| Dong quai | “Health-promoting” and estrogen effects | - May increase INR, PT, aPTT
- May be associated with photosensitivity
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| Echinacea | URIs, arthritis, open wounds | - Immunostimulatory effects with short-term use, thus contraindicated in autoimmune disease and immunosuppressive regimens
- Immunosuppression with long-term use with implications on wound healing, opportunistic infections
- Inhibitor of cytochrome P450 3A4 (see below)
- Possible hepatotoxicity
- Possible allergic reactions
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| Ephedra | Weight loss, energy increase/stimulant, respiratory tract conditions | - Dose-dependent sympathomimetic effects with increased BP, HR, vasoconstriction with many reported cases of cardiac and CNS complications including death
- Increased risk of ventricular arrhythmias with concomitant use of agents that sensitize myocardium such as halothane
- Long-term use depletes endogenous catecholamines; associated with tachyphylaxis with potential perioperative hemodynamic instability (use direct-acting sympathomimetic agents intraoperatively)
- Concomitant use with MAOIs can result in life-threatening hyperpyrexia, hypertension, coma
- Should discontinue at least 24 h prior to surgery
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| Feverfew | Primarily migraine treatment. Also headaches, arthritis | - Inhibits platelet activity
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| Garlic | Antimicrobial, immunostimulatory, decreases blood pressure, lowers cholesterol | - Decreases blood pressure
- Likely irreversible inhibition of platelets and may potentiate other platelet inhibitors
- Discontinue at least 7 days prior to surgery
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| Gingko | Cognitive disorders, peripheral vascular disease, age-related macular degeneration, vertigo, tinnitus, erectile dysfunction, altitude sickness | - Inhibits platelet-activating factor
- Discontinue at least 36 h prior to surgery
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| Ginseng | Protects against stress, restores homeostasis, lowers blood glucose | - Hypoglycemia
- Platelet inhibition, possibly irreversible
- Interference with efficacy of warfarin-induced anticoagulation
- Discontinue at least 7 days prior to surgery
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| Kava | Anxiolytic, sedative | - May potentiate sedation
- Potential for abuse, addiction, tolerance, and withdrawal unknown
- Possible association with hepatic dysfunction
- Discontinue at least 24 h prior to surgery
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| Saw palmetto | BPH | - Anti-inflammatory effects that may cause platelet dysfunction
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| St. John’s wort | Mild anxiety and depression, wounds and burns | - Unknown mechanism; inhibits serotonin, norepinephrine, dopamine reuptake
- Potential MAOI and SSR inhibitor. Discontinue in patients taking these medications
- Induces photosensitivity. Avoid photosensitive drugs and laser treatments
- Induces cytochrome P450 3A4 (decreasing activity of warfarin, cyclosporin, oral contraceptive, digitalis, midazolam, lidocaine, calcium channel blockers)
- Affects digoxin pharmacokinetics (decreases levels)
- Discontinue at least 5 days prior to surgery
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| Valerian | Insomnia treatment | - Produces sedation and hypnosis (GABA)
- Potentiates sedation
- Abrupt discontinuation may lead to benzodiazepine-like withdrawal symptoms
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