Cardiovascular and Hypertensive Medication
GI agents
Pulmonary
Endocrine
Hormone Medications
Medications Affecting Homeostasis
Psychiatric Medications
Chronic Opioid Therapy
Neurological Medications
Rheumatologic Medications
Gout Medications
Immunosuppressants for transplant
Hematology and Oncology Medications
Parathyroid Hormone Analogs
PDE Inhibitors (i.e. sildenafil)
Herbal Medications
Resources

Peri-Operative Medication Management

Cardiovascular and Hypertensive Medication

Beta Blockers- continue through surgery
Alpha 2 Blockers (clonidine)- continue through surgery
Calcium Channel Blockers- continue through surgery
Diuretics
- HCTZ for hypertension- hold day of surgery
- Furosemide, Bumentanide and other loop diurectics and spironolactone for CHF- take day of surgery ONLY if EF<40% on recent Echo, hold day of surgery if EF>40%
ACE/ARB and renin inhibitor (aliskiren/Tekturna)- hold day of surgery
Non statin lipid agents, niacin, fibric acid agents (gemfibrozil, fenofibrate) and ezetimibe (zetia)- stop day prior to surgery
Statins- continue through surgery
Repatha (evolocumab)- continue through surgery
Ranexa (ranolazine)- can take day of surgery

GI agents

H2 Blockers and PPIs- continue through surgery

Pulmonary

Metered dose inhalers- continue through surgery
Theophylline- stop the night before surgery
Leukotriene inhibitors (zileuton, zafirlukast, montelukast)- continue through surgery

Endocrine

Glucocorticoids

Patients taking glucocorticoids < 3 weeks or daily dose prednisone equivalent < 5mg or taking chronic every other day therapy are unlikely to need stress doses, continue usual meds through surgery
Patient with daily dose > 5mg or treated with > 5mg/day for > 3 weeks in the past year need stress dosing.

Diabetic Medications

Hold sulfonylureas, metformin and other oral agents on day of surgery (if risk of hypotension or need IV contrast, hold metformin for 48 hours).
SGL T2 Inhibitors (dapagliflozin, empagliflozin, ertugliflozin) – hold for 3 days prior to surgery (5 days for bariatric surgery)
Evening prior to surgery
- BG > 120—give usual dose of long-acting PM insulin (Lantus, Detemir, NPH)
- BG < 120—give 50% of usual dose of long-acting PM insulin (Lantus, Detemir, NPH)
- Give bedtime sliding scale correction of short-acting insulin ONLY if BG>150 at bedtime
Day of Surgery
- Give 50% dose of AM long-acting insulin (Lantus, Detemir, NPH) on the day of surgery
- Mixed dosage insulin (70/30, 75/25) severely reduce or avoid all together AM of surgery
Insulin Pump—continue basal rate
- U500-hold for surgery and cover with short acting insulin, resume post op (in hospital) at 50% of previous dose. If used in hospital, use U500 pen to avoid dose problems
The following meds are ok for surgery-won’t cause hypoglycemia BUT hold for GI surgery if ileus expected or may cause nausea and vomiting. Ok to hold also.
- GLP-1 receptor Agonist
  - Exenatide (Bydrueon, Byetta), Lixisenatide (Aldyxin), Liraglutide (Victoza), Abliglutide (Tanzeum), Dulaglutide (Trulicity), Glargine-Lixisenatide(Soliqua), Degludec-liraglutide(Xultophy)
- Dipeptidyl Peptidase-4 Inhibitors
  - Sitagliptin (Januvia), Saxagliptin (Ongliza), Linagliptin (Tradjenta), Alogliptin (Nesina)

Hormone Medications

Oral Contraceptives
- Low risk surgery for VTE can continue
- Intermediate risk or high risk procedures consider stopping 4-6 weeks prior to surgery (will need alternative contraceptive and pre surgery pregnancy test)
Post-Menopausal Hormone Therapy
- Low risk procedure for VTE can continue treatment
- Intermediate and high risk procedures can consider stopping 4-6 weeks prior to surgery
Thyroid Medication-continue to take

Medications Affecting Homeostasis

Antiplatelet Agents

Patient at high risk for CV event and low risk for complications if bleeding occurs—continue ASA (call surgeon if any questions)
Stop ASA 7 days prior to surgery where bleeding would be catastrophic (e.g. intracranial, spinal, urological procedures) or where patient is low risk for CV event
Avoid stopping dual antiplatelet therapy for Percutaneous Transluminal Coronary Angioplasty < 2 weeks, Bare Metal Stent < 3 months, Drug-Eluting Stent(DES) < 12 months. After this time continue ASA 81 mg and stop other agent. Current recommendations 2018 from ACC state SOME patients may stop dual antiplatelet therapy at 6 months if needed. Need to discuss with cardiology if considering stopping before one year of DES.
Stop Plavix(clopidogrel) x 7 days
Stop Effient(prasugrel) x 7 days
Stop Brilinta(ticagrelor) x 5 days

Other Antiplatelet Agents

Stop cilostazol(Pletal) x 5 days
Stop dipyridamole x 2 days
Stop Aggrenox (aspirin/dipyridamole) x 7 days

NSAID

Stop 7 days prior to surgery.
Celebrex (celecoxib), if needed can consider to continue through surgery as little effect on platelets (elevated CV mortality)

Anticoagulation

Follow anticoagulation bridging protocol if prescribed by surgeon, PCP or anticoagulation clinic.
Coumadin (warfarin)
- INR > 3.0 STOP > to 6 days prior to surgery
- INR 2.0 to 3.0 STOP 5 days prior to surgery
- If any question, order preop PT/INR
Dabigatran
- CRCL > 50 ml/min stop 2 days prior to surgery
- CRCL < 50 ml/min stop 3 to 5 days prior to surgery
Rivaroxaban and apixaban—stop 2 days prior to surgery, only 1/3 renal cleared—consider additional time for severe renal disease
SPINAL OR EPIDURAL ANESTHESIA—hold Factor Xa inhibitors or Direct Thrombin Inhibitor 72 hours minimum before procedure.

Psychiatric Medications

TCA—continue through surgery
SSRIs—may affect platelet function, generally continue
Lithium and Valproate—continue through surgery
Antipsychotics—may increase QT, especially with volatile anesthetics, continue with care for volatile anesthetics and antibiotics
Psychostimulants—for ADHD- hold on day of surgery
Antianxiety Agents—continue through surgery
MAO-Is - hold 2 weeks prior to surgery
Muscle relaxants including baclofen and cyclobenzaprine (Flexeril)-continue throughout surgery.
Phentermine-used for weight loss. Stop 7 days before surgery
Phendimetrazine-Stop 7 days before surgery

Chronic Opioid Therapy

Continue through surgery
For patients on high dose narcotics, consider Pain Management consultation for management postoperatively
Suboxone (buprenorphine/naloxone)—hold greater than or equal to 5 days prior. DO NOT resume until 2-3 days after patient’s last opioid dose. Send pts to providers that are prescribers for instructions on hold/not hold
Contrave (naltrexone/bupropion)-Stop 72 hours before surgery
Disulfiram (Antabuse)
- Stop 10 days before surgery
- May decrease effectiveness of analgesics/sedatives
Buprenorphine—Hold 24 hours prior to surgery
Naltrexone—Hold for 3 days for opioid addiction. Hold for 5 days for other dx, i.e. weight loss

Neurological Medications

Seizure medication—continue through surgery
Muscle relaxants-see under psych meds. Continue throughout surgery
Antiparkinson Medication
- For Deep Brain Stimulator and Parkinson Meds
  - Oral medications should be stopped by 6pm the night before Stage 1(lead implantation) of the procedure.
  - Extended release tablets should be stopped 24 hours prior to Stage 1 of the procedure.
  - Patches should be removed 72 hours prior to Stage 1 of the procedure.
  - For Stage 2 of the procedure, patients can continue their Parkinson medications as prescribed.
  - If DBS is being done as a Stage 1 procedure under general anesthesia, patients can take all usual Parkinson medications like normal up to and including the day of surgery.
- Sinemet (levodopa/carbidopa)and Dopamine agonist—continue through surgery if patient will be taking oral meds. If expected period NPO (greater than or equal to several days) decrease dose by half the week prior to surgery to avoid Parkinsonism Hyperpyrexia Syndrome.
- If patient is on a transdermal patch for Parkinson’s/dystonia (e.g. Neupro), apply according to schedule to avoid post-op rigidity but apply out of surgical field
MAOB-hold two weeks prior to surgery
Myasthenia Gravis
- Pyridostigmine-continue as ordered, give day of surgery

Rheumatologic Medications

Non-biologic DMARDS

Sulfasalazine, azathioprine, mycophenolate (Cellcept), cyclophosphamide—consider holding one week prior to surgery due to neutropenia
Methotrexate, hydroxychloroquine, leflunomide—continue through surgery
Nonacetylated NSAIDs (i.e. salsalate) have no effect on platelets and can continue through surgery

Biologic DMARDS

Best to discuss with Rheumatology and/or Surgeon for guidance of management in the Perioperative period.
Hold for 2-3 half-lives before surgery—restart with wound closure ~ 2 weeks after surgery. Consult with rheumatology if any questions about medication management.

TNF Blockers

Etanercept (Enbrel)—t ½ 3.5-5.5d, hold 7-10 days prior to surgery
Apremilast (Otezla)—
Infliximab (Remicade)—t ½ 9.5d, hold 3 weeks prior to surgery
Adalimumab (Humira)—t ½ 10-20d, hold 4 weeks prior to surgery
Certolizumab (Cimzia)—t ½ 14d, hold 4 weeks prior to surgery
Golimumab (Simponi)—t ½ 14d, hold 4 weeks prior to surgery

PDE-4 Inhibitor

Apremilast (Otezla) - t ½ 6-9 hrs, hold 3 days prior and resume when stitches are out

T cell costimulator

Abatacept (Orencia)—t ½ 13d, hold 4 weeks prior to surgery

Interleukins antagonist

Tocilizumab (Actemra)—t ½ 11-13d, hold 3 weeks prior to surgery
Anakinra (Kineret)—t ½ 4-6 hrs, hold 1 day prior to surgery

B cell depleting agent and other biological modifiers

Rituximab (Rituxan)—t ½ 18 d, hold 4 weeks prior to surgery
Tofacitinib (Xeljanz)— t ½ 3-8 hrs, hold 5-7 d prior and resume 5-7 d post-op if ok
Belimumab (Benlysta)— t ½ 18.3-19.4 days, hold 3 wks prior to surgery and about 10-14 d after surgery
Alirocumab (Praluent)— t ½ 17-20 days, not immune modulating, do not need to stop for surgery
Secukinumab (Cosentyx)— t ½ 22-31 days, hold 4 wks prior to surgery and about 10-14 d after surgery
Upadacitinib (Rinvoq)- t ½ 8-14hrs, ok to continue through surgery for low-risk procedure (per Dr. Knibbe)

Gout Medications

Hold colchicine, allopurinol and probenecid on day of surgery

Immunosuppressants for transplant

Continue through surgery
If patient is on an mTOR inhibitor (sirolimus or everolimus), recommend discussion with nephrology prior to surgery as these can cause post-op wound healing issues, seromas and lymphoceles.

Hematology and Oncology Medications

Best to discuss IN ADVANCE OF SURGERY with Hematologist and surgeon for guidance during perioperative period.
Palbociclib (Ibrance)– can cause neutropenia, dosed 3 weeks on/1 week off to allow ANC to recover. May need to be held before surgery and up to 1 week after to allow for healing but needs to be discussed with oncologist MUCH PRIOR to surgery to coordinate
Anastrozole (Arimidex), tamoxifen, letrozole, exemestane (Aromasin)– hold 1 day prior to surgery and day of surgery due to risk for clotting. Should be held up to 1 week after surgery depending on mobility

Parathyroid Hormone Analogs

Teriparatide (Forteo) and other similar osteoporosis agents are ok to continue through surgery.

PDE Inhibitors (i.e. sildenafil)

If for ED, hold for 24 hrs prior to surgery. Continue if for pulmonary HTN.

Herbal Medications

CBD oil should also be held for 1 week prior to surgery.
Stop ALL herbal supplements for 1 week prior to surgery.

Resources

Anestheia Associates of Boise Recommendations

preop

Table of Contents

Peri-Operative Medication Management

Cardiovascular and Hypertensive Medication

GI agents

Pulmonary

Endocrine

Glucocorticoids

Diabetic Medications

Hormone Medications

Medications Affecting Homeostasis

Antiplatelet Agents

Other Antiplatelet Agents

NSAID

Anticoagulation

Psychiatric Medications

Chronic Opioid Therapy

Neurological Medications

Rheumatologic Medications

Non-biologic DMARDS

Biologic DMARDS

TNF Blockers

PDE-4 Inhibitor

T cell costimulator

Interleukins antagonist

B cell depleting agent and other biological modifiers

Gout Medications

Immunosuppressants for transplant

Hematology and Oncology Medications

Parathyroid Hormone Analogs

PDE Inhibitors (i.e. sildenafil)

Herbal Medications

Resources