Preoperative medication management
Patients often have a long list of medications they take, and decisions must be made about whether to continue or hold them prior to surgery.
Cardiovascular
Beta blockers
Continue if taking chronically
- Reduces coronary ischemia
- Acute withdrawal of chronic beta blocker associated with increased morbidity/mortality
ACE inhibitors/Angiotensin receptor blockers (ARB)
Discontinue morning of surgery. However, could consider continuing for certain cardiac procedures on patient-by-patient basis
- Inhibition of RAAS leads to refractory intraoperative hypotension
- For most surgeries, appears to be no increase in mortality or cardiovascular events from holding ACE/ARB
- However, some studies suggest myocardial protection in CABG
Diuretics
Discontinue morning of surgery if taking for hypertension and euvolemic
Continue if unstable volume status or history of poorly controlled heart failure
- Theoretical risk of worsened hypotension due to intravascular depletion, though limited studies showing this in practice
- Theoretical risk of hypokalemia, though this has not been observed in practice
Calcium channel blockers
Continue
- Limited data showing neither benefit nor harm with continuation
Alpha 2 agonists (e.g. clonidine)
Continue if taking chronically
- Prevent rebound hypertension
Digoxin
Continue
- Limited data, though no evidence of adverse effects from continuation
Statins
Continue
- Shown to prevent vascular events perioperatively
Hematologic
Anticoagulation (e.g. warfarin, DOAC)
Case-by-case basis balancing increased risk of intraoperative blood loss with prevention of thromboembolic complication
- AC should be continued if:
- risk factors of recent stroke, MI, atrial fibrillation, or prosthetic heart valve are present
- AC should be discontinued if:
- anticipated high surgical blood loss (e.g. CABG)
- procedure lasting longer than 45 min
- there is heavy consequence of bleeding (e.g. neurosurgical procedure)
- Timing of discontinuation:
- Discontinue warfarin 5 days before surgery (with PT/INR day of surgery) with consideration for heparin bridging
- Discontinue DOAC 1-2 days before surgery depending on bleeding risk
Antiplatelet (e.g. aspirin, clopidogrel)
Case-by-case basis balancing increased risk of intraoperative blood loss with prevention of thromboembolic complication
- DAPT should be continued if:
- recent stent or bypass procedures, given high likelihood of stenosis
- non-cardiac procedure
- DAPT should be discontinued if:
- there is heavy consequence of bleeding (e.g. neurosurgical procedure)
Ideally, a decision is facilitated by surgeon and cardiologist discussion.
Nonsteroidal antiinflammatory drugs (NSAID)
Discontinue 24 hr prior to surgery
- Increased risk of perioperative bleeding
- Could consider continuing if patient's pain control outweighs risk of surgical bleeding
Endocrine (Diabetes)
DPP-4 inhibitors (e.g. sitagliptin)
Continue
- No risk for hypoglycemia, though increased risk of gastric motility changes with continuation
Insulin
Continue basal (long-acting) insulin and discontinue mealtime insulin, but assess on patient-by-patient basis
- Discontinuing insulin increases risk of DKA, particularly in type 1 diabetics
- Continuing insulin increases risk for hypoglycemia, particularly when NPO
- Insulin pumps should remain on basal rate as well
- For long and/or complex surgeries, intraoperative glucose management may include IV insulin and dextrose infusions
Meglitinides (e.g. repaglinide)
Discontinue day of surgery
- Increased risk of hypoglycemia
Metformin
Discontinue day of surgery
- Increased risk of lactic acidosis
GLP-1 agonists (e.g. dulaglutide)
Continue
- No risk for hypoglycemia, though increased risk of gastric motility changes with continuation
SGLT2 inhibitors
Discontinue 3-4 days before surgery
- Increased risk of hypovolemia, AKI, and postoperative euglycemic DKA (elevated ketones, normal glucose)
Sulfonylureas (e.g. glipizide)
Discontinue day of surgery
- Increased risk of hypoglycemia
Thiazolidinediones (e.g. rosiglitazone)
Discontinue day of surgery
- Increased risk of hypervolemia (CHF, peripheral edema)
Endocrine (Non-diabetes)
Glucocorticoids
Continue, but consider stress dosing for patients on high-dose steroids or surgeries of long duration:
- Stress dosing is indicated if daily dose (>3 weeks) is at least:
- Dexamethasone 2 mg
- Hydrocortisone 80 mg
- Methylprednisolone 16 mg
- Prednisone 20 mg
- No stress dose is indicated if daily less less than:
- Any dose of steroid taken for less than 3 weeks
- Dexamethasone 0.5 mg
- Hydrocortisone 20 mg
- Methylprednisolone 4 mg
- Prednisone 5 mg
- For intermediate range, defer to patient history and HPA axis evaluation
If stress dose is indicated, hydrocortisone 300 mg/day (or equivalent) is common practice
Note: Avoid etomidate as an induction agent due to increased risk of adrenal crisis
Levothyroxine
Continue
- To maintain euthyroid state
- Can be given IM/IV at 80% dose if necessary
Methimazole/Propylthiouracil (PTU)
Continue
- To maintain euthryoid state
Oral contraceptives (OCP)
Continue unless patient is has high risk of venous thromboembolism (VTE), in which case stop 4 weeks before surgery
- If continued, requires perioperative VTE prophylaxis
Selective estrogen receptor modulators (SERM)
Continue
- Should be taken with VTE prophylaxis to offset increased VTE risk
Bisphosphonates
Discontinue day of surgery
- Unable to be taken as recommended (with >8 oz water) due to NPO status
Pulmonary
Beta agonists
Continue
- Significant reduction in COPD/asthma complications
Anticholinergics
Continue
- Significant reduction in COPD/asthma complications
Glucocorticoids (inhaled)
Continue
- Avoids risk of adrenal insufficiency, particularly during stress of surgery
- Inhaled dosage relatively low and unlikely to cause adverse events
Gastrointestinal (GI)
H2 blockers/Proton pump inhibitors (PPI)
Continue
- Very safe intraoperatively
- Prevents stress ulcers
- Prevents gastric aspiration/chemical pneumonitis