When to Stop Medications Before Surgery: A Practical Guide

Proper medication management before surgery is crucial to ensure patient safety and optimize surgical outcomes. Discontinuation or adjustment of certain medications may be necessary to reduce risks such as bleeding, hemodynamic instability, glucose instability, or interference with anesthesia. Below is a comprehensive guide based on common medication categories.

1. ADHD Medications

• Policy: Hold on the day of surgery.

• Examples: Adderall, Concerta, Ritalin, Vyvanse, Strattera, and Focalin.

• Rationale: These drugs may increase sympathetic activity and interact with anesthesia, potentially leading to cardiovascular instability.

2. Weight-Loss Medications before surgery

• Appetite Suppressants: Hold for one week.

  • Examples: Phentermine, Phendimetrazine.

• GLP-1 Receptor Agonists:

  • Daily medications: Hold the day of surgery.

  • Weekly medications: Hold for one week.

  • Examples: Ozempic, Trulicity, Victoza.

• Rationale: These medications may affect gastric emptying and pose risks of aspiration during induction of anesthesia

3. Anticoagulation Drugs

• Policy: Follow specific instructions from the prescribing physician or your surgeon.

• Examples of Anticoagulation medications before surgery: 

  • Warfarin (Coumadin): Hold for 5 days

  • Xarelto (Rivaroxaban), Eliquis (Apixaban): Hold for 2-3 days

  • Pradaxa (Dabigatran): Hold for 2-3 days

• Rationale: These drugs increase bleeding risk. The timing of discontinuation depends on the medication's half-life and the patient’s thromboembolic risk.

• Reversal Agents: Used in emergency situations to reverse the effect of the drug quickly 

  • Warfarin: Plasma, Vitamin K, 4F PCC

  • Xarelto, Eliquis: Andexxa

  • Pradaxa: Praxbind 

4. Antiplatelet Medications

• Policy: Typically hold for 5 days. However, Aspirin 81mg is safe to continue perioperatively

• Examples: Plavix, Aspirin, Brilinta

• Rationale: These drugs increase bleeding risk. No reversal agents are available

5. ACE Inhibitors

• Policy: Hold on the day of surgery.

• Examples: Lisinopril, Enalapril, Ramipril.

• Rationale: These drugs can cause intraoperative hypotension, especially when combined with anesthesia.

6. Beta Blockers

• Policy: Must be continued perioperatively 

• Examples: Carvedilol, Propranolol, Metoprolol 

• Rationale: Abruptly stopping these medications can increase the risk of cardiac complications preoperatively

5. Phosphodiesterase-5 Inhibitors

• Policy: Hold for 36 hours before surgery.

• Examples: Viagra, Cialis, Levitra.

• Rationale: These medications can interact with anesthesia and lead to severe hypotension.

6. Diabetes Medications:

If you have diabetes, you should start checking your sugars when you wake up and every 4 hours until surgery. If your sugar is less than 70, take a sugar pill or 4 oz of a clear fluid like apple juice or Gatorade. Do not drink Oranje Juice. If medications need to stop more than one day before surgery, contact your diabetes care provider for further instructions. 

• Oral Hypoglycemics: 

  • Daily medications: Metformin, Micronase, Glucotrol. Do not take the morning of surgery. 

  • GLP 1 agonist (Semaglutide, Rybelsus®): Stop 7 days prior to surgery. 

  • SGLT-2 Inhibitor (Canagliflozin, Dapagliflozin, Ertugliflozin): Stop 3 days prior to Surgery

• Injectables: 

  • GLP-1 Inhibitors (Byetta™, Victoza®; Saxenda®, Adlyxin®): Stop 24 hr before surgery

  • GLP-1 Inhibitors (Trulicity™, Ozempic®, Wegovy®, Mounjaro®, Zepbound™):  Stop 7 days prior to surgery

• Insulin:

  • Rapid-acting or short-acting: Hold on the day of surgery.

  • Intermediate-acting: Take half the usual morning dose.

  • Long-acting: Depending on the time of the surgery, take half the usual morning dose the day of the surgery or ½ dose the evening before surgery.

  • Insulin pump: Continue at the same rate for procedures <2 hours; adjust to infusion for longer surgeries.

• Rationale: Prevent hypoglycemia during fasting and avoid complications during surgery. Make sure to contact your diabetes care provider for detailed instructions

7. Naltrexone

• Policy:

  • Oral: Hold for one week.

  • IM injection: Hold for four weeks.

• Rationale: Naltrexone blocks opioid receptors and can interfere with pain management during and after surgery.

General Considerations

• Always consult with the prescribing physician and anesthesiologist for specific recommendations.

• During preoperative evaluation, patients should provide a complete and accurate list of all medications, including over-the-counter and herbal supplements.

• The timing of medication discontinuation should balance the risks of the underlying condition with surgical and anesthetic safety.

By following these guidelines, healthcare providers can reduce complications and ensure a smooth surgical experience for patients.