An estimated one third of United States adults use herbal supplements, often without reporting use to their physicians. These supplements can potentially alter bleeding and coagulation during surgery, and when used concomitantly with anticoagulants. Our objective is to provide a comprehensive review of the evidence of bleeding risks of the most popular herbal and dietary supplements. A PubMed search and review of the literature was performed. We found that garlic and hawthorn supplementation are strongly associated with surgical bleeding independent of anticoagulants; cordyceps sinensis, echinacea, and aloe vera are loosely associated with surgical bleeding independent of anticoagulants. In patients on anticoagulants, ginkgo biloba, chondroitin-glucosamine, melatonin, turmeric, bilberry, chamomile, fenugreek, milk thistle, and peppermint are associated with bleeding risk; no evidence was found for bleeding with these supplements independent of anticoagulants. Fish oil, ginseng, and saw palmetto are not associated with bleeding. Evidence for overall bleeding risk associated with St. John’s Wort, ginger, ginkgo biloba, or cranberry supplementation is conflicting. In conclusion, physicians must be aware of the potential anticoagulant effects of these supplements. It is imperative to report dietary and herbal supplement usage to physicians and is best to discontinue non-essential supplement use 2 weeks prior to surgery.

Coronary artery disease is a leading cause of mortality worldwide, and patients with obstructive coronary artery disease require optimal cardiovascular medical therapy along with lifestyle modification for secondary prevention of future cardiac events. Optimal medical therapy includes antiplatelet agents, high-intensity statins, beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, aldosterone antagonists, and calcium channel blockers. There are differences in the medical therapy guidelines of the American Heart Association/American College of Cardiology and the European Society of Cardiology. In addition, there are emerging medical therapies that may be added to future guidelines with additional cardiovascular outcome benefits.

The effects of polypharmacy on geriatric populations are an emerging concern that merits more exploration. The primary goal of this review was to evaluate the current body of knowledge on polypharmacy and explore the preventive and corrective measures to avoid negative outcomes. Even if a medication has an appropriate indication, polypharmacy in the geriatric population is associated with an increased risk of drug-drug or drug-condition interactions. Recent efforts to prevent polypharmacy include the development of interprofessional teams in clinics dedicated to medication review and reconciliation, deprescription plans aimed to safely discontinue potentially inappropriate medications, and inpatient screening tools that provide prescribing recommendations. In conclusion, polypharmacy affects a high percentage of the geriatric population. Current efforts to address and prevent polypharmacy are ongoing but have not been widely adopted.

Systemic anticoagulants are widely prescribed to prevent and treat thromboembolism, among other indications. A common com-plication of using these agents is gastrointestinal bleeding. While early resumption of anticoagulants after the bleeding has resolved can increase the risk of rebleeding, delayed resumption puts the patient at increased risk of thromboembolic events and mortality. There is limited data on this topic to guide clinicians on resuming anticoagulation after hospitalization for gastrointestinal bleeding and to educate patients regarding the subsequent risks of recurrent gastrointestinal bleeding, thromboembolism, and mortality. The optimal time to resume anticoagulation is also unknown. This review summarizes the existing literature and available data on the commonly encountered dilemma of restarting anticoagulation therapy after hospitalization for gastrointestinal bleeding.