Stopping medications preoperatively in some patients

This topic will discuss strategies of stopping medications preoperatively in some patients...
Abdelwahab Ward, BS Pharm, PharmD

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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Abdelwahab Ward, BS Pharm, PharmD