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November 28, 2001

Use of Herbal Medications Before Surgery—Reply

Author Affiliations

Stephen J.LurieMD, PhD, Senior EditorIndividualAuthorJody W.ZylkeMD, Contributing EditorIndividualAuthor

JAMA. 2001;286(20):2542-2544. doi:10.1001/jama.286.20.2542

In Reply: We are not surprised that our article came to the attention of Dr Betz and the American Herbal Products Association, whose purpose is to act as the "voice of the herbal products industry."1 We took a balanced approach to herbal medicines because our mission is to evaluate both benefits and risks of herbs. Betz questions the validity of making recommendations based on case reports, animals studies, and in vitro data. In our article, we acknowledged that randomized controlled trials are often lacking and that mechanisms for tracking adverse events provide insufficient information. The inability of the herbal industry to achieve reliable standardization of their products makes such information even less clinically relevant. For example, ginseng preparations that listed specific concentrations of active ingredients contained as little as 11% and as much as 328% of the labeled concentrations.2 Despite such problems with herbal preparations, a third of the patients in our sample took them before surgery. Such widespread use mandates that clinicians have guidelines to aid in managing their preoperative use. We made conservative recommendations, relying on relevant case reports and the pharmacology of active constituents. We believe that timely preoperative discontinuation is warranted because the risks of discontinuing herbal medicines are outweighed by the benefits of preventing perioperative complications. This is particularly true with herbs such as ginkgo, garlic, and ginseng that may cause bleeding, since over half of all blood transfusions in the United States occur intraoperatively.3 A conservative approach toward managing these agents is also supported by the American Society of Anesthesiologists, who recommend the discontinuation of all herbal medicines 2 to 3 weeks before surgery.4