Perioperative Medication Management
Perioperative Medication Management
Perioperative Medication Management
DEPARTMENT OF ANESTHESIOLOGY
Preoperative Medication Management Guidelines
Purpose: To provide recommendations regarding medication management for patients in the preoperative setting.
The following medications SHOULD BE CONTINUED up to and including the day of surgery
(Instruct patients to take with a small sip of water):
1. Alzheimer’s medications
3A. Other Anti-Hypertensive Agents and Cardiac Medications. (e.g. hydralazine, nitrates, calcium channel blockers,
digoxin, alpha antagonists)
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FMLH Preoperative Medication Management Guidelines
The following medications SHOULD BE CONTINUED up to and including the day of surgery
(Instruct patients to take with a small sip of water):
4. Anti-seizure medications
6. Asthma medications (inhalers and nebulizers please USE on the morning prior to arrival)
8. COX-2 inhibitors (check with surgeon if there is concern about new bone growth/healing)
9. Eye drops
10. Heartburn or anti-reflux medications [e.g. esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole
(Prilosec), ranitidine (Zantac)]
11. Immunosuppressants and Rheumatologic medications [e.g. allopurinol, azathioprine, cyclosporine, tacrolimus
(Prograf), sirolimus (Rapamune), methotrexate, infliximab (Remicade), adalimumab (Humira), etanercept (Enbrel)] -
Do not stop any immunosuppressant medications without speaking with the prescribing physician. Patients with
organ transplants should be continued on immunosuppressants. Patients taking these medications for other
diseases (i.e. rheumatoid arthritis, crohn's) may have them discontinued perioperatively only AFTER a discussion of
risks/benefits between the surgeon and the prescribing physician has taken place.
12. Opioids (e.g. morphine (e.g. MS Contin), oxycodone (e.g. Oxycontin), fentanyl patch)
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FMLH Preoperative Medication Management Guidelines
1. ACE inhibitors (angiotensin converting enzyme inhibitors, anything ending in -pril) – hold on day of surgery
(EXCEPTION—patients going for Stage 1 DBS should CONTINUE ACE inhibitors)
2. ARBs (angiotensin II receptor blockers, anything ending in -artan) – hold on day of surgery
(EXCEPTION—patients going for Stage 1 DBS should CONTINUE ARBs)
3. Direct Renin Inhibitor, Aliskiren (Tekturna, Tekturna HCT, Amturnide, Tekamlo) – Hold on day of surgery.
5. Antiplatelet agents [e.g. clopidogrel (Plavix), ticlopidine (Ticlid), prasugrel (Effient), ticagrelor (Brilinta)] – Please
refer to FMLH Algorithm for Management of Perioperative Antiplatelet Therapy. Discuss with prescribing physician.
Aspirin-See SPECIAL SITUATIONS at the end of the document. If patient does not have cardiac or carotid stents, stop
7 days prior to surgery.
6. Warfarin (Coumadin) – If normal coagulation is required, discontinue 5 days before surgery – will need to check
PT and PT/INR preoperatively. Discuss with prescribing physician and consider bridging therapy.
7. Dabigatran (Pradaxa) – Length to hold depends on renal function and risk of bleeding. If possible, discontinue 1
to 2 days (CrCl ≥ 50 mL/min) or 3 to 5 days (CrCl <50 mL/min) before invasive or surgical procedures because of the
increased risk of bleeding. Consider longer times for patients undergoing major surgery, spinal puncture, or
placement of a spinal or epidural catheter or port, in whom complete hemostasis may be required. Discuss with
prescribing physician and consider bridging therapy.
8. Rivaroxaban (Xarelto) – Hold minimum 24 hours prior to surgical procedure. Discuss with prescribing physician
and consider bridging therapy.
9. Apixaban (Eliquis) – Discontinue at least 48 hours prior to elective surgery or invasive procedures with
moderate or high risk of unacceptable bleeding; discontinue at least 24 hours prior to elective surgery or invasive
procedures with low risk of bleeding or where bleeding would be non-critical or easily controlled. Discuss with
prescribing physician and consider bridging therapy.
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FMLH Preoperative Medication Management Guidelines
10. Heparin, Low molecular weight heparins [e.g. dalteparin (Fragmin), enoxaparin (Lovenox)] – Patients receiving
either UFH or LMWH should have their doses held for 12 hours preoperatively if prophylactic dosing and 24 hours if
therapeutic dosing.
12. Herbal supplements and Vitamin E-containing multivitamins– Discontinue 7 days prior to surgery.
14. Insulin – Please refer to FMLH protocol for insulin management (see below). Order finger stick on arrival on day
of surgery. Please note that if the surgical start time is delayed, the anesthesiologist assigned to the case needs to
be contacted regarding blood sugar monitoring and IV placement.
Patient with insulin pumps should continue their basal rate ONLY.
18. Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra) – Hold 24 hours preoperatively.
19. MAO inhibitors – Patient may need special instructions – consider Anesthesiology Consultation preoperatively
See table on following page for MAO inhibitor medications and alternative medicines
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FMLH Preoperative Medication Management Guidelines
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FMLH Preoperative Medication Management Guidelines
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