudication 
Guarana  Weight loss, improves performance, stimulant 
St. John's wort  Treatment of anxiety and mild-to-moderate depression, obsessive compulsive disorder 
Olive Leaf  Breast cancer, cardiovascular disease, biliary stones, rheumatoid arthritis 
Horny Goat Weed  Called the herbal Viagra® herbal, it is used for impotence, premature ejaculation, weakness 
Ginger  Chemotherapy-induced nausea and vomiting, hyperemesis gravidarum, vertigo 
Kava  Antispasmodic and anticonvulsant due to its central muscle relaxant action, hypnosis, sedation, analgesia, psychotropic, menopause-related symptoms, management of benzodiazepine withdrawal syndrome 
Onagra  Asthma, dermatitis, mastalgia, diabetic neuropathy, psoriasis, schizophrenia 
Pycnogenol  Improves performance in athletes, dysmenorrhea, asthma, boosts the immune system, pain control 
Dwarf American palm  Benign prostatic hyperplasia 
Bell pepper  Topical use for pain, fibromyalgia, gastric ulcer, rheumatoid arthritis 
Licorice  Asthma, dyspepsia, hepatitis 
Grape seed  Venous insufficiency, circulatory disorders 
Soy  Cancer prevention, renal stones, hypertension, dyslipidemia, obesity 
Green tea  Antioxidant, cancer prevention, Parkinson's disease and hypertension; increases alertness 
Red clover  Dyslipidemia, hot flashes in menopause, osteoporosis 
Cat's claw  Anti-inflammatory, gastrointestinal tract inflammation, osteoarthritis, rheumatoid arthritis 
Valerian  Nervousness, depression, insomnia 
Yohimbe  Erectile dysfunction, xerostomia 

Source: Jiang5, CRN Consumer Survey on Dietary Supplements6, Norred et al.13, Stanger et al.14, Skinner y Rangasami18, Bajwa y Panda20.

In 1994, the US Congress passed a law defining dietary supplements as substances mainly for oral intake containing, as their main characteristic, a “dietary ingredient” designed to supplement the diet. Some examples of dietary supplements are vitamins, minerals, herbs (alone or in a mix), aminoacids, and food components such as enzymes and gland extracts. They come in different presentations including tablets, soft gels, liquids and powders. They are not presented as food substitutes or as meal replacements, and they are labeled as dietary supplements.7 On the other hand, nutraceuticals are dietary supplements containing a concentrated form of a bioactive substance originally derived from a food source but now present in a non-food matrix, used as health enhancers at higher doses than those found in normal foods.8

Tsen et al.9 showed that up to 32% of patients assessed during the pre-operative phase used dietary supplements, herbal products, or both. Effects associated with plant-derived products include pharmacokinetic alterations (alteration of absorption, distribution, metabolism, and clearance of conventional medications; pharmacodynamic alterations; and direct interactions with drugs.10

Dickinson et al.3 surveyed cardiologist, dermatologists and orthopedic surgeons in order to determine if they used dietary supplements and recommended them to their patients. They found that up to 75% of them used supplements and up to 91% recommended their use in situations related to their specialties, for example, lowering cholesterol, reducing joint pain, anxiety, etc. They recommended substances such as omega-3 oil, calcium, vitamins and glucosamine. Noteworthy is the concern of these professionals for the absence of continuing education courses on this subject. Table 1 shows a list of the most common uses of some dietary supplements.

The objective of this work was to perform a socio-demographic characterization, determine the prevalence of the use of dietary supplements in patients who are going to be taken to surgery and receive a pre-anesthesia assessment, and to offer a consultation guideline to help anesthesiologists take action during the pre-anesthesia assessment.

Materials and methodsDesign

A descriptive cross-sectional study was proposed in order to determine the prevalence of dietary supplement use.

Population and sample

A sample was taken at the investigator's convenience in those cities where the cooperative (ANESTECOOP) operates.

Procedure

Data were collected through interviews conducted by anesthesiologists during the pre-anesthesia consultation, and recorded in a format designed for that purpose. The interviews were conducted in 13 cities of the country (Pereira, Valledupar, Apartadó, Cartago, Sincelejo, Armenia, Bogotá, Montería, Buga, Manizales, Riohacha, Cali, La Dorada), totaling 1248 patients interviewed in the pre-anesthesia assessment. Of that total, 1130 were taken into account for analysis and the remaining 118 were excluded for different reasons (incomplete or illegible surveys, etc.).

Variables

They correspond to the questions in the survey, which in turn match each of the specific objectives.

Inclusion criteria

Patients over 18 years of age scheduled for elective surgery of any type attending the preoperative consultation.

Statistical analysis

Frequencies were performed for the qualitative variables together with a bivariate analysis using chi2, with a statistical significance value of 0.05. The only quantitative variable (age) was analyzed using means and standard deviations and then recoded in ranges. Prevalence was determined and results were contrasted with the data of the NHANES 2002 and 2008 surveys.

Ethical considerations

This is a descriptive observational study based on interviews for which a verbal consent was obtained from the patients. A form was used to record data pertaining to the study and there was no experimentation with the patients at any time; there were no physical examination or biochemical measurements; hence, the Helsinki declaration does not apply.

Results and analysis

It was determined that the prevalence of dietary supplement use was 20.7%, with a higher consumption among females (62.8%) compared to males. By age group, the higher consumption was found between 41 and 60 years (39.8%); in patients over 60 years of age, the rate was 23.4%, for an overall consumption of 63.2% in adults over 41. Table 2 shows the socio-demographic characteristics of the surveyed population.

Table 2.

Socio-demographic characteristics of individuals who use dietary supplements.

Characteristic  Frequency (%) 
Age (mean and SD)  43.62 (16.81) 
Gender
Female  145 (62.8) 
Male  77(33.3) 
Income bracket
Low  77(33.3) 
Medium  134(58) 
High  12(5.2) 
Education
Illiterate  3 (1.3) 
Incomplete primary  24 (10.4) 
Complete primary  29 (12.6) 
Incomplete secondary  40 (17.3) 
Complete secondary  45 (19.5) 
University  49 (21.2) 
Technical  27 (11.7) 
Graduate  14 (6.1) 
Geographic location
Urban  197(85.3) 
Rural  26(11.3) 

Consumption prevalence according to level of education was distributed as follows: complete primary education, 24.2%; complete secondary education, 36.7%; and 39% among patients with technical, university or graduate education.

Consumption prevalence in income brackets 1 and 2 (lower) was 34.5%, 60.1% in income brackets 3 and 4 (middle), and 5.4% in income brackets 5 and 6 (upper); of the patients surveyed, 88.3% came from the urban area.

To the question of how they had started using these products, 72.8% reported self-medication and the remaining 27.2% reported medical recommendation; 51.9% had started using supplements on a recommendation from a friend or relative.

When asked about the reasons for using nutritional supplements, 44.5% of the respondents reported that they were healthy but wanted to supplement their diets, and 33.7% reported illness and the desire to improve their health. Another reason, given by 8.6% was the feeling of fatigue.

To the question of how long they had been using supplements, 50.5% reported between three and six months, 30% reported 7–12 months, and the remaining 19.5% reported more than one year.

Bearing in mind that patients in the pre-anesthesia consultation are going to undergo surgery, to the question of whether they were planning to stop using the product, or interrupt its use temporarily, or if they were planning to continue to use it despite the procedure, 22.6%, 40.8% and 36.6%, respectively, gave a positive response.

In the bivariate analysis, a statistically significant association was found between consumption and age, income bracket, gender and level of education. It was found that, the older the age the higher the consumption, the higher the income bracket the higher the consumption (63% among people in middle and upper income brackets); there was higher consumption among females, and higher consumption also among people with a higher level of education.

As far as the different substances used as dietary supplements, a wide range of products were reported with close to 200 different responses including Green tea, multivitamins, folic acid, omega-3, glycerine, beta carotene, guarana, gingko biloba, valerian, duck embryos, artichokes, soy, spirulina, transfer factors, shark cartilage, ginseng, plus a whole variety of brand names.

Discussion

Adverse reactions to herbal medicines and supplements are not well recognized and, what is even worse, not reported. Most of the people using dietary supplements do not stop using conventional medications prescribed by their physicians.11 Even more difficult than detecting adverse reactions to medications, is detecting adverse reactions to dietary supplements. It is important to set up a system of reporting and follow-up of potential interactions and adverse reactions caused by these substances in order to be able to evaluate these products and create policies regarding their use.7Table 3 summarizes the main reasons why the general population uses these products, as determined by three independent studies; it shows that the reasons are similar to those found in this research, and points to the fact that most people hope to improve their health and start using these substances without thinking about potential interactions with medications they may be taking at the same time.

Table 3.

Reasons for consuming dietary supplements.

Kennedy (2007)  ConsumerLab.com  Kaufman et al. 
1. Back pain  1. Preserve health  1. Supplement diet 
2. Neck pain  2. Common cold  2. Improve health 
3. Joint pain  3. Osteoarthritis  3. Arthritis 
4. Arthritis  4. Increase energy  4. Improve memory 
5. Anxiety  5. Control cholesterol  5. Increase energy 
6. Cholesterol lowering  6. Prevent cancer  6. Boost immune system 
7. Common cold  7. Allergies  7. Joint disorders 
8. Muscle-skeletal disorders  8. Weight control  8. Help sleep 
9. Migraine    9. Prostate diseases 
Taken and adapted from Ref. 7.

Two studies conducted in 200012 in pre-surgical patients reported that almost half of those patients used dietary supplements. The biggest source of concern though, is that patients rarely offer this information and, worse still, anesthesiologists rarely ask about it. Later on, in 2004, MacKichan et al. asked about the reasons why patients do not discuss the use of these substances with their physicians, and found the following answers: products are labeled as natural and therefore they assume that they are safe; a medical prescription is not required; they are not considered medications. This study found that 72.8% of people using supplements simply self-medicate, and perhaps the argument for not asking their physicians, as was found in the previous studies, is that the products are labeled as natural and they assume they are safe.10

Some statistics show that close to 50% of the patients undergoing surgery discontinue the use of dietary supplements on their own. Consequently, the obvious conclusion is that the other 50% continues to use them.2 In our case, the result is somewhat different, as we found that only 22.6% of the people who use these products think about interrupting their use before the surgery. This reinforces the idea of the sense of trust regarding dietary supplements.

There is an association between use and age over 41, female gender, upper socio-economic bracket, and higher level of education. This may be due to the fact that, the higher the level of education, the higher the purchasing power and the higher the income bracket. Leung et al., reported similar results in 2000, in a study similar to ours: 39.2% used some form of supplement; 56.4% did not mention the use of these products to their treating physician; 53% planned to discontinue their use before surgery. The authors report the following variables as associated with the use of dietary supplements: female gender, high income, high education level, and age range between 39 and 45 years.2

NHANES, The National Health and Nutrition Examination Survey is a representative survey conducted nationwide in the United States. It comprises medical exams and tests, as well as detailed questions about respondent health, lifestyle and diet, and also the use of dietary supplements. The results of this survey in 2002 showed an association between the use of dietary supplements and a high level of education and age over 60. Of the respondents, 16.8% used four or more types of supplements,13 with results similar to ours.

The NHANES 2008 survey16 estimated the use of complementary and alternative medicine among American adults and children. They used data from prior surveys conducted by the CDC and also compared the data with the 2002 survey. They found that 4 out of every 10 adults and 1 out of every 9 children used this type of medicine.

Hogg et al. used a survey in United Kingdom hospitals to ask whether they had specific policies or protocols for managing patients who were taking herbal medicines during the perioperative period, and they found that 90% of the participating institutions had none.4 The situation may be the same in the hospitals in our country. Table 4 shows adverse reactions and interactions of the most commonly used dietary supplements.

Table 4.

Commonly used supplements, adverse effects and interactions.

Substance  Adverse effects  Interactions 
Garlic  Hypertension, hypoglycemia, tendency to bleed when used with NSAID or warfarin; avoid excess in early pregnancy, use with care in hypothyroidism  With sugar-lowering medications; potentiates warfarin, indomethacin and dipyridamole 
Cranberry  None documented  Acidity may counteract antacids. May improve vitamin B12 absorption 
Indian chestnut  No problem when esculin is removed; avoid the raw herb because of potential poisoning. In children it may cause fasciculations, poor coordination, vomiting, diarrhea, depression, paralysis  Esculin has antithrombotic effects; interaction with all anticoagulants or anti-platelet aggregation products and drugs; blood-lowering effect 
Mary's thistle  Rarely gastrointestinal adverse effects; there is a case report of liver enzyme elevation  Protects against liver damage caused by alcohol, phenytoin, paracetamol and halothane; may alter some aspects of cytochrome p-450 metabolism 
Black Cohosh  Must be avoided in the first trimester of pregnancy and during breastfeeding; may increase estrogen-dependent tumor growth; in high doses it may cause headache, vision changes, dizziness and sweating  May lead to excess estrogen with hormone replacement; may increase blood levels of antihypertensive medications 
Dandelion  Must be used with care in patients with irritable bowel; increases gastric acid; must be avoided in biliary duct obstruction; it must be used with care in jaundice or hyperbilirubinemia; laxative effect  May worsen lithium toxicity due to higher sodium excretion; increases the effects of anticoagulant medications and may interact with diuretics 
Dong quai  Must be avoided during pregnancy; may produce bleeding; must be avoided in acute diarrheic disease  Increases the effect of warfarin; alters the effect of medications with an estrogenic effect; increases the possibility of drug-induced arrhythmias 
Echinacea  Must be avoided in systemic autoimmune diseases and tuberculosis; may cause allergic reactions and liver toxicity when used with anabolic steroids, amiodarone, methotrexate and ketoconazole; immune suppression  Prevents recurrent la candidiasis when used with econazole; reduces immune suppressive effects of drugs 
Elder  Stems, roots, berries and seeds contain cyanide (only ripe berries can be used); blood sugar lowering effect  Unknown; interactions with diuretics and laxatives; may alter levels of theophylline 
Eleuthero  Caution in cardiovascular disease, (particularly in rheumatic heart disease); it may cause drowsiness, anxiety, irritability, mastalgia in high doses; sciatic nerve inflammation may occur with prolonged use; alteration of glucose levels in diabetics  Potentiates anticoagulant and anti-platelet effects of drugs; interacts with sedatives; increases the effects of anti-psychotics, SSRIs, propranolol, theophylline, amitriptyline, diazepam, verapamil and warfarin 
Ephedra  Produces insomnia, tachycardia, headache, irritability, nausea, anxiety, arrhythmias, infarction, seizures, stroke and death  None known 
Euphrasia  High-dose eye drops may cause confusion, photophobia, gastrointestinal symptoms, headache and increased intra-ocular pressure; it may cause eye infections because of solutions prepared in poor hygienic conditions  None known 
Hawthorn  Rarely produces adverse effects  Potentiates the effects of digoxin; may increase the effects of antihypertensive drugs 
Gingko  Inhibits platelet aggregation, prolongs clotting times and increases the risk of bleeding; lowers blood sugar and blood pressure  Potentiates the anticoagulant effect of aspirin and warfarin; lowers antidepressant levels; there is a reported case of coma after interaction with trazodone; may potentiate MAO inhibitors; potentiates papaverine. May increase attacks and anti-psychotic side effects 
Ginseng  Inhibits platelet aggregation, inhibits the risk of bleeding; lowers blood sugar; edema; hypertension; produces exacerbations of asthma; tachycardia and increased QT interval  Interacts with warfarin and stimulants; increases alcohol metabolism; may cause hypertension if taken with caffeine; may cause mania if combined with MAO inhibitors 
Ginseng, American  Limited case report; contains many compounds found also in Chinese ginseng  In vitro work in breast cancer with tamoxifen, cytoxan, doxorubicin, taxol and methotrexate. See Chinese ginseng 
Guarana  Similar effects as those of green tea due to its caffeine content  Similar to those of green tea 
St. John's wort  May cause photosensitivity (high doses); psychosis or bipolar disorder may worsen; avoid in patients with HIV  Serotoninergic syndrome with SSRIs and trazodone; reduces theophylline levels; reduces the metabolism of indinavir, digoxin, estrogens, cyclosporine and general anesthetics; reduces the effect of warfarin; may interact with calcium channel blockers, beta-blockers, tricyclic antidepressants 
Olive leaf  May lower blood pressure and reduce serum glucose  None known 
Horny Goat Weed  Anxiety; cardiac arrest in high doses  May increase the effects of hypotensive drugs; potentiates anticoagulant and anti-platelet drugs 
Ginger  Avoid more than 1g during pregnancy; avoid in case of biliary stones; lowers blood sugar  Reduces nausea from anesthetics; increases the absorption of some oral drugs; potentiates the effects of anticoagulants; antagonizes antacids; interferes with inotropes; increases sedative effects 
Kava  Must be avoided in liver disease – there are documented cases of hepatitis; may create a habit after 3 months of use; produces bleeding, cramps, pulmonary hypertension, skin discoloration, and eye problems with chronic use  Reduces the effect of levodopa, and may increase the effects of benzodiazepines, MAO inhibitors and barbiturates; interacts with hepatotoxic drugs 
American dwarf palm  None to this date although it is not recommended during pregnancy or breastfeeding; may lower specific prostatic antigen values; there are documented cases of bleeding  Inhibition of alpha-1 agonist binding; potentiates uterine relaxation effect with propranolol; alters body responses to sexual hormones 
Bell pepzper  May cause bronchial spasm and exacerbate asthma; must not be used topically on non-intact skin; must not be used in cases of gastric ulcer, irritable bowel or gastroesophageal reflux  Exacerbates cough when used with ACE inhibitors; antagonizes antacids 
Pycnogenol  None reported  Interferes with immunosupressants 
Onagra  May cause seizures or mania; may alter blood pressure  May cause seizures in patients taking phenothiazines; increases response to tamoxifen; reduces the efficacy of anticonvulsants 
Licorice  Avoid in renal failure or hypertension (may cause pseudohyperaldosteronism); avoid in diabetes, pregnancy, hepatic cholestasis, alcoholism reduces male libido  Potentiates digoxin and topical steroids; reduces testosterone; alcohol and aspirin-related GI bleeding; may reduce the effects of estrogens; may increase potassium loss through the use of laxatives, thiazides and furosemide; antagonizes spironolactone; increases acetaminophen metabolism 
Soy  Sometimes produces gastrointestinal effects and migraines; may increase the risk of endometrial hyperplasia and cancer; effects on breast cancer; avoid its use in cystic fibrosis and hypothyroidism  Effects may be reduced by antibiotics; may inhibit estrogens; may antagonize tamoxifen; reduces the effect of warfarin in a patient 
Spirulina  Product contamination with microcystine; may produce gastrointestinal disorders, shock; contains phenylalanine  None known 
Grape seed  None greater than placebo in most studies; may have laxative effects  May boost the effects of warfarin; may inhibit lactobacillus; reduces the effects of tricyclics, antipsychotics, cyclobenzapine 
Green tea  Lowers estrogen levels; may increase renal, cardiac, duodenal and psychiatric disorders; side effects related to the concomitant use of caffeine  Reduces iron absorption in children; reduces the effects of warfarin, clozapine, adenosine, pentobarbital, benzodiazepines, beta-blockers 
Red clover  Estrogenic activity; avoid use during pregnancy; avoid in hormone-sensitive cancers  Increases the anticoagulant effects of warfarin 
Cat's claw  Avoid in transplants, and skin grafts; may improve immune function; contraceptive, use with care during pregnancy or breastfeeding  Reduces intestinal damage caused by indomethacine; may sensitize to blood products, hormones and vaccines; increases the effects of fexofenadine, lovastatin, azoles; interferes with immunosuppressants 
Valerian  None. Potential withdrawal symptoms after long-term use  Useful in benzodiazepine withdrawal; potentiates substances with CNS action (anesthetics, barbiturates, benzodiazepines); may prolong the effects of anesthesia 
Yohimbe  May worsen schizophrenia, depression, anxiety, hypertension and renal disease; harmful during pregnancy; liver disorders  Multiple drug interactions: tricyclics, antipsychotics, clonidine, sympathomimetics; potentiates naloxone side effects 

Source: Leung et al.2; Hogg y Foo4, Rindfleisch et al.7, Tsen et al.9, Norred et al.13, Barnes et al.17, Skinner y Rangasami18, Bajwa y Panda20.

Conclusions

We submit this paper not only as the product of a research process but also as study material and guideline for the country's anesthesiologists. It is important to ask these questions of our patients and try to determine, as accurately as possible, what substances they are consuming, how these can affect the planned procedure, and how to act, not only for the benefit of the patients but also for our own peace of mind. There are reports in the literature about serious adverse events when these substances are associated with anesthetic agents. This is one of the few studies conducted in Colombia in relation to the intake of nutritional supplements prior to a surgical intervention.

The lack of sound studies plus the absence of knowledge regarding the effectiveness of these products, creates a false sense of reassurance. The use of these products becomes a challenge for healthcare providers, in particular with patients going to surgery, considering that interactions between some supplements and anesthetic drugs may be fatal.10 Education to the public is required in order to avoid abuse of these substances, self-medication and the false belief that natural products are free from adverse effects.

The following is a list of general recommendations for anesthesiologists8,15,16,18,19:

  • 1.

    Always ask about the use of supplements and herbal medicine and turn this into a habit as part of the routine patient interview.

  • 2.

    Always document patient use of supplements in the clinical record.

  • 3.

    Discontinue supplements in cases of pregnancy and breastfeeding.

  • 4.

    Ask patients to bring (physically) all medications and supplements that they are using.

  • 5.

    Evaluate the components in the supplements used by the patient at the time, and consider potential adverse reactions and drug interactions.

  • 6.

    The American Society of Anesthesiologists recommends discontinuation of these substances two weeks before elective surgery.

Table 5 shows evidence-based recommendations for the use of some dietary supplements.8

Table 5.

Evidence-based recommendations for the use of some dietary supplements.

Recommendation grade  Substance  Description 
Cat's claw  Joint pain 
  Co-enzyme q10  Hypertension 
  Cranberry  Urinary tract infection prophylaxis 
  Ginger  Gestational nausea and vomiting 
  Glucosamine sulfate  Delays arthritis progression (particularly in the knee) 
  Hawthorn  Stage I or II heart failure 
  Indian chestnut  Chronic venous insufficiency 
  Melatonin  Induces sleep in people with intellectual disability 
  Mary's thistle  Cirrhosis 
  Mint oil  Irritable bowel syndrome 
  Probiotics  Irritable bowel syndrome, antibiotic-associated diarrhea, or traveler's diarrhea 
  St. John's wort  Moderate-to-severe depression 
  Valerian  Insomnia 
  Carnitine  Primary deficiencies 
  Choline  Pregnancy and breastfeeding 
  Glutamine  Critical illness 
  Omega-3 fatty acid  Cardiovascular health 
  Phytosterols  Dyslipidemia 
  Flavonoids  Lower the risk of coronary heart disease 
Chondroitin  Osteoarthritis 
  Glucosamine  Osteoarthritis 
  Omega 3 fatty acid  Hypertriglyceridemia 
  Dwarf palm  Benign prostatic hypertrophy 
  Flavonoids  Osteoporosis 
  Taurine  Chronic alcoholism 
  Alpha lipoic acid  Neuropathy 
  Linoleic acid  Neuropathy 
Carnitine  Improved physical performance 
    Cardiac and renal function 
  Choline  Liver disease induced by total parenteral nutrition 
  Coenzyme q10  Mitochondrial disease 
    Congestive heart failure 
    Reperfusion ischemia 
  Glutamine  Stomatitis 
  Melatonin  Sleep inducer; sleep disorder due to time zone changes 
  Omega-3 fatty acid  Irritable bowel disease 
  Probiotics  Antibiotic-related diarrhea 
  Taurine  Liver disease induced by total parenteral nutrition 
Androstenedione  Improves physical performance 
  Choline  Improves memory 
  Chondroitin  Improves cognitive level 
    Cardiovascular health 
    Kidney stones 
  Coenzyme q10  Improves physical performance 
    Anti-aging 
    Boosts immunity 
    Diabetes mellitus 
    Hypertension 
    Cancer 
  Dehydroepiandrosterone sulfate  Androgen replacement 
    Improves physical performance 
    Anti-aging 
    Improves libido 
    Boosts immunity 
  Glutamine  Crohn's disease 
    Boosts immunity 
    Cancer 
    Improves physical performance 
  Melatonin  Cancer 
  Omega-3 fatty acid  Boosts immunity 
    HIV 
    Hypertension 
    Improves asthma 
    Rheumatoid arthritis 
    Psoriasis 
    Chronic fatigue syndrome 
  Phytosterols  Dyslipidemia 
    Cancer 
    Chronic diseases 
  Flavonoids  Hormonal replacement 
    Hot flashes 
    Cognitive therapy 
    Anti-aging 
  Taurine  Congestive heart failure 
    Diabetes mellitus 
    Dyslipidemia 
  American Ginseng  Blood sugar control 
  Ginkgo biloba  Peripheral neuropathy 
    Erectile dysfunction 
    Intermittent claudication 
Level of evidence-description  Detail 
Levels of evidence
1. Large prospective, randomized, controlled trials  Data derived from a significant number of adequately powered trials. Large meta-analyses with raw or clustered data. Consistent finding pattern in the population for which the recommendation is made 
2. Randomized, controlled, prospective trials in small populations  Limited number of trials, with small population sizes. Only one well-conducted prospective cohort study. Limited but well performed meta-analysisInconsistent findings or results that cannot be generalized to the population 
3. Outcomes of other types of experimental or non-experimental studies  Non-randomized or controlled trialsNon-controlled or poorly controlled trialsAny randomized clinical trial with a high risk of biasRetrospective or observational data.Contradictory data that cannot support a final recommendation 
4. Expert opinion  Shortage of data for inclusion in the categories above; literature summary by an expert panelExperience based on the information 
Grade  Description  Detail 
Recommendation grade
Conclusive level 1 publications showing that benefit is greater than risk  The indications described in the publications may be followed; may be conventional or “first-line” therapy 
Conclusive level 2 publications that demonstrate that benefit is greater than risk  The indications described in the publications may be followed. Monitor adverse effects; may be recommended as “second-line” therapy 
Conclusive level 1, 2, 3 publications. No risk, no benefit  The indications described in the publications may be followed if the patient refuses or does not respond to conventional therapy. No objection to recommend use 
Non-conclusive level 1, 2, 3, publications. Conclusive level 1, 2, 3 publications showing that risk is greater than benefit  Not recommended 

Source: Rindfleisch et al.7

Funding

None.

Conflicts of interest

The authors have no conflicts of interest to declare.

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Please cite this article as: Franco Ruiz S, González Maldonado P. Los suplementos dietéticos y el anestesiólogo: resultados de investigación y estado del arte. Rev Colomb Anestesiol. 2014;42:90–99.

Copyright © 2013. Sociedad Colombiana de Anestesiología y Reanimación
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