Which Medications to Continue or Hold Before Surgery

There should be a discussion about the patient's present and recent medication use, including prescription drugs, over-the-counter treatments, herbal remedies, and dietary supplements. It's crucial to weigh the pros and cons of halting or maintaining each medication; decisions about initiating preoperative medications to manage coexisting medical conditions also need to be made. Below are some broad recommendations for medications that can be safely maintained, those that should be stopped before surgery, and drugs that may require dosage adjustments on the morning of the surgery. This is not an exhaustive list of all possible medication: 

• Stop 14 days before surgery
  • Any herbal supplements
• Stop 7 days before surgery
  • Plavix (clopidogrel). Direct oral anticoagulants such as Pradaxa and Eliquis need only 1 to 3 days, depending on renal function and bleeding risk; warfarin is held about 5 days, with a preoperative INR goal of 1.5 or less
  • Aspirin, unless it is prescribed for coronary disease or a coronary stent; those patients usually continue it, in coordination with the cardiologist and surgeon
  • Any nonsteroidal anti-inflammatory medication: Ibuprofen, Advil, Midol, Naproxen, Voltaren
  • Vitamins (multivitamins, etc.)
• Medications to withhold on the day of surgery (restart postoperatively)
  • Diuretics (to avoid hypovolemia or hypokalemia) but must discuss with ordering physician (? volume overload with all heart failure)
  • ACE inhibitors (associated with hypotension with anesthesia)
  • Angiotensin receptor blockers (associated with hypotension with anesthesia) However, after their withdrawal, perioperative hypertension can occur along with an increase in acute kidney injury in some thoracic patients. Anesthesia Analgesia 2014; 118:909-11 
  • Antihyperlipidemic agents (non-statins such as Locholest, Prevalite, Questran, WelChol, Colestid, Nexletol) due to risk of rhabdomyolysis and gastrointestinal obstruction. 
  • Diabetic medications: perioperative blood glucose monitoring should be done. The Diabetes Control and Complications Trial (DCCT) showed that intensive glycemic control could reduce the microvascular complications of type 1 diabetes mellitus. Subsequent studies showed that macrovascular and microvascular complications could be substantially reduced with tight control of glucose levels, blood pressure, and lipid levels in adults with type 2 diabetes.
    • Oral hypoglycemic agents: discontinue 12-72 hrs before surgery depending upon the half-life of the drug and risk of hypoglycemia.
    • SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin): stop 3 days before surgery (ertugliflozin 4 days) per FDA guidance, for the risk of euglycemic ketoacidosis.
    • Short-acting insulin: withhold morning of surgery.
    • Intermediate-acting insulin: reduce dose, typically one-half of usual dose.
    • Long-acting insulin: continue at previous dose or reduce dose by two-thirds.
• Drugs to continue perioperatively
  • Celebrex can be continued as it’s a selective COX-2 inhibitor.
  • Anti-Parkinson: continue medication regimen throughout the perioperative period.
  • Neuro/psych: continue medication regimen throughout perioperative except with MAO inhibitors (can cause hemodynamic instability or neurologic symptoms), should be stopped 2-3 weeks before surgery based on ordering physician’s recommendation.
  • Anti-viral: continue medicines but discuss in preoperative evaluation
  • Thyroid replacement 
  • Corticosteroid therapy: add intraoperative stress dosing if daily dose is > 5 mg/day currently or if a course was taken within the previous 6 months
  • Cardiac: antihypertensives, antianginal, antiarrhythmic, beta-blockers, and calcium channel blockers
  • Inhalers: beta-agonist, anticholinergics, and steroid inhalers
  • Anticonvulsants: continue medication regimen unless planned neuromonitoring or neuromapping are to take place in surgery
  • Statins: not only have long-term primary prevention of cardiac events but there is evidence to suggest that preoperatively starting statins an average of 30 days prior to surgery help prevent cardiac events during surgery.  Another study demonstrated these drugs significantly reduce acute kidney injury from surgery.
  • Digoxin: usually continued up to day of surgery
  • Opioid agonists: continue chronic opioid regimen throughout the perioperative period
• Questionable - these should be discussed in preoperative eval and with the ordering physician
  • Alpha 2 agonists: clonidine (may need decreased dose; do not completely stop suddenly) 
  • ACE inhibitors and angiotensin II receptor blockers.
  • Naltrexone: hold PO dose one week and IM 4 weeks prior to surgery. Coordination of perioperative pain management should take place between the surgeon, primary care physician, and anesthesia provider
  • Agonist, partial agonist, and antagonist: coordination of perioperative pain management should take place between the surgeon, primary care physician, and anesthesia provider
  • Selective estrogen receptor modulators (tamoxifen; raloxifene, used for osteoporosis): may increase risk of deep vein thrombosis
  • Data has not been clear whether bridging anticoagulation is necessary for patients with atrial fibrillation who need an interruption in warfarin treatment for an elective operation or other elective invasive procedure. 
  • Anticoagulant bridging therapy is required for a patient who has had a mitral valve replacement, two or more mechanical valves, an older-generation (non-bileaflet) aortic valve replacement, or a bileaflet aortic valve replacement with other risk factors. Bridging is also required if the patient has “nonvalvular” atrial fibrillation with a prior stroke or embolic event, cardiac thrombus or a venous thromboembolism within the previous 3 months or has severe thrombophilia.
    • No bridging therapy required if the patient has had an aortic valve replacement, bileaflet prosthesis, no stroke or embolic event with “nonvalvular” atrial fibrillation or history of venous thromboembolism is > 3 months.