American Society of Regional Anesthesia and Pain Medicine August 2016 - 39


Table 2: Known case reports of spinal or intracranial hematoma
associated with select herbs.
Herb

Case reports of associated spinal
or intracranial hematoma*

Garlic

130

Danshen

0

Dong Quai

0

Gingko biloba

232,33

Ginseng

0

6. Persiani S, Roda E, Rovati LC, Locatelli M, Giacovelli G, Roda A. Glucosamine
oral bioavailability and plasma pharmacokinetics after increasing doses
of crystalline glucosamine sulfate in man. Osteoarthritis Cartilage.
2005;13(12):1041-1049.

the ingestion of supplements; a brief PubMed search with the
terms (MeSH) "garlic" and "hematoma" resulted in only one
case report of spinal epidural hematoma associated with garlic
ingestion, which occurred spontaneously and was associated
with platelet dysfunction (Table 2). 5,6 Thus, both the potential
risks as well as the benefits of discontinuing or continuing
individual supplements should be discussed with the patient and
appropriately weighed.
The mechanisms by which herbal and nutritional supplements
exert their anticoagulant and antiplatelet effects require further
elucidation to inform future guidelines. The National Center for
Complementary and Integrative Health, a government agency at
the National Institutes of Health, maintains an alphabetized list of
more than 50 herbs and includes current evidence regarding their
effects and potential risks. However, even herbs that have been
well researched may require further exploration.
REFERENCES

2.

4. Köhler A, Sarkkinen E, Tapola N, Niskanen T, Bruheim I. Bioavailability of fatty
acids from krill oil, krill meal and fish oil in healthy subjects-a randomized,
single-dose, cross-over trial. Lipids Health Dis. 2015;14:19.
5. Woodbury A, Soong SN, Fishman D, García PS. Complementary and alternative
medicine therapies for the anesthesiologist and pain practitioner: a narrative
review. Can J Anaesth. 2016;63(1):69-85.

* PubMed search with MeSH terms to include listed herb and "hematoma."
Results exclude bleeding events occurring outside of the central nervous
system.
It is clear that further research is necessary to fully describe the pleiotropic
effects of the myriad herbs and supplements available to the general
population. Several herbs and supplements have clear anticoagulant
effects, though the clinical impact is unclear. For now, we must guide our
decisions based on information currently available and ensure that both we
and our patients are as informed as possible.

1.

3. Zuijdgeest-van Leeuwen SD, Dagnelie PC, Rietveld T, van den Berg JW, Wilson
JH. Incorporation and washout of orally administered n-3 fatty acid ethyl
esters in different plasma lipid fractions. Br J Nutr. 1999;82(6):481-488.

Narouze S, Benzon H, Provenzano DA, et al. Interventional spine and pain
procedures in patients on antiplatelet and anticoagulant medications: Guidelines
from the American Society of Regional Anesthesia and Pain Medicine, the
European Society of Regional Anaesthesia and Pain Therapy, the American
Academy of Pain Medicine, the International Neuromodulation Society, the North
American Neuromodulation Society, and the World Institute of Pain. Reg Anesth
Pain Med. 2015;40:182-212.
National Center for Complimentary and Integrative Health. Use of
complementary health approaches in the U.S.: Most used natural products.
2015. Retrieved from https://nccih.nih.gov/research/statistics/NHIS/2012/
natural-products. Accessed June 10, 2016.

7. Conte A, de Bernardi M, Palmieri L, Lualdi P, Mautone G, Ronca G. Metabolic
fate of exogenous chondroitin sulfate in man. Arzneimittelforschung.
1991;41(7):768-772.
8. Wirtz PH, Spillmann M, Bärtschi C, Ehlert U, von Känel R. Oral melatonin
reduces blood coagulation activity: a placebo-controlled study in healthy
young men. J Pin Res. 2008;44:127-133.
9. Aldhous M, Franey C, Wright J, Arendt J. Plasma concentrations of melatonin
in man following oral absorption of different preparations. Br J Clin
Pharmacol. 1985;19(4):517-521.
10. Bhagavan HN, Chopra RK. Coenzyme Q10: absorption, tissue uptake,
metabolism and pharmacokinetics. Free Radic Res. 2006;40(5):445-453.
11. Jedlinszki N, Rédei D, Haller J, Freund TF, Hohmann J, Zupkó I. Possible role of
fat tissue in the pharmacokinetics of Dodeca-2E,4E,8Z,10E/Z-tetraenoic acid
isobutylamides after oral administration of Echinacea angustifolia extract in
rats. Nat Prod Commun. 2014;9(6):843-845.
12. El Haouari M, Rosado JA. Medicinal plants with antiplatelet activity. Phytother
Res. [April 6, 2016, Epub ahead of print]
13. McKay DL, Chen CY, Zampariello CA, Blumberg JB. Flavonoids and phenolic
acids from cranberry juice are bioavailable and bioactive in healthy older
adults. Food Chem. 2015;168:233-40.
14. Fukao H, Yoshida H, Tazawa Y, Hada T. Antithrombotic effects of odorless garlic
powder both in vitro and in vivo. Biosci Biotechnol Biochem. 2007;71(1):84-
90.
15. Sunter WH. Warfarin and garlic. Pharm J. 1991;246:722.
16. Jastrzebski Z, Leontowicz H, Leontowicz M, et al. The bioactivity of processed
garlic (Allium sativum L.) as shown in vitro and in vivo studies on rats. Food
Chem Toxicol. 2007;45(9):1626-1633.
17. Wang C-Z, Moss J, Yuan C-S. Commonly used dietary supplements on
coagulation function during surgery. Medicines (Basel). 2015;2(3):157-185.
18. de Rooij BM, Boogaard PJ, Rijksen DA, Commandeur JN, Vermeulen NP.
Urinary excretion of N-acetyl-S-allyl-L-cysteine upon garlic consumption by
human volunteers. Arch Toxicol. 1996;70(10):635-639.
19. Fujisawa H, Suma K, Origuchi K, Kumagai H, Seki T, Ariga T. Biological
and chemical stability of garlic-derived allicin. J Agric Food Chem.
2008;56(11):4229-4235.
20. Teng CM, Kuo SC, Ko FN, et al. Antiplatelet actions of panaxynol and
ginsenosides isolated from ginseng. Biochim Biophys Acta. 1989;990(3):315-
320.
21. Lee JG, Lee YY, Kim SY, Pyo JS, Yun-Choi HS, Park JH. Platelet antiaggregating
activity of ginsenosides isolated from processed ginseng. Pharmazie.
2009;64(9):602-604.
22. Jin YR, Yu JY, Lee JJ, et al. Antithrombotic and antiplatelet activities of Korean
red ginseng extract. Basic Clin Pharmacol Toxicol. 2007;100(3):170-175.

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