Perhaps you have seen delayed wound healing recently that seemed particularly stubborn and mystifying. Another patient may have unusual lower extremity swelling. In the midst of a seemingly simple surgical procedure for another patient, you notice excessive bleeding. All of these side effects may be possible if you’re treating patients who do not divulge they are taking an herbal medication. Approximately 10 to 12 percent of adults in the United States use herbal medications, according to the Centers for Disease Control and Prevention and other recent estimates. In the article “Herbal Medicines: Perioperative Considerations,” from the Podiatry Institute’s Update 2002, Francois Harton, DPM, points out some potentially alarming statistics. Dr. Harton notes that 63 percent of patients don’t tell their doctors they are using herbal medications unless they are specifically asked about them. When you combine the lack of formal scrutiny of herbal medications (many of which can be marketed without FDA approval) and the fact that more and more patients are seeking out health care information over the Internet, there are considerable risks. This is especially the case for an older patient population as they are likely taking multiple medications for various ailments. Asking patients about herbal drug use and having a solid awareness of these medications and their potentially adverse interactions can certainly go a long way toward detecting any red flags. For example, patients may be using gingko to help treat peripheral vascular disease, neurosensory problems or depression. However, MayoClinic.com warns that patients who are taking prescribed antidepressants or insulin should stay away from gingko as the combination may “cause spontaneous and excessive bleeding.” In the aforementioned article, Dr. Harton confirms the warning, noting that gingko has been associated with intraoperative and postoperative bleeding, and recommends that patients stop using it at least 36 hours before undergoing a surgical procedure. A recent article in the New England Journal of Medicine (NEJM) also notes that bleeding has been reported when patients combine gingko with aspirin, rofecoxib or warfarin. Another popular herbal medication is echinacea, which is reportedly used for fungal infections and to facilitate wound healing. However, Dr. Harton points out that echinacea “may interfere with immunosuppressive drugs, including those used for the treatment of rheumatoid arthritis.” MayoClinic.com also advises against combining this herbal treatment with the antifungal medication ketoconazole as well as prescribed medications that can potentially cause liver damage. Given this, it may be wise to ask patients if they use echinacea when considering the possible use of terbinafine or itraconazole. Given the vulnerability of diabetes patients to depression, another herbal medication to watch out for is St. John’s Wort, which patients may be using to help counteract mild to moderate depression. According to the NEJM article, when patients use St. John’s Wort for two or more weeks, it may “reduce the plasma levels or efficacy of various conventional medicines.” These are just a few of the available herbal medications but the potential risks certainly warrant asking about them during the patient history. How you ask about them is also important. If patients perceive a negative tone toward the use of these medications, they may not be so forthcoming with answers that may be invaluable in prescribing safe and effective treatment.