Herbal medicines have become a popular form of therapy, either prescribed for or self-administered by an estimated 40% of the U.S. population. Promoted by homeopathic physicians and health food stores and perceived as natural and therefore harmless, they may be anything but for certain patients. Along with known allergic effects and possible product contamination, such "safe" remedies are known to have serious toxic effects and may cause significant drug interactions or have adverse physiologic effects. A major problem is that most people do not consider such remedies as drugs or medicines and often do not inform doctors of their use.

Some more common herbal remedies in use, with known side effects, follows:

1. Alfalfa is high in vitamin K and may interact with Coumadin.

2. Comfrey is a hepatotoxic alkaloid which is banned in Canada.

3. Ephedra (ma huang) is also known as herbal fen-phen and has generated 800 reports (including 22 deaths) of MI, stroke, cardiac irregularities, seizures, and hypertension. Fifty-six percent of those reports have involved persons younger than 40 years of age! Although the dominant users are females desiring to lose weight, men who use Ephedra for enhanced athletic effects and for bodybuilding suffer an inordinate number of kidney stones.

4. Ginseng has a questionable interaction with blood thinners and may elevate blood pressure.

5. Ginko Biloba has antioxidant properties and inhibits platelet aggregation. Four reports of spontaneous bleeding have been reported to the FDA, one case from the iris when used in conjunction with a daily aspirin tablet. Anticoagulant effects are also known to occur from Garlic and Vitamin E.

6. Goldenseal also called Yellowroot, it may decrease WBCs.

7. Kava can cause extrapyramidal effects, including oral and lingual dyskinesia. It should not be used with barbiturates and benzodiazepines.

8. Licorice Tea causes increased potassium excretion and raises BP.

9. Lobelia used in herbal smoking cessation programs, it may increase pulse rate, cause hypotension, and convulsions. It has been banned in Great Britain.

10. Sassafras Tea effects platelets enough to act as an anticoagulant. It also has a hepatotoxic effect which may increase the half-life of drugs metabolized in the liver.

11. St. John's Wort is used as an antidepressant. It effects certain neurotransmitter levels (increased levels of serotonin, dopamine and norepinephrine) and should not be used with MAO inhibitors. It also may prolong narcotic-induced sleep time a possible concern with intravenous sedation. Conversely, a recent Lancet article reported concern with the drugs potential to clear a wide variety of drugs, including antibiotics, from the body before they have time to work. A toxic symptom is dry mouth.

Undoubtedly, many of these adverse effects relate directly to the amount ingested and duration of exposure. The risk management message is that we should remember to ask patients about their use of such products. Consider including this question on your printed health history form: Are you taking any natural product, herbal supplement or tea, or other natural or homeopathic remedy? Positive answers should be followed with further questions: Are you taking any prescription or non-prescription medications for the same purpose as the herbal remedy? Have you used this herbal remedy before? Do you notice any side effects from this herbal product?

Many herbal remedies are beneficial. This article is not an attempt to condemn a historic, popular, and generally safe form of therapy. However, natural does not always mean safe we should stay abreast of trends in naturopathic remedies and the potential for adverse effects or possible interaction with anesthetics or surgical procedures. Objective information about herbal products may be obtained from publications such as Alternative Medicine Alert (800-688-2421) and Review of Natural Products (314-216-2100). Remember to report adverse events to the FDA MedWatch Program (800-FDA-1088.)