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Supplements to Stop Before Surgery: Bleeding, Anaesthesia, Blood Sugar and What to Tell Your Team

Tell your surgical and anaesthesia team about every supplement; if they ask you to stop, the anaesthesiologists' society says this may be at least two weeks before surgery. Garlic, ginkgo, ginseng and vitamin E can add to bleeding, kava and valerian to sedation, and St John's wort lowers some medicines' levels (grade B). In heart-surgery trials fish oil did not increase bleeding (grade B), but follow your team. Never stop a blood thinner, diabetes medicine or antidepressant yourself.

Published How we grade evidenceEditorial policy

This guide is for adults facing a planned operation or procedure, including dental surgery, who take vitamins, herbs or other supplements.

Tell your surgical and anaesthesia team about everything you take, including vitamins, herbs, powders, teas, cannabis or CBD products, and bring the bottles to your pre-surgery visit. Then follow their plan. Don't stop, skip or change a prescribed medicine, especially a blood thinner, diabetes medicine or antidepressant, unless the team tells you to.

The short version

  • Tell the team and bring the bottles. The American Society of Anesthesiologists (ASA) says half of people who use herbal supplements don't tell their doctors before surgery, and that some supplements can prolong anaesthesia, increase bleeding, raise blood pressure or interfere with medicines (ASA). If the team asks you to stop, the ASA says this may be at least two weeks before the procedure; follow your own team's timeline. A 2021 expert consensus covering 83 supplements reasons that pausing one with no demonstrated benefit costs little (Cummings 2021).
  • St John's wort lowers the levels of some medicines, including the sedative midazolam, and the effect takes about a week to fade after stopping. Grade B (Wang 2001; Imai 2008).
  • Fish oil did not raise bleeding in 1,516 people having heart surgery, and a review of 20 studies in surgical patients agreed. Your team may still ask you to pause it. Grade B (Akintoye 2018; Begtrup 2017).
  • Vitamin E raised bleeding strokes by about 22% in trials in the general population, a borderline result; a later analysis found a smaller rise that was not statistically significant. Grade B (Schürks 2010; Loh 2021).
  • Garlic, kava and valerian: the evidence for harm around surgery comes from case reports (bleeding during surgery with garlic, coma when kava was combined with a benzodiazepine sedative, withdrawal after stopping valerian suddenly). Grade D (Woodbury 2016; Almeida 1996; Garges 1998).
SupplementConcern around surgeryWhat the evidence showsGradeWhat to do
St John's wortLowers levels of some medicinesFaster breakdown of midazolam in 12 healthy adults; back to normal about 1 week after stoppingBTell the team; stop only on their advice
Fish oilBleeding (long-held worry)No extra bleeding in 1,516 heart-surgery patientsBFollow your team's instruction
Vitamin EBleedingAbout 22% more bleeding strokes in the general population (borderline)BTell the team; ask about pausing
GinkgoBleedingNo change in clotting tests in trials; bleeding case reportsB (tests)Tell the team; ask about pausing
Garlic supplementsBleedingCase reports of heavy bleedingDTell the team; ask about pausing
Ginseng, berberineLow blood sugar; drug levelsGinseng lowered fasting glucose a little; berberine raised midazolam levels by 40%B, CTell the team, especially with diabetes
Kava, valerianExtra sedation; kava liver injury; valerian withdrawalCase reportsDTell the team; don't stop valerian suddenly without advice

What supplements should you stop before surgery?

Usually the ones you don't need, and only on your team's plan. The ASA leaflet says your anaesthesiologist may ask you to stop supplements at least two weeks before the procedure, and names ephedra, garlic, ginkgo, ginseng, kava, St John's wort, valerian and vitamin E as common problem products (ASA). A 2024 anaesthesia review says the ASA and the nurse anaesthetists' association advise stopping herbal medicines 1 to 2 weeks before planned surgery (Elvir Lazo 2024); a 2022 review of bleeding risks suggests 2 weeks for non-essential supplements (Hatfield 2022).

"Non-essential" matters: iron for anaemia, B12 for a deficiency, or anything a clinician prescribed may need to continue, so ask rather than stopping everything. Before urgent surgery there is no time to stop anything, which is why telling the team is the step that always counts.

Why does your surgical team need to know about supplements?

Because many people take them and few mention them. In a Czech hospital, 42% of 256 surgical patients had used a supplement in the month before their operation, and 45.8% saw no risk in mixing supplements with medicines (Zubrova 2020). In 478 patients in three Italian hospitals, about half used herbal products or supplements, valerian most often (Lucenteforte 2012). A 2024 review puts non-disclosure at 50% to 70% of surgical patients (Elvir Lazo 2024).

Supplements can affect bleeding, blood pressure and the heart, blood sugar, sedation and how fast the body clears drugs (Ang-Lee 2001), and the bottles show the team exact ingredients and amounts.

Which supplements raise bleeding risk during surgery?

The evidence ranges from clotting-test trials to single case reports: a reason to tell the team, not a verdict.

  • Vitamin E, grade B. In the 5 trials that reported them, bleeding (haemorrhagic) strokes rose by 22%, roughly one more per 1,250 people on vitamin E, a borderline result in people in general, not surgical patients (Schürks 2010); pooling 18 trials, a 2021 analysis found a smaller rise that was not statistically significant (Loh 2021). NIH notes the signal came from ordinary doses: 50 mg a day in one trial and 400 IU every other day in another (NIH ODS). Upper limit for adults: 1,000 mg of vitamin E a day from supplements, set because higher amounts can cause bleeding; don't exceed it without medical supervision (NIH ODS).
  • Ginkgo, grade B for no change in clotting tests. In a pooled analysis of 18 placebo-controlled trials (1,985 adults), standardized extract left platelet clumping and clotting times unchanged (Kellermann 2011). A case report still describes bleeding after keyhole gallbladder surgery in someone taking ginkgo (Fessenden 2001), the ASA lists it, and NCCIH says it may raise bleeding risk in people taking anticoagulants such as warfarin (NCCIH).
  • Garlic supplements, grade D. A man bled heavily during spine surgery with no clear source; he took no blood thinners (he was on sertraline, an antidepressant that may affect clotting) but had eaten the equivalent of 12 g of garlic a day in the days before (Woodbury 2016). An older report linked heavy garlic intake to a bleed around the spinal cord (Rose 1990). NCCIH says to tell your providers about garlic supplements, especially before surgery (NCCIH).
  • Hawthorn, turmeric, ginger and others, grade D. A 2022 review found hawthorn, like garlic, strongly linked to surgical bleeding even without blood thinners. It linked turmeric, ginkgo, glucosamine and melatonin to bleeding in people on blood thinners, found no such evidence in people not on them, and called the ginger evidence conflicting (Hatfield 2022). See can I take turmeric with Eliquis?
  • Ginseng: the ASA says it can raise heart rate and bleeding risk, though the 2022 review found no link to bleeding (Hatfield 2022).

On a blood thinner or antiplatelet drug, these effects can add up; the team plans any pause of the medicine itself. More in supplements and blood thinners.

Do you need to stop fish oil before surgery?

Grade B: in trials, fish oil did not raise surgical bleeding, but follow your team's instruction. In a placebo-controlled trial of 1,516 adults having heart surgery, high-dose fish oil started a few days before the operation did not increase major bleeding (6.1% of all patients had it; odds ratio 0.81 with fish oil), and the fish oil group needed fewer units of blood (Akintoye 2018). Fish oil makes platelets clump less in healthy people, yet a review of 52 studies, 20 in surgical patients (some gave fish oil by drip rather than by mouth), found no extra bleeding or transfusions and did not support stopping it beforehand (Begtrup 2017).

Many teams still ask for a pause, and our surgical recovery protocol lists fish oil among supplements to stop. That advice is cautious rather than wrong, but these trials found no bleeding signal. With a blood thinner too, read can I take fish oil with Eliquis?

Why does St John's wort matter before surgery?

Grade B: it makes the liver and gut clear some medicines faster, so they may work less well. After 2 weeks of St John's wort, 12 healthy adults cleared midazolam taken by mouth about twice as fast, and its blood level after an injection fell by 20% (Wang 2001). Midazolam is a sedative used before and during anaesthesia (midazolam label). In 12 healthy men the effect faded to normal about 1 week after the last dose (Imai 2008).

Not every drug is affected: a month of St John's wort did not change how 8 healthy volunteers handled fentanyl, a strong painkiller, given into a vein, compared with 8 on placebo (Loughren 2020). Case reports describe slow waking from anaesthesia (Crowe 2002) and circulatory collapse during anaesthesia (Irefin 2000) in people taking it.

The bigger risk is often after surgery. NCCIH lists medicines it weakens, including cyclosporine (an anti-rejection drug), warfarin, birth control pills, some heart, seizure, HIV and cancer medicines and simvastatin (NCCIH). The labels for apixaban and rivaroxaban say to avoid St John's wort because it lowers their levels, which could leave you less protected against clots (apixaban label; rivaroxaban label). If you go home on any blood thinner, don't restart St John's wort unless the prescriber agrees. A review of 11 case reports and 2 case series found it lowered cyclosporine levels, in several cases leading to transplant rejection (Ernst 2002; Ruschitzka 2000). With antidepressants it can cause serotonin syndrome; the warning signs are in can I take St John's wort with SSRIs?. If you take it for low mood, ask the prescriber and the surgical team together before stopping.

Do kava and valerian affect anaesthesia?

Grade D: the ASA says both can increase or prolong the effects of anaesthesia, and the human evidence is case reports.

  • Kava. A case report describes a coma after kava was taken with alprazolam, a benzodiazepine sedative (Almeida 1996); NCCIH says not to combine kava with benzodiazepines, alcohol or other sedatives (NCCIH). Kava has also been linked to severe liver injury: by 2002, 11 people who used kava products had needed liver transplants, and the FDA issued a consumer advisory (CDC 2002).
  • Valerian. NCCIH warns against combining it with sedatives and says some people who stop it abruptly after long use get withdrawal symptoms such as anxiety, heart disturbances and insomnia (NCCIH). Case reports describe heart problems and delirium after sudden withdrawal (Garges 1998; Burke 2020). After long nightly use, ask the team how to come off it rather than stopping the night before.

Both matter after surgery too, alongside pain medicines or sleeping pills that cause drowsiness.

Can supplements lower your blood sugar while you fast for surgery?

Some lower blood sugar a little, and fasting lowers it further, so tell the team, especially if you have diabetes.

  • Ginseng, grade B for a small drop. Across 16 trials in people with and without diabetes, ginseng lowered fasting blood glucose by 0.31 mmol/L (Shishtar 2014); a perioperative review warns this could cause unintended low blood sugar in someone fasting before surgery (Wang 2015). In people with diabetes, NCCIH calls the research on blood sugar control inconclusive and conflicting (NCCIH).
  • Berberine, grade C for a drug-level effect. In type 2 diabetes it lowered fasting glucose (37 studies, 3,048 patients) without significantly more low-sugar episodes (Xie 2022). In a trial of healthy men, 2 weeks of berberine raised midazolam blood levels by 40% (Guo 2012).

Other "blood sugar" products are covered in supplements for blood sugar. On insulin or diabetes tablets, follow the team's separate instructions for them.

Are weight-loss and energy products a risk before surgery?

Yes, partly because of what may be hidden in them. The ASA warns that ephedra can interact with some blood pressure medicines to cause dangerous rises in blood pressure or heart rate. Supplements containing ephedrine alkaloids have been banned from sale in the US since 2004 (21 CFR 119), but stimulants still turn up: of 776 supplements the FDA flagged for hidden drugs from 2007 to 2016, 317 were sold for weight loss, and 269 of those contained sibutramine, a weight-loss drug (Tucker 2018). Energy and pre-workout products can also carry a lot of caffeine; the FDA cites 400 mg a day as an amount not generally linked to negative effects for most adults (FDA). Bring any weight-loss, pre-workout, energy or muscle-building product to the pre-surgery visit.

When should you stop supplements, and when can you restart?

Stop on your team's timeline and restart only when they say so. You may go home on a new blood thinner, pain medicine or antibiotic, so ask before restarting St John's wort, kava, valerian, ginkgo, garlic or vitamin E. Taking several products? Add up your stack against the upper limits.

Is vitamin C, vitamin D or CoQ10 safe before surgery?

None of the three is on the ASA's list of problem supplements, but tell the team anyway.

  • Vitamin C. Very large doses can cause diarrhoea and, in G6PD deficiency (an inherited red blood cell condition), can break down red blood cells (Wang 2015). Because vitamin C raises iron absorption, NIH says long-term high doses could worsen iron overload in hereditary haemochromatosis. Upper limit for adults: 2,000 mg a day; above that, diarrhoea, nausea and stomach cramps become likely, so stay under it unless a clinician says otherwise (NIH ODS). More in vitamin C supplements.
  • Vitamin D. The adult upper limit is 100 mcg (4,000 IU) daily; above it, the risk of side effects such as high blood calcium rises, so ask a clinician before taking more (NIH ODS). See vitamin D supplements.
  • CoQ10. NCCIH says it may interact with warfarin and insulin (NCCIH), which matters if either is part of your surgical plan. See CoQ10 supplements.

Can any supplement help with recovery from surgery?

A few, given or approved by the surgical team rather than taken on your own.

  • Ginger for sickness after surgery, grade B for a small effect. An early pool of 5 trials (363 patients) found at least 1 g before an operation lowered nausea and vomiting against placebo (Chaiyakunapruk 2006), but a larger 2022 review of 14 trials (1,506 patients) found only lower nausea scores in the first hours, with no reliable drop in vomiting or in the need for anti-sickness medicine (Lu 2022); NCCIH calls the evidence uncertain (NCCIH). The ginger and bleeding evidence is conflicting (Hatfield 2022), so take it only if the team agrees.
  • Immune-enhancing nutrition around cancer surgery, grade A. Nutrition with arginine, omega-3 fats or glutamine, given as drinks, tube feeds or by drip, cut total complications (relative risk 0.78) and infections (0.71), with high certainty, across 48 trials in adults having mouth, throat or digestive cancer operations (Matsui 2024). The surgical or oncology team plans these.
  • Probiotics before bowel surgery, grade B. In 28 trials (2,686 people having planned colorectal surgery), probiotics or synbiotics went with fewer infections in the month after surgery (relative risk 0.55), though the best regimen is still unsettled (Paterson 2025).

What we'd skip

  • Starting new supplements in the weeks before surgery to "help healing" without asking: the 2021 consensus reasons that a product with no demonstrated benefit is better paused (Cummings 2021).
  • Kava around surgery: extra sedation and rare but severe liver injury (CDC 2002).
  • Weight-loss, stimulant and "fat burner" products, which can hide drugs that affect the heart and blood pressure (Tucker 2018).
  • Vitamin E supplements in the weeks before surgery unless your team agrees: the bleeding-stroke signal came from ordinary doses, well below the upper limit (Schürks 2010; NIH ODS).

Safety and interactions

  • Blood thinners and antiplatelet drugs: never stop or restart warfarin, apixaban, rivaroxaban, aspirin or clopidogrel on your own; the team decides. St John's wort lowers apixaban and rivaroxaban levels, and their labels say to avoid it.
  • Diabetes medicines: glucose-lowering supplements, fasting and insulin or tablets together can push blood sugar too low.
  • Transplant, seizure, heart, HIV and cancer medicines, and birth control pills: St John's wort can weaken them (NCCIH).
  • Liver disease: avoid kava; turmeric and green tea extracts carry their own liver warnings (supplements and your liver).
  • Pregnancy, including a planned caesarean: ask your midwife or obstetric team about every supplement, including prenatal vitamins.
  • Children: for a child's operation, tell the team about every supplement or remedy the child takes.

When to see a doctor

  • Before surgery: call the team if you remember a supplement you didn't list, or if you're unsure whether to stop something.
  • Go now after surgery for bleeding that won't stop with pressure, a fast-growing swelling at the wound, vomiting blood, black or tarry stools, or blood in your urine.
  • Go now for severe drowsiness, slow or shallow breathing or confusion, especially if you've restarted kava, valerian or another sedating product alongside pain medicine.
  • Get help for shaking, sweating and confusion that may be low blood sugar, particularly with diabetes.
  • Get seen the same day for skin or eye yellowing or dark urine (possible liver injury), and stop kava, turmeric or other herbal products until you've been checked.
  • After a transplant, call your transplant team straight away about any supplement you've started, and about any warning sign of rejection they told you to watch for.

FAQ

How long before surgery should I stop supplements? Follow your team's timeline. The American Society of Anesthesiologists says your anaesthesiologist may ask you to stop supplements at least two weeks before; a 2024 review cites 1 to 2 weeks for herbal medicines. Don't stop prescribed medicines without asking.

Do I need to stop fish oil before surgery? Ask your team. In a trial of 1,516 people having heart surgery, fish oil did not increase bleeding, and a review of 20 studies in surgical patients agreed, but many teams still ask for a pause.

Is it safe to take vitamin C before surgery? Vitamin C isn't on the anaesthesiologists' list of problem supplements. Stay at or under 2,000 mg a day unless advised otherwise, and tell the team, especially if you have G6PD deficiency or haemochromatosis.

Why does St John's wort matter before surgery? It lowers the levels of some medicines, including the sedative midazolam in studies of healthy adults, and the effect lasts about a week after stopping. It also weakens anti-rejection drugs, warfarin and birth control pills.

Should I stop valerian before surgery? Tell the team. It may add to anaesthesia's sedating effect, but stopping suddenly after long use has caused withdrawal symptoms in case reports, so ask how to come off it.

Sources

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