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Risks of mixing drugs with supplements range from increased bleeding to central nervous system and cardiac effects to death

Article-Risks of mixing drugs with supplements range from increased bleeding to central nervous system and cardiac effects to death

Key iconKey Points

  • Propanolol topped the list of dangerous drug interactions emerging from the study.
  • Surgeons are advised to exercise caution when mixing sumatriptan and avitriptan with facial plastic surgery.

ANTIDEPRESSANTS: Effects on Perioperative Patients
Patients should stop taking herbal supplements two weeks prior to cosmetic surgery and confer with a psychiatrist, and in some cases a cardiologist or internist regarding cessation and titration of antidepressants prior to elective surgery, according to a retrospective study out of the Manhatten Eye, Ear and Throat Hospital's Department of Plastic Surgery. As antidepressant and herbal supplement use becomes ubiquitous, it behooves cosmetic surgeons to familiarize themselves with the side effects and possible interactions of these medications when combined with elective surgery, says lead author Simon H. Chin, M.D. along with Sherrell Aston, M.D. The study, which was based on a literature review of the 29 most commonly used herbals and antidepressants, found that complications of these medications when mixed with anesthesia and the stress of surgery range from increased risk of bleeding to central nervous system and cardiac effects to death.

As Dr. Chin's patients increasingly disclosed their use of antidepressants and herbals and he was left to wonder about the possible interactions of these drugs when combined with surgery, he decided to research the topic. "Other than the risk of bleeding and bruising associated with herbals, little was known about interactions with surgery and these medications, so we thought it was a topic worth exploring," says Dr. Chin.


HERBS AND SUPPLEMENTS: Effects on Perioperative Patients
Propanolol topped the list of dangerous drug interactions emerging from the study. While this beta blocker is not a classic anti-depressant it is often prescribed as an anti-anxiety agent. "This is one of the medications that I think many do not sufficiently appreciate the consequences of," says Dr. Chin. "When Propanolol is combined with epinephrine it can cause a potentially fatal reaction. The combination of the two drugs can lead to a hypertensive episode followed by a profound reflex bradycardia, which can lead to cardiac arrest," he explains. Dr. Chin says surgeons should be particularly careful about propanolol during facelifts and liposuction. "In both of these procedures, the surgeon utilizes larger quantities of both lidocaine and epinephrine, and although these two drugs can cause toxicity by themselves, the addition of propanalol can open the patient to the possibility of cardiac arrest," says Dr. Chin, who adds that he has reviewed reports of the consequences that can occur when patients have continued propanolol and it has been combined at surgery with epinephrine. He says discontinuation of propanolol may require the guidance of an internist or cardiologist, but he advocates that the consultation takes place at least two weeks prior to surgery.

In an interview with Cosmetic Surgery Times , Dr. Chin also cautions about the use of implants in conjunction with antidepressants and herbals. "With implants you have to worry about infection, and none of these medications or herbs increase the risk of infection as far as we can tell, but I would be cognizant of the ones that cause bleeding, which is most of them," he says. "There is literature that supports the theory that bleeding and hematomas can lead to higher capsular contraction rates. I would be very careful of hemostasis and bleeding in patients on herbal medications and therefore I would recommend the cessation of herbs in general and select anti-depressants as long as they could safely be stopped [temporarily]," he says.

Dr. Chin also warns surgeons of the dangers of mixing sumatriptan and avitriptan with facial plastic surgery. Both can cause postoperative hypertension which he cautions can be particularly troublesome for facelift patients. Sumatriptan and avitriptan are prescribed in the treatment of migraine headaches, which are common among patients diagnosed with depression. "Studies have shown that these medications can lead to increases in blood pressure, and anecdotal case reports have demonstrated increases in systemic and pulmonary blood pressure and coronary artery vasoconstriction after sumatriptan," says Dr. Chin. "We perform a high volume of face lifts, so this medication is something that we are cognizant of in these patients; they will want to take their sumatriptan postoperatively because they have a migraine and then sure enough they develop high blood pressure," says Dr. Chin.


As is commonly known, many herbal supplements exacerbate bleeding, but according to Dr. Chin, recognition of this possibility is particularly crucial in the case of Dong Quai, a Chinese herb that is typically prescribed for menopausal or menstrual complaints. "Dong Quai contains six coumadin derivatives, which are vitamin K antagonists," warns Dr. Chin. He recommends that in general, herbs be stopped two weeks before surgery. This approach is also endorsed by the American Society of Anesthesiologists.

In addition to the increased risk of bleeding, St. John's Wort, which is used to treat depression, anxiety and sleep disorders, can cause even more profound side effects. If taken in combination with selective serotonergic reuptake inhibitors (SSRIs) Dr. Chin's study shows it may increase the effect of midazolam and lidocaine. The active ingredient in St. John's Wort, hypericin, acts as an irreversible inhibitor of monoamine oxidase A and B, which can lead to the deleterious effects of MAOIs. According to his findings, hypertensive crises can occur when MAOIs are mixed with sympathicomimetics such as epinephrine.

For more information
Simon Chin, M.D.

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