SeriousConflict
Ticagrelor is metabolised by CYP3A4 and is a P-glycoprotein substrate. St. John's wort potently induces both, and the model CYP3A4/P-gp inducer rifampin reduces ticagrelor AUC by 86% and Cmax by 73%, with a measurable loss of platelet inhibition. The same effect is expected with St. John's wort, risking treatment failure (stent thrombosis, MI, stroke).
Recommendation: Avoid St. John's wort while on ticagrelor. If you have been taking both, stop the St. John's wort and tell your prescriber so antiplatelet adequacy can be reassessed (e.g., platelet reactivity testing if available).
SeriousCaution
Ginkgo biloba inhibits platelet-activating factor and platelet aggregation. Added to ticagrelor's reversible P2Y12 inhibition, the antiplatelet effect of ginkgo creates an additive bleeding risk, including the spontaneous intracranial and ocular bleeding reported in ginkgo case literature.
Recommendation: Avoid ginkgo biloba while on ticagrelor. If you have been combining them, stop the ginkgo and call your prescriber if you notice unusual bruising, nosebleeds, or any sign of bleeding.
ModerateCaution
Concentrated garlic supplements inhibit platelet aggregation. Combined with ticagrelor's P2Y12 inhibition, garlic supplements stack antiplatelet activity and can raise bleeding risk, particularly perioperatively.
Recommendation: Avoid concentrated garlic supplements (aged garlic, allicin capsules) while on ticagrelor, and stop them at least 7 days before any planned surgery. Cooking with garlic is fine.
ModerateCaution
Fish oil's omega-3 fatty acids reduce platelet thromboxane A2 generation and modestly prolong bleeding time. Added to ticagrelor's P2Y12 inhibition, high-dose fish oil (more than 3 g/day EPA+DHA) can additively raise bleeding risk, particularly around procedures.
Recommendation: Keep fish oil dose modest (≤2 g/day combined EPA+DHA) on ticagrelor and keep the dose constant. Stop fish oil at least 7 days before any planned surgery.
DangerousCaution
Nattokinase can add fibrinolytic and anticoagulant effects to ticagrelor's potent antiplatelet action. Human studies show nattokinase lowers clotting-related proteins, and a published case report describes cerebellar hemorrhage after nattokinase was combined with aspirin. The combination is especially concerning in anyone with prior stroke, recent PCI, dual antiplatelet therapy, kidney disease, or upcoming procedures.
Recommendation: Avoid nattokinase while taking ticagrelor unless your cardiologist has explicitly approved it. Do not manage this by separating doses because both effects persist beyond the dosing window. Get urgent help for severe headache, one-sided weakness, black stools, vomiting blood, or uncontrolled bleeding.
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