Safety Guidelines for Panax Notoginseng Root Extract
Panax notoginseng should be discontinued at least 2 weeks before any surgical procedure due to significant antiplatelet and anticoagulant effects, and it must not be used concomitantly with warfarin or other anticoagulants. 1
Perioperative Management
Hold Panax notoginseng for 2 weeks before surgery. The Society for Perioperative Assessment and Quality Improvement (SPAQI) explicitly categorizes ginseng preparations, including Panax species, as requiring discontinuation 2 weeks preoperatively due to bleeding risk. 1
Panax notoginseng has more potent antiplatelet effects than other Panax species (Panax ginseng and Panax quinquefolium), with documented inhibition of collagen-induced platelet aggregation and prolongation of bleeding time in animal models. 2
The antiplatelet mechanism involves adenosine and guanosine compounds that directly interact with human platelets and inhibit aggregation induced by arachidonic acid, ADP, and thrombin. 3
Steamed preparations have significantly more potent antiplatelet and anticoagulant effects than raw extracts, with effects increasing with longer steaming durations. 2
Drug Interactions
Absolute contraindication with warfarin. The National Stroke Association guidelines explicitly warn that ginseng (including Panax species) may alter bleeding time and should not be used concomitantly with warfarin. 1
Panax notoginseng affects both platelet aggregation and plasma coagulation pathways (prothrombin time, activated partial thromboplastin time, and thrombin time). 2
The herb modulates cytochrome P450 enzymes and P-glycoprotein transporters, creating potential interactions with drugs that have narrow therapeutic windows. 4
Documented interactions exist between Panax ginseng and phenelzine, though specific data for Panax notoginseng with MAO inhibitors is limited. 5
Special Population Considerations
Exercise extreme caution in patients with estrogen-receptor positive breast cancer. While the ASCO/SIO guidelines note that American ginseng (Panax quinquefolius) can be considered for cancer-related fatigue, they emphasize that some ginseng preparations may have estrogenic properties, particularly ethanol extracts. 1
The safety and efficacy of ginseng vary significantly by species, extraction method, and quality control. 1
Patients should seek guidance from healthcare professionals before using any ginseng supplement, as over-the-counter preparations vary substantially in content and quality. 1
Common Adverse Effects
Mild and transient side effects are most common. Clinical trial data for Panax ginseng monopreparations show adverse event rates similar to placebo. 5
The most frequently reported adverse events include headache, sleep disturbances, and gastrointestinal disorders. 5
Serious adverse events are rare with monopreparations but have been reported with combination products containing ginseng alongside other ingredients, making causal attribution difficult. 5
Critical Clinical Pitfalls
Do not assume all ginseng species have equivalent safety profiles. Panax notoginseng demonstrates stronger antiplatelet effects than Panax ginseng or Panax quinquefolium, requiring more stringent bleeding precautions. 2
Verify the preparation method. Steamed Panax notoginseng has markedly increased anticoagulant potency compared to raw preparations, which is opposite to traditional assumptions about processing reducing hemostatic effects. 2
Screen all cardiovascular patients for herbal use. Clinicians must specifically inquire about alternative complementary medicines when assessing cardiovascular risk or prescribing anticoagulants, as patients often fail to disclose herbal supplement use. 1