Do patients need to stop taking vitamins prior to surgery?

Preoperative Vitamin and Supplement Management

Most vitamins and supplements should be stopped 2 weeks before surgery due to bleeding risk, CNS effects, or metabolic interactions, though certain supplements like fish oil/omega-3 fatty acids can be safely continued. 1

Risk-Based Approach to Supplement Management

The Society for Perioperative Assessment and Quality Improvement (SPAQI) provides the most comprehensive and recent guidance, categorizing supplements by their primary perioperative risks 1:

Supplements That MUST Be Stopped 2 Weeks Before Surgery

Bleeding Risk Supplements - These affect platelet function or coagulation pathways and require a 2-week discontinuation period 1:

• Vitamin E - Has antiplatelet effects through protein kinase C inhibition, worsened when combined with aspirin 1, 2
• Garlic, ginger, ginkgo biloba, ginseng (all types: American, Panax, Siberian) 1
• Turmeric, saw palmetto, feverfew, dong quai, danshen 1
• Arnica, boldo, bromelain, cat's claw, devil's claw, evodia 1
• Fenugreek, guarana, horse chestnut, policosanol, resveratrol, vanadium 1
• Aloe (when taken systemically) 1

Blood Glucose-Altering Supplements - Hold 2 weeks due to unpredictable perioperative glucose effects 1:

• American ginseng, Panax ginseng, alpha-lipoic acid, chromium 1
• Bitter melon, fenugreek, gymnema, prickly pear cactus 1
• Agaricus mushroom, aloe, banaba, Cassia cinnamon, glucomannan 1

CNS-Depressant Supplements - Risk of excessive sedation with anesthetics 1:

• Kava, lemon balm (hold 2 weeks) 1
• St. John's wort (hold 2 weeks due to CYP3A4 induction affecting drug metabolism) 1

Cardiovascular Effects - Hold 2 weeks 1:

• Caffeine supplements and kola nut preparations (should be tapered; coffee/tea as beverages are safe) 1
• Yohimbine (causes unpredictable blood pressure effects) 1

Supplements With Shorter Hold Periods

48-Hour Hold 1:

• Chondroitin and glucosamine (faster metabolism and shorter half-life) 1

24-Hour Hold 1:

• 5-hydroxytryptophan, L-tryptophan, S-adenosylmethionine (rapid metabolism but serotonergic concerns with certain anesthetics like meperidine or tramadol) 1
• Theanine and L-tryptophan (rapid metabolism) 1

Supplements That Can Be CONTINUED

Fish Oil/Omega-3 Fatty Acids - The most important exception: these should be continued through surgery 1, 3:

• Prior bleeding concerns have been definitively disproven in prospective studies 1, 3
• A large randomized trial of 1,516 cardiac surgery patients showed fish oil did NOT increase bleeding (odds ratio 0.81) and actually reduced blood transfusions 4
• Higher omega-3 levels were associated with LOWER bleeding risk 4
• Multiple studies in spinal surgery confirm no increased bleeding risk 5

Anxiolytic Supplements - Safe to continue and may provide perioperative benefit 1:

• German chamomile, melatonin, passionflower 1
• Valerian (may protect against cognitive dysfunction) 1
• Lavender extract and hops (no convincing evidence of problematic CNS interactions) 1

Green Tea Extract - Can continue; while it may theoretically increase bleeding, the catechins improve cardiac function 1

Critical Supplements to AVOID Entirely

SPAQI explicitly recommends against these due to serious adverse effects 1:

• Garcinia cambogia - Contains hydroxycitric acid associated with hepatotoxicity 1
• Kratom - Has opioid agonist properties; FDA warns against use; requires tapering due to withdrawal risk 1

Common Pitfalls and Clinical Pearls

The "Multivitamin" Problem: Standard multivitamins containing typical doses of vitamins A, C, D, and B-complex can generally be continued, but those containing vitamin E at doses >400 IU should be stopped 2 weeks preoperatively 1, 2.

Patient Disclosure Issues: Approximately one-third of patients use supplements but don't report them to physicians 6. Explicitly ask about ALL supplements, herbal products, and "natural" remedies - patients often don't consider these "real medications."

The Fish Oil Controversy: Despite older recommendations to stop fish oil, the 2021 SPAQI guidelines and high-quality RCT evidence clearly support continuation 1, 3, 4. This represents a major shift from previous practice.

Lower-Risk Procedures: For minor procedures with minimal bleeding risk, cautiously proceeding with surgery even if supplements weren't stopped may be reasonable with increased vigilance 1.

Timing of Resumption: Supplements affecting coagulation should only be restarted once postoperative bleeding risk is minimal - typically when surgical drains are removed and hemostasis is secure 1.

Practical Algorithm

1. At preoperative visit (ideally 2-4 weeks before surgery): Obtain complete supplement history including "natural products," vitamins, and herbal remedies
2. Categorize by risk: Use bleeding, CNS, glucose, or cardiovascular categories
3. Stop high-risk supplements 2 weeks preoperatively (most supplements fall here)
4. Continue fish oil/omega-3 explicitly
5. Continue anxiolytic supplements (may help with perioperative anxiety)
6. For supplements with 24-48 hour holds: Provide specific stop dates
7. Document clearly in medical record with patient education materials