A 'naturist' patient has replaced their conventional medications with natural products, including garlic and St. John's wort. What precaution is MOST appropriate during treatment?

Correct answer: C. Use local anesthetic without (or minimize) epinephrine, and take bleeding precautions

• A. Completely avoiding anesthesia is unnecessary and would compromise patient comfort; an epinephrine-free or reduced-epinephrine agent solves the concern.
• B. Increasing epinephrine is the opposite of what is indicated and could provoke a cardiovascular event.
• C. Correct. St. John's wort inhibits reuptake of norepinephrine/epinephrine and alters adrenergic transmission, so added epinephrine can exaggerate cardiovascular effects — favoring caution or an epi-free/low-epi anesthetic. Garlic has antiplatelet activity that increases bleeding risk, so bleeding precautions also apply. (St. John's wort is additionally a potent CYP3A4 inducer, lowering levels of many co-administered drugs.)
• D. Herbal supplements are not 'free of effects' — these specific herbs carry real anesthetic and bleeding interactions, so unmodified treatment is unsafe.