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Q: How thorough do I need to be in determining my client’s use of over the counter medication, supplements and CAM treatment.
A: More than 50% of the population uses some form of over the counter medication and/or supplement on regular basis. Complimentary and Alternative Medicine (CAM), such as chiropractic, acupuncture and massage, is also widely used. In the vast majority of medical legal cases supplements will not play a significant role. It is a little more likely that OTC medications come into play. However, there are a number of instances when both can have a big impact. Knowing which types of cases these are can make a difference in how the cases are handled. Any case that involves some type of bleeding or blood clot complication should be investigated with OTC medications and supplements in mind. These cases would include deep vein thrombosis, pulmonary embolism, stroke, subdural and epidural hematoma and intraoperative or postoperative bleeding. Many OTC medications and supplements affect the clotting mechanism. The blood thinning properties of aspirin and ibuprofen are fairly well known. Less well known by the general population is the potential additive effect of taking multiple medications or taking much more than the recommended amounts. Common herbal supplements like garlic, ginger and turmeric can also affect bleeding. People taking prescription blood thinners, such as Coumadin and Plavix, have to be especially careful with OTC medications and supplements. Medical providers are usually very good about warning their patients not to take aspirin or ibuprofen. They may not be as good at warning about supplements such as ginkgo biloba, ginseng, and St. John’s wort. Even something as innocent sounding as green tea extract, a common ingredient in weight loss supplements, can be very dangerous for people on blood thinners. One study revealed that 35% of patients on Coumadin were taking supplements and of those 54% were unaware of any potential interaction. A partial list of common herbals and supplements known to interact with blood thinners or to have blood thinning properties:
  • Coenzyme Q
  • Garlic
  • Ginger
  • Ginkgo
  • Ginseng
  • Glucosamine
  • Green Tea
  • St. John’s Wort
  • Arnica
  • Bilberry
  • Chamomile
  • Clove Oil
  • Evening Primrose
  • Kava
  • Papaya
  • Saw Palmetto
Not only are patients on blood thinners not always cautioned about herbal supplements, they frequently do not report to their doctors that they are taking them. Only about 40% of patients will report supplement use to their medical providers. Patients may not want their doctors to know they are taking them or be embarrassed about it. More likely is the attitude many people have, that since these things are commonly sold in stores and online they must be safe or have no effect on prescription medications. Sadly, there is also evidence that medical providers do not always ask their patients about supplement use. Because patients often fail to report use of these substances and providers often fail to ask there may be no documentation in the medical record one way or the other. Determining whether a blood clot or excessive bleeding is due to inadequate monitoring or dosage adjustment may not be as straight forward as the lab reports and medical records would indicate. If the patient does not inform their provider they are taking OTC medications or supplements that can have serious side effects the provider may not be able to prevent complications. Conversely, if the provider does not ask about OTC and supplement use he or she may not have the information needed to best treat the patient. In a case hinging on a bleeding complication this information can be critical. Being caught by surprise while litigating such a case could result in a substantial difference in outcome for you and your client. Obtaining whatever information is available from CAM providers, especially those proclaiming to be naturopathic or holistic, can be very useful. Patients will often disclose the use of vitamins, minerals, herbal and other supplements to non-allopathic providers. CAM providers are also more likely to ask about, document and recommend their use. Complementary and Alternative Medical treatment can also come into play in other medical legal cases. Watch for more information in an upcoming newsletter.