Your patients are taking supplements, but will they stop before surgery?
Clinicians concerned about bleeding and other complications
By Joy Daughtery Dickinson, Executive Editor
Herbal supplements are falling under increased scrutiny. In the fall, The Children’s Hospital of Philadelphia (CHOP) became the first hospital in the United States to enact a policy to discourage patients from using dietary supplements without a doctor’s provision.
CHOP announced that it no longer will include most dietary supplements on its formulary. The hospital explained that the Food and Drug Administration (FDA) does not routinely review the manufacturing of dietary supplements, and therefore cannot guarantee their safety and effectiveness. Potential risks include contamination, mislabeling, interactions with medications, or potential unforeseen adverse effects, CHOP said in a released statement.1 The policy does acknowledge that certain medical conditions might require vitamin or nutrient supplements, and a very limited number of acceptable products are listed, said Sarah Erush, PharmD, BCPS, pharmacy clinical manager and a member of the hospital’s Therapeutic Standards Committee.
Such a strong stand against supplements has caught the attention of outpatient surgery managers, particularly since so many surgery patients take supplements. In fact, a recent study reported that about half of patients having facial cosmetic surgery are taking herbal and other supplements.2
The researchers analyzed 200 patients undergoing cosmetic facial surgery, and 49% were using at least one type of supplement. The average number of supplements was 2.8 per patient, although one patient was taking 28 supplements. In the general surgery patient population, are half of patients taking supplements? Alan Matarasso, MD, attending surgeon at Manhattan Eye, Ear, and Throat Institute/Lenox Hill Hospital/Long Island Jewish Medical Center in New York City, said the percentage at his practice is at least that high. "It’s a $30 billion industry," Matarasso said.
In the study mentioned above, 35 patients were taking supplements that have been linked to an increased risk of bleeding, such as bilberry, bromelain, fish oil, flaxseed oil, garlic, methylsulfonylmethane (MSM), selenium, and vitamin E.
"In their report, I was surprised to learn that bromelain, a supplement that I have used in my practice, increased the risk of bleeding, just as I was by their previous report that Arnica montana caused hypertension," Matarasso wrote in a discussion of the study.3 Those two supplements are the most commonly recommended herbals, he said.
"The most common adverse event from many supplements is excessive bleeding and hematoma formation," Matarasso wrote. "I adhere to the concept that a second operation, for example evacuating a hematoma, can take longer and have a more adverse impact than the initial operation."
Dry eyes also can be a side effect of supplements, which can be a particular concern for patients having eyelid surgery, says Bahman Guyuron, MD, chairman of the Department of Plastic Surgery at University Hospital and Case Medical Center, Cleveland, OH. Guyuron was a co-author of the study mentioned previously.
Concerns with herbal supplements and general surgery include the fact that they can raise blood pressure and can prolong the effects of anesthesia, according to the American Society of Anesthesiologists (ASA).
John Dombrowski, MD, chair of the ASA Communications Committee and director of the Washington (DC) Pain Center said of supplements, "How your body reacts to that medication can affect that anesthetic."
Take these steps to avoid problems
Patients often think of supplements as safe and natural products, so they often don’t think to list these products when their physicians ask what medications or drugs they’re taking.
"A lot of people don’t recognize that what they buy in a health food store and another store is a medication, even though taking that, they want a medical benefit," Matarasso says. "We specifically advise about health food stores."
He asks patients about their use of prescriptions, over-the-counter medications, and dietary supplements. "We want to know anything they put in their mouth that they consider helpful to their health," he says.
Guyuron uses a questionnaire that asks patients what they are taking, including pharmaceutical products and herbal medications. (See an ASA questionnaire listed in the resources at the end of this story.) He specifically asks, "What herbal supplements do you consume?"
"Otherwise, it’s not on their radar," he says. They don’t consider the herbal product to be a medication, so unless you ask for that information specifically, they won’t volunteer that they take some herbal products, Guyuron says.
Dombrowski asks the question in an even more general manner. "I always ask my patients, cosmetic surgery or just outpatient surgery, what pills do you take? Pills. Then I also remind them: This is what I mean: vitamin, supplement, and any medication you get from your doctor."
Guyuron advises that you ensure the patient is questioned multiple times: by the physician, nurse during initial consultation, and at the preop visit. Patients also can be reminded at the preoperative call, Dombrowski says.
Explain to patients why
Patients today are much more likely to question healthcare providers about their instructions, so be prepared to address their questions about why they need to stop taking supplements.
"If you tell them, `you have to stop herbal medications,’ they might think you don’t want them to take them because you’re a doctor," Guyuron says. He discusses specific conditions, consequences, or risks, rather than leading the patient to the assumption that he dislikes herbal medications. (See list of risks, right.)
CHOP created an education sheet that can be used to discuss prior medication/supplement use with patients and their families. (The forms that CHOP uses are included in the online issue of Same-Day Surgery. Go to www.reliasmedia.com and select "Access your newsletters." For assistance, contact customer service at (800) 688-2421 or firstname.lastname@example.org.)
Matarasso tells patients that calcium or vitamin D are fine, but fish oils and supplements that begin with "G" (garlic, ginko, etc.) are not OK. "They finally understand: Supplements can be in the same category as taking an aspirin, which is not advised," he says. He provides patients with a three-page list of medications and tells them to stop taking them two weeks before surgery. (See list with the online issue of Same-Day Surgery.) He tells patients if there is any question about whether to take their supplement, don’t take it. He says they should consult the list or call him. Matarasso tells them: "Unless you can tell me these things are essential, don’t take them." Patients normally are allowed to keep taking medication for hypertension and thyroid disease.
By taking these steps to stop supplement use before surgery, the patient is less likely to develop problems with bleeding, which is the number one complication from surgery, or other complications. "Controlling every step of the operation and the perioperative period is essential to achieving a safe and satisfying outcome," Matarasso wrote.3
- Children’s Hospital of Philadelphia. Children’s Hospital of Philadelphia becomes first in nation to disallow use of dietary supplements. Oct. 8, 2013. Accessed at http://bit.ly/17wlTbE.
- Zwiebel SJ, Lee M, Alleyne B. The incidence of vitamin, mineral, herbal, and other supplement use in facial cosmetic patients. Plastic & Recon Surg 2013; 132:78-82; doi: 10.1097/PRS.0b013e3182910cd9.
- Matarasso A. Discussion: The incidence of vitamin, mineral, herbal, and other supplement use in facial cosmetic patients. plastic and reconstructive surgery. Plastic & Recon Surg 2013; 132:83-34; doi:10.1097/PRS.0b013e31829491e7.