Stopping medications preoperatively in some patients

One of the most important questions, when to temporarily stop chronic medications before NONcardiac surgery?.. Consider these tips to manage common home medications before surgery...

• Diabetes medications. Stop most non-insulin drugs the morning of surgery. But consider stopping metformin 24 hours pre-operative and SGLT2 inhibitors (empagliflozin, etc) at least 24 hours before surgery to limit the risk of ketoacidosis. Skip short- or rapid-acting insulin while the patient is NPO. But continue at least 50% of a long-acting insulin home dose. See note, "Preoperative management of diabetes medications in hospitalized patients undergoing surgery".
• Antidepressants. Generally, continue antidepressants, abruptly stopping them can lead to withdrawal symptoms.
• Antiplatelet medications. Continue aspirin for most patients at high CV risk unless surgical bleeding risk is very high, such as with intracranial or intraocular surgeries. Consult cardiology and surgery for patients on TWO antiplatelet medications (aspirin plus clopidogrel, etc). If needed, usually stop clopidogrel (Plavix) or ticagrelor (Brilique) 5 days before surgery and prasugrel (Effient) 7 days pre-operative but CONTINUE aspirin.
• Anticoagulants. Stop warfarin about 5 days before most invasive surgeries. And DON'T "bridge" with low-molecular-weight heparin unless thrombosis risk is high, such as venous thromboembolism within 3 months. Stop direct oral anticoagulants (apixaban, etc) at least 1 to 2 days pre-op. OR 3 to 5 days before surgery if neuraxial anesthesia is planned.
• Blood pressure medications. Keep patients on beta-blockers, calcium channel blockers, and clonidine. Consider stopping ACEIs or ARBs up to 24 hours pre-op. in those withOUT heart failure or uncontrolled blood pressure to limit surgical blood pressure drops. And stop diuretics in most patients the day of surgery to minimize electrolyte and fluid imbalances.

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References

1. Guidelines for the management of chronic medication in the perioperative period: systematic review and formal consensus. J Clin Pharm Ther. 2011 Aug;36(4):446-67.
2. Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery: An Analysis of the Vascular events In noncardiac Surgery patIents cOhort evaluatioN Prospective Cohort. hAnesthesiology. 2017 Jan;126(1):16-27.
3. 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation: A Report of the American College of Cardiology Clinical Expert Consensus Document Task Force. J Am Coll Cardiol. 2017 Feb 21;69(7):871-898.

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