A 72-year-old man is scheduled for right knee replacement surgery due to severe osteoarthritis. He has no other medical problems. He takes ibuprofen and occasionally oxycodone for knee pain. He also takes herbal supplements that he purchases from a health food store.
Which of the following herbal supplements increases the risk of bleeding in this patient?

Question

A 72-year-old man is scheduled for right knee replacement surgery due to severe osteoarthritis.  He has no other medical problems.  He takes ibuprofen and occasionally oxycodone for knee pain.  He also takes herbal supplements that he purchases from a health food store.
Which of the following herbal supplements increases the risk of bleeding in this patient?

Quizplus · Accepted Answer

11ec193a_989d_f8ed_853d_2971776c8b1e_MD0002_00 This patient is scheduled for knee surgery and admits to use of herbal supplements. Many commonly used herbs may interact with anticoagulants or increase the risk of bleeding (Table). It is generally recommended that patients stop taking supplements known to affect hemostasis at least 14 days prior to scheduled procedures. Ginkgo biloba, ginseng, and saw palmetto are associated with increased bleeding risk and should be stopped before surgery or dental procedures. (Choice A) Echinacea is used as an immune stimulant to protect against the common cold and flu. Prolonged use of the supplement (> 10 days) is not recommended. It does not cause bleeding problems, but some studies have shown anaphylaxis in patients with allergy/atopy. (Choice B) Ephedrine was used in the early 1990s for weight loss, improving athletic performance, and treating common colds. It is known to cause elevated blood pressure, fatal arrhythmias, and even sudden death. The sale of ephedra-containing products is now illegal in the United States. (Choice D) Kava is used as an anxiolytic and sedative and also to treat ADHD in children. There have been several cases of severe liver toxicity, including cirrhosis and liver failure, associated with its use. (Choice E) St John's wort has been used for centuries to treat depression. It may cause hypertension and serotonin syndrome when used with antidepressants. It also decreases INR in patients on anticoagulants, and thus drug levels may need close monitoring. Educational objective: Herbal supplements are used frequently by the general population. Many such supplements (eg, ginkgo biloba, ginseng, and saw palmetto) increase risk of bleeding and should be discontinued 14 days prior to surgical procedures. __________ References: Ginkgo biloba and cerebral bleeding: a case report and critical review. (http://www.ncbi.nlm.nih.gov/pubmed/21364361) Intraoperative haemorrhage associated with the use of extract of saw palmetto herb: a case report and review of literature. (http://www.ncbi.nlm.nih.gov/pubmed/11489067)

A 72-Year-Old Man Is Scheduled for Right Knee Replacement Surgery