Drugs to hold for at least 2 weeks preoperatively
Aspirin: Hold for a minimum of 1 week; consider 2 weeks for neuro/spine surgery
Warning: Must evaluate whether patient has received a cardiac stent (see Chap. 7). Note that some surgeons are comfortable continuing aspirin for certain procedures; communicate with surgeon if desirable to continue aspirin in light of newer data
MAO inhibitors (see Chap. 26 for Parkinson’s disease management, e.g., selegiline, rasagiline)
Oral central alpha agonists (e.g., methyldopa)
See “Discussion” for clonidine (if necessary to continue; advise converting this to transdermal form)
Supplements (e.g., fish oil, garlic, gingko, ginseng, ephedra, oral vitamin E)
Consider holding
Oral contraceptive pills (OCPs) (see “Discussion”)
Selective estrogen receptor modulators (SERMS) (see “Discussion”)
Menopausal hormone therapy (MHT) (see “Discussion”)
SSRIs in orthopedic patients (see “Discussion”)
Antirheumatic agents (see Chap. 35)
Drugs to hold for 4–5 days preoperatively
P2Y12 receptor blockers (clopidogrel, prasugrel, ticagrelor): Hold for a minimum of 5 days. Warning: Must evaluate whether patient has received a cardiac stent (see Chap. 7)
NSAIDs, selective COX-2 inhibitors (generally hold 4–5 half-lives; depending on the NSAID, this may be more or less than 4–5 days. See “Discussion”)
Dipyridamole (Persantine®). If combined with aspirin (Aggrenox®), see above
Cilostazol, hold for 5 days
Anticoagulants (e.g., warfarin, factor Xa inhibitors, low-molecular-weight heparin, direct thrombin inhibitor (see Chap. 18 and consult anticoagulation clinic if available)
Drugs to hold on the morning of surgery
Prandial insulin (see Chap. 13)
Non-insulin diabetes medications (including injectable hypoglycemic agents (e.g., exenatide) and oral hypoglycemic agents)
Niacin, gemfibrozil, cholestyramine, and colestipol
Stimulant medications (e.g., methylphenidate)
Diuretics (see “Discussion”)
ACE-I/ARBs (see “Discussion”)
Dopamine agonists used for Parkinson’s Disease (e.g., bromocriptine, pramipexole, ropinirole); see Chap. 26)
Drugs to give on the morning of surgery. Meds should be taken with a small sip of water only
Most cardiac meds (antiarrhythmics, digoxin, nitrates, beta-blockers)
Certain antihypertensive medications; see “Discussion” on calcium channel blockers
Pulmonary medications (e.g., inhalers, nebulizers, oral leukotriene inhibitors, pulmonary hypertension agents)
Endocrine medications (including thyroid meds and corticosteroids; may need stress dosing—see Chap. 14)
Most GI medications (e.g., H2 blockers, PPIs)
Most psychoactive meds (except MAOIs and stimulants); see “Discussion” on SSRIs
Statins (if taken in the morning)
Seizure medications
Gabapentin/pregabalin
Baclofen (oral and intrathecal) to avoid withdrawal
Eye drops
Narcotics (coordinate with anesthesia and primary team)
Transdermal medications
Transplant medications (see Chap. 42)
Immunosuppressives
Antiretrovirals (check with pharmacist and HIV provider regarding possible drug–anesthesia interactions)
Postoperative
Resume usual outpatient medications as tolerated by patient’s ability to take oral medications and current and expected medical indication, with certain exceptions (such as diabetes medications if the patient is not eating—see Chap. 13). Always discuss with the surgeon when restarting antiplatelet agents and anticoagulants (see Chaps. 7 and 18), including nonsteroidal anti-inflammatory drugs (NSAIDs).
Most cardiovascular medications should be continued postoperatively. However, a patient’s blood pressure often falls postoperatively (especially if the patient has an epidural), so we suggest writing holding parameters for all vasoactive medications. Dose reduction is frequently necessary for the first 2–3 days. Sequentially add back each vasoactive medication as blood pressure permits.
Following some surgeries, particularly those involving major manipulation of the gastrointestinal tract, the administration of oral medications might be temporarily prohibited. For essential medications, consider using alternate formulations such as intravenous, transdermal, or per rectum if available. In other cases, e.g., after gastric bypass surgery, esophagectomy, or with feeding tubes, medications may need to be crushed for administration. Keep in mind that extended-release formulations cannot be crushed, necessitating a substitution with shorter-acting equivalents. We advise reviewing the medication list with a pharmacist and the surgical team to ensure that appropriate adjustments are made.
See Table 4.2 for recommendations on restarting common outpatient medications.
Table 4.2
Postoperative medication management
Drugs to restart as soon as clinically possible | Beta-blockers |
Antiarrhythmics | |
Statins | |
Nebulizers and inhalers | |
Corticosteroids (discuss with surgical team as needed and see Chap. 14) and thyroid meds
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