It is imperative that providers be aware of patients’ supplement usage, particularly in the pre-operative setting. Although many supplements may not meaningfully influence a patient’s peri-operative course, some have the potential to alter bleeding risk, anesthetic effectiveness, or various physiologic and hemodynamic parameters1. Therefore, a comprehensive and accurate evaluation of patients’ supplement consumption is essential before a medical procedure, and it is critical that patients disclose any supplement use, even if it seems unimportant.

There are a wide range of products which may be considered supplements. This list includes – but is not limited to – multivitamins, minerals, herbs/botanicals, sleep aids, fatty acids, probiotics and prebiotics, sports supplements, and unprescribed weight loss products1,2. Although not considered a supplement by many patients, cannabis and related psychoactive molecules like ∆-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) are also medically relevant substances which should be discussed during the pre-procedure assessment as part of medication and/or substance use history. This is particularly relevant given marijuana’s increasing availability for medical and recreational uses.

Estimates of the prevalence of supplement usage are variable and largely based on survey data. However, it is clear that supplement usage is common and increasing3, with recent studies estimating that between half and two-thirds of American adults consume some form of supplement4.

Unfortunately, patients do not consistently report supplement consumption. Recent data from the geriatric population suggests that 71.9% of patients disclose supplement use to their primary care physician5. More concerningly, a study from 2001 indicated that nearly 70% of patients taking herbal supplements did not disclose them during routine pre-operative anesthesia assessment6.

The at-times inconsistent reporting of supplement use is particularly problematic given that some supplements can have clinically meaningful implications for medical procedures. Recent herbal substance use may exert drug-drug interactions, potentially altering the metabolism of anesthetic agents. Other supplements, such as gingko balboa, may increase bleeding time. Supplement usage also has the potential to lead to a wide array of physiologic effects, including cardiovascular stimulation or depression depending on the specific agent1. A review in The British Journal of Anaesthesia details the potential anesthetic considerations of various herbal supplements2. For providers, thoroughly investigating supplement use is necessary, and for patients, disclosing supplement use before a procedure can improve safety and outcomes. It is important to note, however, that physicians’ understanding of supplement-anesthetic interactions is continuously evolving, and that certain interactions observed in vitro do not consistently exert clinically meaningful effects in vivo.

Patients may fail to report supplement use for a variety of reasons. For example, they may feel that their physician is unknowledgeable about these products or would be biased against them7. Others may be reluctant to disclose what is perceived as “unconventional” therapy8, believe that supplements are unrelated to their care9, or simply not view supplements as medications.

In any case, providers within anesthesia and other specialties must pursue a comprehensive evaluation before the procedure in which the use of medications and supplements alike are actively elicited. Ideally, this should occur in the setting of a non-judgmental, open clinician-patient relationship, as previous data has shown the level of patient trust in their physician to be associated with rates of supplement disclosure5. This may be particularly important for substances with any level of societal stigma attached to them, such as cannabis or non-prescription weight loss drugs.

References

1. Elvir Lazo, O. L. et al. Use of herbal medication in the perioperative period: Potential adverse drug interactions. J. Clin. Anesth. 95, 111473 (2024).
2. Ang-Lee, M. K., Moss, J. & Yuan, C. S. Herbal medicines and perioperative care. JAMA 286, 208–216 (2001).
3. Bailey, R. L. et al. Dietary supplement use in the United States, 2003-2006. J. Nutr. 141, 261–266 (2011).
4. Dickinson, A. & MacKay, D. Health habits and other characteristics of dietary supplement users: a review. Nutr. J. 13, 14 (2014).
5. Golden, J., Kenyon-Pesce, L., Robison, J., Grady, J. & Guerrera, M. P. Disclosure of Complementary and Alternative Medicine Use Among Older Adults: A Cross-Sectional Study. Gerontol. Geriatr. Med. 9, 23337214231179839 (2023).
6. Kaye, A. D. et al. Herbal medicines: current trends in anesthesiology practice–a hospital survey. J. Clin. Anesth. 12, 468–471 (2000).
7. Blendon, R. J., DesRoches, C. M., Benson, J. M., Brodie, M. & Altman, D. E. Americans’ views on the use and regulation of dietary supplements. Arch. Intern. Med. 161, 805–810 (2001).
8. Eisenberg, D. M. Advising patients who seek alternative medical therapies. Ann. Intern. Med. 127, 61–69 (1997).
9. Elder, N. C., Gillcrist, A. & Minz, R. Use of alternative health care by family practice patients. Arch. Fam. Med. 6, 181–184 (1997).