[toc]With traumatic injuries and emergency situations, preplanning is not a luxury you have.
On the other hand, many types are scheduled days, weeks, or even months in advance. Even if you want that breast biopsy ASAP, you still need to get in queue for it. For something like cataract removal, joint replacement, or cosmetic surgery, you’re probably having it done on your own schedule.
So what supplements to avoid prior? The answer is not black and white.
A concern that’s across the board are supplements which cause blood thinning. Excess bleeding in any surgery is never a good thing!
In addition, some circumstances warrant caution when it comes to blood pressure, heart rate, and other metabolic markers. Especially for those who have related diseases, like high blood pressure or diabetes. Controlling those is already a balancing act and when under anesthesia, it’s even more complicated. You want as few unknown variables as possible.
Then there’s the potential for drug interactions specific to surgery – such as with the anesthesia – as well as the potential risk for increase in liver damage, when combined with the antibiotics and other medications typically used.
You have a lot to watch out for. Let’s review them one at a time.
Blood thinning supplements to avoid
This category is the most universally applicable. Whether you’re undergoing deep sleep or just local anesthesia, the complication of bleeding is always a concern. Ranked from most to least common, herbs and supplements not to take before surgery include:
- Vitamin E
- Fish oil and omega 3
- Garlic
- Red chili pepper (capsaicin)
- Ginkgo biloba
- Saw palmetto
- Ginseng
- Chondroitin and glucosamine
- Bromelain
- Arnica montana
- Ginger
- Licorice
- Arnica montana
- Oil of wintergreen
- Feverfew
- Devil’s claw
- Seasonal tonic tea
- Japanese honeysuckle
- Baical skullcap root
- Fritillaria bulbs
- Ta gastronol tea
- Poncitrin (jishi)
- Dan Shen
- Guilinggao (tortoise jelly)
- Chinese agrimony
- Chinese peony
- Geum japonicum
- Kangen-karyu
- Bak foong pill
The herbs and formulations found on this list are from Aesthetic Surgery Journal, Volume 32, Issue 3. It’s a publication of The American Society for Aesthetic Plastic Surgery. (1)
Bear in mind that these are only examples. There are thousands of different herbal formulas on the market and no one really knows much about how the most common may interfere, let alone the more obscure. Just because you don’t see yours listed, that doesn’t necessarily mean it’s safe.
Foods containing high amounts of these can also be an issue.
Now before you freak out about that garlic bread you had with spaghetti, or that spicy Chipotle burrito, know that you may have other issues from those that are bigger; sodium overload.
Post-op side effects of increased swelling and edema (fluid retention) can be exacerbated by high salt diets. (2)
Chipotle is so unhealthy that just one spoon of their salsa has almost twice the salt of a large order of McDonald’s fries.
Pick any store-bought marinara sauce at random and you will see it has 250 to 700 mg per serving, with the typical entrée-sized pasta using 2-4 servings.
With garlic, chili pepper, and many foods/supplements, their avoidance is recommended simply out of an abundance of caution, based on very limited research.
Capsaicin in chili appears to interfere with platelet aggregation in one study, while another suggests it may do the opposite and help prevent gastric hemorrhaging. (3) (4)
Garlic is one herb with more compelling research. Its volatile oil, ajoene, does appear to interfere with platelet aggregation. Possibly even more so for those on warfarin, heparin, aspirin, and other anticoagulant medications. (5) (6) (7)
Omega 3 and fish oils are often at the top of the list when it comes to vitamins and supplements to stop taking before surgery. In 2017, a systematic review was done based on 52 published studies; 20 involving surgery patients and 32 involving healthy individuals. (8)
Based on all that research, the authors’ conclusion was this:
“Fish oil supplements reduced platelet aggregation in healthy subjects. This biochemical effect was not reflected in increased bleeding risk during or after surgery evaluated in randomised controlled trials. Consequently, this systematic review does not support the need for discontinuation of fish oil supplements prior to surgery or other invasive procedures.”
Vitamin E before surgery is another that always makes the naughty list. The aforementioned Aesthetic Surgery Journal cited research both for and against the theory that it can thin blood. They said:
“Therefore, it is clear that additional studies in humans are needed to determine whether a positive association indeed exists between vitamin E and bleeding risk. In the meantime, guidelines set forth by the Institute of Medicine can be employed, which suggest that a dose of 1,000 mg daily is safe.”
Multivitamins often have a small fraction of that. For example, here at Superfoodly, we take Garden of Life’s myKind Organic multi and per serving you get 40 IU, which equates to 59.6 mg of vitamin E or 130% of your daily value.
Surgery aside, using high dosages of vitamin E, like 1,000 IU capsules, is probably not the best idea in the long run. Being fat-soluble means you can overdose on it as it builds up in your liver. High amounts interfere with the metabolism of vitamin K and that will inhibit platelet aggregation. (9)
The good news is that food sources of vitamin E and these other herbs appear to be a low risk, assuming one is only eating a typical amount.
Supplements are of greater concern because they can contain exponentially more than the amount of say, omega 3 in a serving of fish, or the vitamin E in sunflower seeds. The latter is the highest food source of vitamin E. You would get 9.3 mg from a 1 oz. serving of seeds. That’s trivial compared to a 400 IU vitamin E capsule, which contains 2,700% more (268 mg). (10)
Even though many herbs and dietary supplements have flimsy data to support an increased risk of bleeding, why take the gamble? Better to be safe than sorry. Discontinue use of whatever your doctor instructs.
Supplements that affect anesthesia
An article in the Journal of the American Medical Association (JAMA) called out kava root, St. John’s wort, and valerian as herbs that might interfere. Kava and valerian were said to possibly increase the effects of anesthesia, while St. John’s wort might increase the metabolism of drugs used before and after the operation. (11)
The American Society of Anesthesiologists has listed those three list, as well as these:
- Ephedra (ha-huang) – Since it has been banned in the U.S. for many years, this advice appears to be aimed internationally.
- Ginseng – May increase heart rate, in addition to the bleeding concern.
- Garlic – May lower blood pressure.
- Vitamin E – May cause blood pressure “problems.”
They also called out garlic for increased risk of bleeding, however that would normally not be a direct anesthesia interaction. The altering of blood pressure, heart rate, and drug metabolism would be a direct interference. (12)
As with blood thinning supplements, these are only some known examples.
General anesthesia and herbal supplements can be a dangerous combination. The American Society of Anesthesiologists instructs (13):
“Be sure to bring all substances with you, prescription or over-the-counter, when you meet with your anesthesiologist before surgery and on the day of your procedure.”
Since you may not have the opportunity to meet your anesthesiologist in the days and weeks before your surgery, it would also be a good idea to do the same with your surgeon far in advance; at least 2 weeks prior. Show the doctor all of your supplements – including OTC medications – and request that this information be relayed to the anesthesiologist ahead of time, too.
Other vitamins, minerals, and herbs
CoQ10 before surgery
This was never classified as a vitamin simply because our bodies produce it naturally and therefore, we technically do not need to get CoQ10 from external sources.
That being said, given the fact that production peaks at around age 20 and that statins further deplete our natural levels, it’s understandable why this has become one of the bestsellers.
Most lists of vitamins and supplements to avoid before surgery do not specifically address CoQ10. It is not known for being a blood thinner or for interacting with anesthesia drugs. Cleveland Clinic advises that since it may lower blood sugar levels in diabetics and interacts with warfarin, patients need to discuss usage with their physician. (14)
Turning to the Mayo Clinic, they don’t one way or another whether you should avoid CoQ10 before surgeries, however they do mention this:
“CoQ10 is safe when taken by mouth daily in recommended doses in people who are about to have heart surgery, or those who have heart disease, gum disease, muscle wasting/weakness, Parkinson’s disease, Alzheimer’s disease, cancer, diabetes, or HIV/AIDS.”
Using before heart surgery is the only type specifically addressed. (15)
Looking elsewhere, a meta-analysis based on 8 clinical trials suggested that patients undergoing cardiac surgery with cardiopulmonary bypass were “were significantly less likely to require inotropic drugs after surgery, and to develop ventricular arrhythmias after surgery.” However that benefit has not been proven and remains theoretical. (16)
As with all other dietary supplements, regardless of the type of operation you are getting, it would be best to hold off on the CoQ10 unless your physician okays it.
If you can use it, consider natural CoQ10 sources.
Vitamin C before surgery
When used in typical dosages, ascorbic acid (vitamin C) is not believed to increase the risk of bleeding or to interact with anesthesia. Should you avoid vitamin C before surgery? Even though most “avoid” lists don’t mention it, ask your doctor since each patient and operation has unique circumstances.
Some doctors actually recommend using more of it before and/or after surgery.
The ascorbic acid dosing page of the Mayo Clinic website reports that:
“For heart conditions, 2 grams of vitamin C has been given by mouth before surgery, followed by 1 gram daily for five days.”
Research from a university in Tokyo found that blood serum levels of vitamin C falls after surgeries. To normalize them and reduce oxidative stress, they say:
“In uncomplicated surgical patients, more than 500 mg/day of vitamin C may be required, with much higher doses in surgical intensive care unit patients.”
To be clear, both of those are reporting research and neither should be construed as advice. More research is needed to determine whether or not it’s beneficial to take more vitamin C prior to surgery. (17) (18)
Risks and complications aside, taking excessive amounts is probably not a good idea regardless. There are side effects of vitamin C, such as kidney stones with long-term high dosages, and when in the presence of certain minerals, acting as a pro-oxidant (which is the opposite of an antioxidant).
Low vitamin D
This essential vitamin is used in over 300 different metabolic pathways within your body.
The percent of the population with a vitamin D deficiency is high in the United States, Canada, United Kingdom, and much of the northern hemisphere. A study using 4,495 adults in the U.S. found that there is an average deficiency rate of 41.6%. African-Americans and Hispanics are the most at risk, with rates of 82.1% and 69.2%, respectively. (19)
Both before and after surgical operations, it’s important to have healthy vitamin D levels. A study found that 38% of hip and knee replacement patients had inadequate levels and 48% were so low, they were classified as deficient. (20)
A recent meta-analysis based on 31 relevant human studies found that overall, there was a correlation with low vitamin D levels and “adverse outcomes after diverse surgical procedures.”
That comes from the University of Wisconsin Department of Population Health Sciences. (21)
Getting a blood test ahead of time would be a good idea, so your doctor can determine whether or not you need supplementation. For adult men and women, the RDA ranges from 600 to 800 IU per day. Consumption of the RDA is not only considered safe before an operation, but also recommended. (22)
Before taking any supplement, make sure you know the truth about vitamin D2 vs. D3.
Excess vitamin K
While it is an essential vitamin, the NIH’s Office of Dietary Supplements reports that using vitamin K before surgery may be a problem if you are on any blood clotting medications, such as Coumadin. (23)
Turmeric and curcumin
Is turmeric safe before surgery? This root and its active ingredient, curcumin, have potent anti-inflammatory and antioxidant properties. Even though the aforementioned lists did not mention them, avoidance before an operation would be a good idea because research has found it to have an anti-platelet effect which may increase bleeding. (24) (25)
Taking minerals
For essential minerals like magnesium, calcium, phosphorus, potassium, iron and zinc, consumption up to the Recommended Dietary Allowance (RDA) is typically advised before and after surgery. Magnesium citrate or another supplemental form is sometimes recommended since the need for it increases during recovery. Patients with iron-deficiency anemia (ferropenic) may be placed on an iron supplement by their physician.
Rates of preoperative anemia are high, with studies indicating the percentage of patients with it may be up to:
- 30% for elective and cosmetic operations (26) (27)
- 34% for non-cardiac surgeries (28)
- 35% for joint arthroplasty (e.g. hip replacement, knee resurfacing) (29) (30)
- 76% during colon cancer (31)
This is why it’s wise for everyone to get a complete blood count (CBC) to test hemoglobin levels, which is the iron-rich protein found in red blood cells. That’s the first step of diagnosing an iron deficiency.
Outside of food sources, using iron pills before surgery should not be done without the guidance of your healthcare provider. For most people it is unnecessary and self-dosing may actually make things worse, as iron is notorious for being a stomach irritant.
Higher levels of magnesium are utilized during the healing phase, so you should also ask if additional amounts would be a good idea. (32)
Among the supplements to promote wound healing, some recommend zinc. It’s an essential trace mineral needed for cell division and the synthesis of DNA and protein. Over 300 enzymes in the body use it. To promote wound healing, 15 to 30 mg has been recommended by research and some physicians even suggest increased usage ahead of time. Ask if you should do this. (33) (34)
Drinking coffee and teas
Some teas contain herbs which should be avoided before surgery because they may lower blood pressure, such as hibiscus, or lower blood sugar, like mulberry leaf. Normally these would be considered benefits, though while under anesthesia, they could add complexity to controlling your baseline metabolic parameters. Due to bleeding concerns, no green tea before surgery is sometimes advised.
As with other herbs, there isn’t much of a consensus as to which teas are bad and good. For example, there is lack of evidence to prove green tea’s blood thinning characteristic, at least with the normal dosages one would drink. In fact, numerous pieces of research even suggest it may offer a benefit for the healing of surgical wounds. (35) (36)
To be safe, tell your doctor about any teas and herbal beverages you drink and if they advise to do so, discontinue their use. Stopping 10-14 days prior is typically what’s advised.
Even if they permit the drinking of it, you definitely don’t want to drink green or black tea during the 24 hours prior, due to its caffeine content.
That’s even more important for coffee, which has much higher caffeine content.
The half-life of caffeine is 3 to 7 hours. That means after 24 hours of not drinking it, you still may have up to 9% left in your system. That’s the reason you may be advised to stop drinking coffee and tea 48 or even 72 hours prior. With delicate and major operations such as heart and brain, your doctor may require you to stop drinking caffeine much further in advance. (37)
Conclusion
Studies have found that anywhere from 33% to 72% of patients don’t tell their doctor about supplements and alternative medicines they are using. While the first inclination is to blame the patient, the truth is that the fault falls on both parties. (38) (39)
Recent research from Boston University found that only 20% of patients were asked during hospital admission what supplements they take. Worse yet, identifying as Hispanic or African American resulted in an even lower chance of being asked the question. (40)
Both patients and physicians need to prompt the discussion of vitamins and herbs to avoid before surgery. Even if you, as the patient, are not pressed for details, still provide your healthcare providers with a full list of what you are using. That includes teas and even the food sources of herbs and spices you may be eating in high amounts.
It is true that with many of these vitamins, minerals, and phytonutrients, no one really knows what effect they’re truly having, if any. Still it’s better to not use them for a short period of time, even if they’re not conclusively proven to thin blood or cause other adverse reactions.
Discontinue use of whatever your doctor tells you to. If you still wish to take a multivitamin leading up to surgery on the premise that it contains a low dose of vitamin E or another “banned” ingredient, you should discuss this with them first. Don’t assume it’s okay to use unless they give you the go ahead.
Best supplements after surgery
Discuss with your doctor if the following foods that promote healing after surgery are appropriate for your circumstances.
Curcumin
Commonly used in Indian cuisine, the orange turmeric root is one of the most researched in the world. The health benefits suggested by research are vast but most relevant here is its anti-inflammatory effect. However since it may increase risk of bleeding, it should not be used prior and even after, do so only with physician’s consent.
In a double-blind, randomized, and placebo-controlled study, 50 patients who had their gallbladder removed were monitored for 50 days post-op.
In addition to their standard pain medications, of which they were allowed to take however many they wanted, 25 of these patients were put on a curcumin regimen, while the other 25 were placed on a placebo regimen.
During this 50 day period, the group getting curcumin only chose to use around 7 pain pills (6.96 on average) while the placebo group had to use 39.32 on average!
If you’re a science or math geek, you will appreciate those p-values. In plain English, these are very statistically significant results. (41)
Given that this root is an acquired taste and that the active ingredient, curcumin, only represents 10% or less by weight, you may want see our reviews of turmeric supplements.
Plant-based protein
During wound remodeling, our bodies utilize high amounts of amino acids. Since whey and casein can promote inflammation, it would be best to stick with plant-based sources post-op. (42)
Check out our review of the best pea protein. For other types, check out what protein powder doesn’t cause gas.
Bromelain
This enzyme is frequently recommended by orthopedic, plastic, and many other types of surgeons for inflammation and pain post-op. Because it also decreases blood clotting, it should not be taken ahead of time. (43)
As an added benefit, it’s an enzyme that breaks down protein. It might act similar to a probiotic during digestion, however this aspect has even less research. (44)
The NIH reports that there is “not enough evidence to determine if bromelain is effective” for anything, but they are funding research to explore its potential benefits for inflammatory conditions and asthma. Many pieces of research suggest it may be useful as an anti-inflammatory agent, including to reduce surgical swelling. (45)
If your doctor recommends using it, your first inclination might be to drink pineapple juice. That won’t work, as it’s instantly destroyed by heat and almost all pineapple juices are pasteurized. (46)
Eating the fruit isn’t much better either, because the highest concentration of bromelain is in the core.
Even if you ate one entire raw fruit – its flesh, core, peel, and crown – the maximum amount you could get would be around 200 to 1,000 GDU (gelatin digestion units). That’s based on an analysis of how much bromelain content there is in the average pineapple of 3 different varieties. (47)
Directions on dietary supplements typically recommend a daily dosage ranging from 600 to 3,000 GDU per capsule, taken 2 to 3 times per day (total of 1,800 to 9,000 GDU daily). In other words, at the maximum dosage, that may be the equivalent of the bromelain found in up to 45 whole pineapples… per day!
Of course, you can’t even eat the richest parts of the fruit and for the edible flesh, because of its high sugar content, you don’t exactly want to be binging on it.
Talk to your doctor if a supplemental form is appropriate for you. Here at Superfoodly, we have found the best bromelain supplement post-op to be the brand Doctor’s Best 3000 GDU. They’re veggie capsules (vegan friendly). When undergoing a procedure, we buy the bottles on Amazon to have on hand for post-op, with our surgeons’ blessings of course.
These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure, or prevent any disease.