Does Ginkgo Biloba Interact with Antiplatelet Agents?
Ginkgo biloba should be discontinued 2 weeks before high-risk procedures in patients on antiplatelet therapy, but controlled clinical trials consistently show no clinically significant interaction with aspirin, clopidogrel, or other antiplatelet agents during routine use. 1
Evidence-Based Recommendation
The Society for Perioperative Assessment and Quality Improvement (SPAQI) explicitly recommends holding ginkgo for 2 weeks before surgery due to theoretical concerns about ginkgolide B displacing platelet-activating factor from binding sites, despite acknowledging that meta-analyses have not demonstrated actual bleeding effects 1. However, this precautionary stance contrasts sharply with the research evidence.
What the Controlled Clinical Trials Actually Show
Multiple randomized controlled trials demonstrate no clinically meaningful interaction between ginkgo biloba and antiplatelet drugs:
A 4-week randomized, double-blind trial of 52 older adults with peripheral artery disease taking 325 mg/day aspirin found that adding ginkgo biloba (EGb 761,300 mg/day) produced no statistically or clinically significant differences in platelet function analysis or platelet aggregation compared to aspirin alone 2
A randomized crossover study of 10 healthy volunteers found that coadministration of ginkgo biloba with clopidogrel (75 mg) did not enhance antiplatelet activity compared with clopidogrel alone 3
A systematic review of controlled clinical studies concluded that ginkgo (specifically EGb 761 extract) does not significantly impact hemostasis nor adversely affect the safety of coadministered aspirin or warfarin 4
The Case Report Problem
The bleeding concerns are largely based on low-quality case reports that typically did not involve the standardized EGb 761 extract used in clinical trials 4. A population-based study from Taiwan examining prescriptions from 2000-2008 found the adjusted odds ratio for hemorrhage with ginkgo plus antiplatelet/anticoagulant drugs was 1.5 (95% CI: 0.5-5.0), which was not statistically significant 5.
Clinical Decision Algorithm
For Routine Outpatient Use:
- Continue ginkgo biloba in patients on aspirin monotherapy, as controlled trials show no interaction 2
- Continue ginkgo biloba in patients on clopidogrel, as pharmacodynamic studies demonstrate no enhanced antiplatelet effect 3
- Counsel patients that while theoretical concerns exist, high-quality evidence does not support clinically significant bleeding risk 4
For High-Risk Endoscopic Procedures:
- Discontinue ginkgo 2 weeks before procedures like endoscopic submucosal dissection (ESD), large colonic EMR (>2 cm), or ampullectomy 1
- Continue aspirin through the procedure unless specifically contraindicated 1
- Hold P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) 5 days before high-risk procedures in low thrombotic risk patients 1
For Perioperative Management:
- Hold ginkgo 2 weeks preoperatively per SPAQI consensus, as this represents the conservative standard of care despite limited evidence of actual harm 1
Important Caveats
The one exception where caution is warranted: Ginkgo biloba combined with cilostazol significantly prolonged bleeding time (though without enhancing platelet aggregation), suggesting a potential interaction specific to this combination 3. This represents a genuine pharmacodynamic concern.
Patient-specific bleeding risk factors matter more than the ginkgo itself: The Taiwan population study found that age ≥65 years (adjusted OR: 3.8) and male sex (adjusted OR: 1.4) were significantly associated with bleeding risk in patients taking ginkgo, but the ginkgo-antiplatelet combination was not 5.
The Bottom Line for Clinical Practice
The disconnect between guideline recommendations (hold ginkgo) and research evidence (no demonstrated interaction) reflects appropriate medicolegal conservatism for high-stakes procedures 1. For routine ambulatory care, continuing ginkgo biloba in patients on antiplatelet therapy is supported by controlled trial evidence 4, 2, 3. For elective procedures, discontinuing ginkgo 2 weeks beforehand represents the standard of care 1, even though the actual bleeding risk appears minimal based on available data.