Natural Products for Anxiety Management in Polytherapy Patients

Recommended Products with High Safety Profile

• The American College of Cardiology recommends melatonin, passiflora, and lavender as safe natural products for anxiety management in polytherapy patients, with a well-documented safety profile and minimal risk of pharmacological interactions 1, 2, 3
• Melatonin can be continued without interruption in patients with polytherapy, reducing anxiety comparable to midazolam, with an excellent safety profile in the perioperative period 3, 4
• Passiflora has well-documented anxiolytic effects, with a favorable safety profile, and can be continued without interruption in patients with polytherapy 2, 3, 4
• Lavender is effective and safe in treating anxiety, including in the preoperative period, with no evidence of clinical interactions that could potentiate anesthetic or sedative effects 3, 4

Products to Use with Caution

• German chamomile may be considered for continuation in polytherapy patients, with modest but significant reductions in anxiety, and no data suggesting effects on the central nervous system that interfere with other medications 1
• Valerian may be considered for continuation in polytherapy patients, with a safe profile, and potential protection against cognitive dysfunction 5
• Hops may be considered for continuation in polytherapy patients, with improvements in sleep demonstrated in some clinical studies, and no documented perioperative adverse effects 2

Products to Avoid in Polytherapy

• Kava should be suspended 2 weeks before any procedure, due to the risk of additive or synergistic effects with anesthetics, benzodiazepines, and opioids, causing excessive sedation 2, 3
• Lemon balm should be suspended 2 weeks before any procedure, due to the risk of additive depression of the central nervous system when combined with sedatives or alcohol 2, 4
• St. John's Wort should be suspended 2 weeks before any procedure, due to its induction of cytochrome P450 3A4, reducing plasma concentrations of numerous medications 5
• L-tryptophan should be suspended 24 hours before procedures, due to the risk of serotonin syndrome when used with medications that inhibit serotonin reuptake 2, 3, 4

Critical Considerations for Polytherapy

• The European Society of Cardiology recommends monitoring patients taking anticoagulants, antiaggregants, antidiabetics, or cardiovascular medications when adding natural products 1, 7
• The American Heart Association recommends starting with low doses and gradually titrating, and documenting all natural products in the medical record as part of medication reconciliation 6, 7
• More than 80% of severe adverse reactions are type A (dose-dependent and predictable), and therefore avoidable 7