Perioperative Herbal Supplement Use in Cancer Patients: Potential Implications and Recommendations for Presurgical Screening

Nagi B. Kumar, PhD, RD, FADA; Kathy Allen, MA, RD; Heather Bell, MS, RD


Cancer Control. 2005;12(3):149-157. 

In This Article

Herbal Supplements That Interact With the Central Nervous System

St John's wort (Hypericum perforatum) contains active compounds such as naphthodihydrodianthrones (particularly hypericin and pseudohypericin) and flavonoids (including quercitrin, rutin, and hyperin).[48] Cancer patients often take St John's wort to reduce anxiety or depression. Situational depression is common among patients with cancer and may lead to increased use of the herb. Although it has shown some improvement of mild depression, effectiveness with long-term use has not been observed. St John's wort is metabolized in the liver and increases the production of cytochrome P450 3A4 enzyme and the active efflux pump P-glycoprotein, both leading to decreased plasma blood levels of medications metabolized by the same enzyme.[49] Perioperative medications metabolized by the enzyme include benzodiazepines, anesthetics, and natural and synthetic opioids. Natural and synthetic opioids are first-line agents in palliating severe pain in cancer patients. Other medications metabolized by P450 3A4 include serotonin receptor antagonists, antiarrhythmics, anesthetics, anticoagulants, barbiturates, irinotecan, and beta-blockers. In addition, St John's wort has been reported to cause organ transplant rejection by decreasing blood cyclosporine levels by 49%,[48] which may be applicable to bone marrow transplant recipients. The half lives of the active ingredients hypericin and hyperforin are 43.1 hours and 9.0 hours, respectively. Discontinuation of the herb is recommended at least 5 days prior to surgery.[50]

The root of the valerian herb (Valeriana officinalis) is often used for treatment of insomnia and fatigue both common symptoms reported by cancer patients. Valerian includes multiple compounds such as isovalerianic, formic, and acetic acids, and pinene. The sedative and hypnotic properties are mediated through modulation of gamma-aminobutyric acid (GABA) neurotransmission and receptor function.[51] Theoretically, valerian could modulate sedative effects of anesthetics, depending on the nature of the binding. When taken with barbiturates and benzodiazepine, it has the potential to increase a sedative effect and also may increase the anesthetic requirements with long-term use.[50] The pharmacokinetics of valerian is currently unknown, but it is thought to be prudent to taper use several weeks before surgery.


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