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.

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