Dietary Supplements

Question 1

What are considered dietary supplements?

Answer 1

Vitamins, minerals, fiber, fatty acids, herbs, and amino acids

Question 2

What are some disadvantages to dietary supplement use?

Answer 2

Little Testing

Unsubstantiated therapeutic claims

Question 3

Why don’t dietary supplements have to go through the same testing as medication?

Answer 3

The U.S. Food and Drug Administration considers these substances “Foods.”

Question 4

Why aren’t dietary supplements sometimes considered for the cause an issue during anesthesia?

Answer 4

Nearly 70% of patients taking a dietary supplement did not provide that information during a routine anesthetic assessment.

Question 5

What are the two types of interactions between dietary supplements and medications?

Answer 5

Pharmacokinetic Interactions

Pharmacodynamic Interactions

Question 6

Define Pharmacokinetic Interactions between dietary supplements and medications.

Answer 6

These are interactions that result from alterations to the cytochrome P450 (CYP450) pathway by the dietary supplement (Enzyme induction or inhibition)

Question 7

Define Pharmacodynamic interactions between dietary supplements and medications.

Answer 7

These interactions result from the interplay of the effects caused by the dietary supplement and the medication.
Similar effects cause an additive effect
Opposing effects cause a reduction in effect

Question 8

Define Pharmacodynamic interactions between dietary supplements and medications.

Answer 8

These interactions result from the interplay of the effects caused by the dietary supplement and the medication.
Similar effects cause an additive effect
Opposing effects cause a reduction in effect

Question 9

When does the ASA recommend discontinuing supplements prior to anesthesia?

Answer 9

The American Society of Anesthesiologists recommends discontinuation 2-3 weeks prior to surgery

Question 10

When can supplements be restarted after surgery?

Answer 10

Dietary supplements should not be restarted until all medications have been discontinued and a period equal to five half-lives of the discontinued medications has elapsed.

Question 11

What is the function of vitamin D?

Answer 11

Maintains plasma concentrations of calcium and phosphate for optimal neuromuscular function and bone mineralization

Question 12

What can occur if a patient has a Vitamin D deficiency?

Answer 12

Leads to poor intestinal absorption of calcium and phosphate
Causes stimulation of PTH to restore the plasma concentration causing osteomalacia

Question 13

What is the function of Vitamin K?

Answer 13

Essential for biosynthesis of clotting factors: converts glutamic acid residues to gamma-carboxyglutamic acid residues in Factors II, VII, IX, and X

Question 14

What can occur if a patient has a deficiency of Vitamin K?

Answer 14

Hypoprothrombinemia

Question 15

When should an anesthetic provider be concerned with serum Vitamin K levels?

Answer 15

Order coags and LFTs on a patient with liver impairment

Question 16

What is the function of thiamine?

Answer 16

Metabolism of carbohydrates, alcohol, and amino acids

Question 17

What can deficiencies of Thiamine lead to?

Answer 17

Mild: Beriberi-loss of appetite, skeletal muscle weakness, decreased BP, and hypothermia
Severe: Wernicke-Korsakoff Syndrome-memory impairment, encephalopathy that can occur as a result of chronic alcohol dependence

Question 18

What is the Thiamine deficiency related to?

Answer 18

Chronic alcohol abuse

Question 19

What is the function of Vitamin B12?

Answer 19

Metabolic processes, DNA synthesis, myelin synthesis, decreases blood homocysteine levels

Question 20

What is the function of Vitamin B12?

Answer 20

Metabolic processes, DNA synthesis, myelin synthesis, decreases blood homocysteine levels

Question 21

What can a deficiency of B12 lead to?

Answer 21

Megaloblastic anemia, peripheral neuropathies, and gastrointestinal symptoms
Prevents synthesis of adequate supplies required for DNA synthesis

Question 22

What is the function of folic acid?

Answer 22

DNA synthesis, decreases blood homocysteine levels

Question 23

What can a deficiency of folic acid lead to?

Answer 23

Megaloblastic anemia, birth defects

Question 24

What birth defect is folic acid related to?

Answer 24

Spina bifida

Question 25

When does the ASA recommend discontinuing herbal supplements prior to surgery?

Answer 25

The American Society of Anesthesiology recommends all herbal medication to be discontinued 2-3 weeks before surgery

Question 26

How can herbal supplements affect anesthesia?

Answer 26

``` Increased surgical bleeding Heart and blood pressure effects Respiratory complications, MI or Stroke Renal disturbances Reactions with sedatives Changes in the body’s interactions with other medications Higher anesthetic consumption Delayed recovery from anesthesia ```

Question 27

What is the most popular herbal remedy used in US?

Answer 27

Echinacea

Question 28

What do people typically take Echinacea for?

Answer 28

Improves immune system | Used to prevent and treat viral, bacterial, and fungal infections

Question 29

What is the mechanism of action of Echinacea?

Answer 29

Modulates cytokine signaling; stimulates macrophages and NK cells

Question 30

What population should Echinacea be used with caution?

Answer 30

Caution use in patients with asthma and atopic or allergic rhinitis due to possible allergic and anaphylactic reactions

Question 31

What is garlic used to treat?

Answer 31

Hypertension, hyperlipidemia, atherosclerosis, diabetes, infections, and tumors

Question 32

What is the mechanism of action of Garlic?

Answer 32

Cysteine found in garlic decreases thromboxane formation and alters arachidonic acid metabolism; inhibits platelet aggregation

Question 33

What medication should be used with caution if a patient is taking garlic?

Answer 33

Can potentiate anti-platelet effects of aspirin and NSAIDs

Question 34

What is ginger used to treat?

Answer 34

Used as an anti-inflammatory, anti-emetic, and GI stimulant

Question 35

What is the mechanism of action of ginger?

Answer 35

Inhibits thromboxane synthetase enzyme; inhibits peripheral and central serotonergic pathways

Question 36

What should be considered, especially to by the surgeon if the patient has taken ginger?

Answer 36

Consideration for bleeding especially when used with NSAIDs and Warfarin

Question 37

What should be considered, especially to by the surgeon if the patient has taken ginger?

Answer 37

Consideration for bleeding especially when used with NSAIDs and Warfarin

Question 38

What is Gingko used to treat?

Answer 38

Used to treat peripheral vascular disease and dementia by protecting vascular walls and nerve cells

Question 39

What is the mechanism of action of Gingko?

Answer 39

Free radical scavenger; inhibits platelet activating factor; effects vasoregulation, modulation of neurotransmitter, and receptor activity

Question 40

What medication interactions are we concerned with if a patient has taken Gingko?

Answer 40

Avoid use in combination with NSAIDs, Aspirin, and Warfarin due to risk for bleeding

Question 41

What is the most expensive herbal supplement used world wide?

Answer 41

Ginseng

Question 42

What is Ginseng used for?

Answer 42

Immunomodulation, mood enhancement, and aphrodisiac effects

Question 43

What is the mechanism of action of Ginseng?

Answer 43

Mild sympathomimetic effects; neuroprotective effects due to inhibition of sodium channels in the CNS; hypoglycemic activity; interferes with platelet aggregation

Question 44

What medication should be avoided with Ginseng use?

Answer 44

May interact with monoamine oxidase inhibitors (MOAIs) causing tremors and mania Use with caution in combination with NSAIDs and Warfarin due to increased risk of bleeding

Question 45

What medication should be avoided with Ginseng use?

Answer 45

May interact with monoamine oxidase inhibitors (MOAIs) causing tremors and mania Use with caution in combination with NSAIDs and Warfarin due to increased risk of bleeding

Question 46

What medication should be avoided with Ginseng use?

Answer 46

May interact with monoamine oxidase inhibitors (MOAIs) causing tremors and mania Use with caution in combination with NSAIDs and Warfarin due to increased risk of bleeding

Question 47

What is Kava used to treat?

Answer 47

Used as an anxiolytic and sedative

Question 48

What is the mechanism of action of Kava?

Answer 48

Potentiates gamma-aminobutyric acid (GABA) transmission

Question 49

What is St Johns Wart used to treat?

Answer 49

Used as an antidepressant and for other mood disorders

Question 50

What is the mechanism of action of St Johns Wart?

Answer 50

Inhibits serotonin, norepinephrine, and dopamine reuptake by neurons

Question 51

What are some anesthetic I'm

Answer 51

Induces hepatic cytochrome P450 CYP3A4 increasing the metabolism of drugs such as Alfentanil, Midazolam, and Lidocaine Induces cytochrome P450 2C9 causing reduction in effects of Warfarin and NSAIDs

Question 52

What are some anesthetic implications for St Johns Warts?

Answer 52

Induces hepatic cytochrome P450 CYP3A4 increasing the metabolism of drugs such as Alfentanil, Midazolam, and Lidocaine Induces cytochrome P450 2C9 causing reduction in effects of Warfarin and NSAIDs

Question 53

What is Valerian used to treat?

Answer 53

Used as an anxiolytic and sedative

Question 54

What is the mechanism of action for Valerian?

Answer 54

Inhibits GABA breakdown and reuptake

Question 55

Why can't a patient abruptly stop taking Valerian?

Answer 55

Taper dose during discontinuation due to risk of benzodiazepine-like withdrawal

Question 56

What is an anesthetic complication of taking Valerian?

Answer 56

Reduces anesthetic agent requirements

Question 57

What is Coenzyme Q10 used to treat?

Answer 57

Hypertension, Heart Failure, Ischemia Heart Disease, and Prevention of Statin-Induced Myopathy

Question 58

What are some anesthetic indications for CoQ10?

Answer 58

Shares a structural similarity to vitamin K and may alter the action of warfarin

Question 59

What is glucosamine used to treat?

Answer 59

Pain associated with knee osteoarthritis

Question 60

What are some anesthetic complications of CoQ10?

Answer 60

May increase INR in patients taking warfarin leading to increased risk for bleeding and bruising.