Herbal supplements

Herbal medicines that increase the risk of bleeding:

• Garlic: inhibits platelet aggregation (organosulfur), discontinue for seven days *Ginkgo: inhibits platelet activating factor (terpenoids, flavonoids), discontinue for thirty six hours.
• Ginseng: inhibits platelet aggregation and lowers blood glucose (ginsensosides [mimic steroids]). Check PT/PTT/glucose, d/c for 24 hours (preferably seven days)
• Saw Palmetto: associated with excessive intraoperative bleeding (mechanism unknown, likely multiple), in the absence of pharmacokinetic data, no recommendations re: preoperative continuation can be made
• Black Cohosh: Claims to be useful for menopausal symptoms. Contains small amounts of anti-inflammatory compounds, including salicylic acid. Theoretically could have intrinsic/additive antiplatelet activity.
• Chamomile: Claims to reduce inflammation and fever, to be a mild sedative, relieve stomach cramps. Increases risk of bleeding because it contains phytocoumarins, which have additive effects with warfarin.
• Feverfew: Claims to prevent migraines. Increases the risk of bleeding because it individually inhibits platelet aggregation, has additive effects with other antiplatelet drugs. Also additive effects with warfarin.
• Fish Oil: Claims to prevent/treat atherosclerotic CV disease (800-1500mg/day). Also used to decrease triglycerides (>4g/day). Dose dependent bleeding risk increases with dose >3g/day.

Herbal medicines that increase clotting risk:

• Coenzyme Q10: Claims to enhance insulin sensitivity in diabetics, and as an antioxidant to act as an anticancer medication. Decreases response to warfarin.
• Goldenseal: Has some antiseptic properties for mouth sores, eye sores, and vaginal infections. Increases risk of thromboembolism by opposing effects of warfarin and heparin.
• St. John’s Wort: For use as an MAOI, for patients with mild to moderate depression. Increases thromboembolism risk by reducing blood levels of warfarin.