Medication changes before surgery
Before surgery there are medications that should be stopped and others that can be continued. Ask your specialist or GP or SHLS staff if you ave any questions!
TProtocol: Medications to avoid in the perioperative period
A. Medications associated with bleeding risk
1. NSAIDs
a. Short-acting agents: Stop 1 day before surgery
i. Diclofenac (Voltaren)
ii. Ibuprofen (Motrin)
iii. Indomethacin (Indocin)
iv. Ketoprofen (Orudis)
b. Mid-acting agents: Stop 3 days before surgery
i. Diflunisal (Dolobid)
ii. Naproxen (Naprosyn)
iii. Sulindac (Clinoril)
c. Long-acting agents: Stop 10 days before surgery
i. Meloxicam (Mobic)
ii. Nabumetone (Relafen)
iii. Piroxicam (Feldene)
2. COX2 Inhibitors (e.g. Celebrex)
a. Stop at least 2 days before surgery (Nephrotoxicity Risk)
B. Antiplatelet Agents: P2Y agents – Clopidogrel (Plavix), Brillanta (Ticagrelor), Effient (Prasugrel) Savaysa: edoxaban
a. Do not stop antiplatelet agents without carefully reviewing indications and minimum duration from stenting, Ask the team if not sure!!
b. Cardiology should be consulted before stopping P2Y agents (Clopidogrel (Plavix), Brillanta (Ticagrelor), Effient (Prasugrel)
in post-stenting patients
i. Consider continuing Aspirin while holding the second antiplatelet agent
c. Clopidogrel (Plavix), Brillanta (Ticagrelor)
i. Stop at least 5 days before surgery if no contraindication to stopping
d. Effient (Prasugrel)
i. Stop at least 7 days before surgery if no contraindication to stopping
e. Restart 24 hours after procedure or per surgeons discretion
2. Aspirin Continue Aspirin FOR CAGS ONLY OPERATIONS
a. Stop at least 5 days before surgery if no contraindication to stopping
b. Continue Aspirin FOR CAGS ONLY and consider continuing for:
i. Patients with high thrombosis risk (e.g. recent Myocardial Infarction)
ii. Minor procedures: Dental, dermatologic and Cataract surgery
iii. Consider stopping before Colonoscopy (especially if polypectomy is performed)
3. Other antiplatelet agents
a. Cilostazol (Pletal)
i. Stop at least 3 days before surgery
b. Ticlopidine (Ticlid)
i. Stop at least 5 days before surgery
c. Aspirin and Extended-Release Dipyridamole (Aggrenox)
i. Stop at least 7 days before surgery
4. Warfarin (Coumadin)
a. Stop 5 days before surgery unless directed to continue
b. If there has been a previous stroke discuss with your surgeon cover with other medication
c. Restart 12 hours after procedure or per surgeons discretion
5. Dabigatran (Pradaxa)
a. Consider doubling days of cessation prior to surgeries with high risk of bleeding
b. Creatinine Clearance >50 ml/min: Stop 2 days before surgery
c. Creatinine Clearance <50 ml/min: Stop 5 days before surgery
d. Restart 24 hours after surgery (72 hours after surgery if high bleeding risk)
6. Rivaroxaban (Xarelto)
a. Stop at least 2-3 days before procedure (longer if Chronic Kidney Disease or very high risk of bleeding)
b. Restart 24 hours after surgery (72 hours after surgery if high bleeding risk)
7. Apixaban (Eliquis)
a. Stop at least 2-3 days before procedure (longer if Chronic Kidney Disease or very high risk of bleeding)
b. Restart 24 hours after surgery (72 hours after surgery if high bleeding risk)
Diabetes Mellitus
1. See Perioperative Diabetes Management (includes Insulin management)
2. Oral Hypoglycemics
a. Hold for NPO period as well as the AM of surgery
3. SGLT2 Inhibitors (e.g. Jardiance)
a. Hold for at least 24 hours prior to surgery (risk of Ketoacidosis)
4. Metformin (Glucophage)
a. Hold at least 24 hours prior to surgery (due to theoretical Lactic Acidosis risk)
D. Antihypertensives
1. Diuretics
2. Consider holding Calcium Channel Blockers while NPO
3. ACE Inhibitors and Angiotensin Receptor Blockers (hold one dose before surgery)
a. Avoiding within 11 hours, reduces risk of immediate post-induction Hypotension
b. Comfere (2005) Anesth Analg 100:636-44 [PubMed]
E.
F. Thromboembolism risk
1. Estrogen Replacement, Birth Control Pills
a. Ideal to stop at least 1 month before surgery
b. Weigh risk versus benefit
c. If agent continued, consider DVT Prophylaxis measures
2. SERMs (Tamoxifen, Raloxifene)
a. Stop at least 1 week before procedures at high risk for Thromboembolism
b. Tamoxifen should only be stopped on Consultation with patient’s oncologist
G. Parkinsonism Agents
1. MAO inhibitors should be tapered off 2-3 weeks before the procedure
a. Includes Selegiline and Rasagiline
b. Risk of interaction with perioperative Meperidine, Dextromethorphan, Ephedrine, Opioids
2. Avoid stopping Sinemet in perioperative procedure (risk of Parkinsonian hyperpyrexia syndrome)
3. Stay moving in the post-operative period (within 2-3 days of procedure – incorporate PT/OT)
H. Miscellaneous agents
1. Alendronate (Fosamax)
a. Stop at time of surgery due to instructions that are difficult to follow perioperatively (e.g. NPO)
I. DMARDs and TNF Agents
1. Stopping before orthopedic procedures (esp. TNF agents) lowers the risk of Surgical Site Infections
2. Agents are stopped 1-2 weeks before procedure and resumed 1-2 weeks after surgery
a. Consult with orthopedics and rheumatology regarding specific medications and patient risk factors
3. den Broeder (2007) J Rheumatol 34(4):689-95 [PubMed]
J. Herbal preparations
1. Stop all Herbals and supplements at least one week before surgery
a. Safest overall strategy due to numerous combination products
2. Specific agents with known risk in the perioperative period
a. Echinacea
b. Ephedra (should be avoided in general)
c. Garlic (discontinue at least 7 days before surgery)
d. Gingko (discontinue at least 36 hours before surgery)
e. Ginseng (discontinue at least 7 days before surgery)
f. Kava (discontinue at least 24 hours before surgery)
g. St. John’s Wort (stop at least 5 days before surgery)
h. Valerian (slowly taper off before surgery)
i. Ang-Lee (2001) JAMA 286:208-16 [PubMed]