Although complementary and alternative medical treatments are growing in popularity, a review article published in the Journal of the American Academy of Orthopaedic Surgeons notes a number of these products, such as herbal
supplements, may have serious, potentially harmful side effects when combined with medications prescribed during and after surgery.
According to the review, around 20% of prescription users also take an
herbal supplement — with rates increasing as high as 35% to 70% among
orthopedic patients who are candidates for surgery.
“Herbal remedies are classified as dietary supplements, meaning
they are exempt from the safety and efficacy regulations that the U.S. Food and
Drug Administration requires for prescription and over-the-counter
medications,” review author David T. Rispler, MD, stated in an American
Academy of Orthopaedic Surgeons press release. “As a result, individual
herbal remedies have not been thoroughly evaluated in large clinical trials,
and little information is available on the interactions between drugs and
The review noted that many of the most popular herbal supplements in use
today can result in serious side effects when used in conjunction with
prescription medications. Feverfew, ginger, cranberry, St. John’s Wort and
ginseng, for example, reportedly interact with warfarin. Other examples cited
in the release include:
- Feverfew, ginger and gingko, which can interact with aspirin;
- Valerian, which can intensify anesthetics;
- St. John’s Wort, which can reportedly interact with
immunosuppressive drugs and potentially lead to transplant rejection;
- Glucosamine, chondroitin and flavocoxid, which can affect clotting
- Black cohosh, which can interact with tamoxifen; and
- Cat’s claw, which can interact with clotting agents.
The review also cautioned that many herbal products can pose additional
danger due to being marketed as “natural” or “homeopathic,”
resulting in patients assuming there is no danger of interaction.
Communication is key
Rispler noted physicians rarely ask patients about alternative medical
products during intake interviews — and thus these patients may continue
using the products because they perceive no risks.
According to the release, most surgery-related side effects can be
avoided by ceasing use of the CAM product at least 1 week to 2 weeks
preoperatively and during the postoperative period while prescription
medications are being administered. The problem, Rispler stated, arises when
physicians do not know a patient is using a CAM product — thus,
communication with the patient about the use of CAM products should be taken
- Rispler DT, Sara J. The impact of complementary and alternative
treatment modalities on the care of orthopaedic patients. J Am Acad
Orthop Surg. 2011;19(10):634-643.
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I commend the authors for writing this interesting review. The use of complementary and alternative medical (CAM) therapies, either available over the counter or via the internet, is a growing industry. As highlighted, many doctors have not routinely included CAM therapies in the drug history. The belief that CAM therapies "do no harm" has been challenged by serious drug interactions. The authors suggest CAM therapies are not subjected to the same level of clinical evaluation as pharmaceuticals.
It is important to respect patient choice. As clinicians we should present an unbiased opinion regarding their choice of alternative therapy, of which many patients feel strongly. This paper adds to the evidence base which may be included in the discussion or decision making process. Clearly, it is important to remember some CAM therapies may offer genuine benefits. The recommendation that CAM therapies should be stopped before and after surgery is sensible.
— Graeme S. Carlile, MBChB, MRCS
Trauma & Orthopaedics Department
Plymouth Hospitals NHS Trust
Disclosure: Carlile has no relevant financial disclosures.