Peri-operative medication management Guideline
Version number
Date clinical guideline approved
Ratification
Date Clinical guidelines ratified
Review date
Lead Authors
1
Kirta Patel (SurgiCentre Pharmacist)
Talat Mumtaz (Consultant anaesthetist)
1
Peri-operative medication management Guideline
Many patients presenting for surgery will be on medication for the management of concurrent diseases. The decision to discontinue, or accidentally omit, medication preoperatively can cause exacerbation of the underlying disease or it can precipitate an acute withdrawal syndrome. On the other hand, continuing routine medication perioperatively may have potentially fatal interactions with some anaesthetics used during surgery.
The following is therefore intended as a guide to indicate which drugs should be continued and which drugs should be stopped in the peri-operative period for patients that
will be undergoing all elective surgery. It is NOT a protocol and where there is any doubt about peri-operative medication, advice should be sought from the anaesthetist,
haematologist, cardiologist or a member of the surgical team. Specific instructions given on the management of individual drugs should be followed.
When changing the route of administration of a drug care should be taken to ensure that the appropriate dose and frequency is prescribed, as they may not be the same as for
the oral route. Contact Medicines Information (ext 1486).
The classification of this guideline is based on BNF categories (e.g. omeprazole can be found under the Gastro-intestinal system).
Guidance on pre-operative fasting in healthy adults
Intake of water up to two hours before induction of anaesthesia for elective surgery is safe in healthy adults, and improves patient wellbeing.
Tea and coffee with milk are acceptable up to six hours before induction of anaesthesia.
The volume of administered fluids does not appear to have an impact on patients’ residual gastric volume and gastric pH, when compared to a standard fasting regimen.
A minimum preoperative fasting time of six hours is recommended for food (solids and milk).
Chewing gum should not be permitted on the day of surgery.
Sweets are solid food, and can be taken up to six hours before induction of anaesthesia.
Regular medication considered appropriate to be taken pre-operatively (e.g. antihypertensive drugs except ACE-inhibitors and angiotensin-2-antagonist) should be taken up
to 2 hours before surgery unless contra-indicated.
Clinical Practice Guidelines. Perioperative fasting in adults and children. Royal College of Nursing; London 2005 .
2
GENERAL RULE:
DO NOT STOP ANALGESIA, ANTIEPILEPTICS, BRONCHODILATORS, SOME CARDIOVASCULAR DRUGS, GLAUCOMA DRUGS, THYROID OR
ANTI-THYROID DRUGS AND PEPTIC ULCER DRUGS PRIOR TO SURGERY.
STOP HERBAL MEDICATIONS 2 WEEKS BEFORE SURGERY.
FOR DRUGS NOT INCLUDED IN THE TABLE BELOW CONTACT MEDICAL INFORMATION (EXT 1486).
BNF 1. Gastro-intestinal system
BNF Classification
Examples
Risk
Recommendation
Antacids
Gaviscon
Risk of acid aspiration if
stopped
Antispasmodics
Antimuscarinics
Mebeverine
Hyoscine butylbromide
Dicycloverine hydrochloride
Risk of paralytic ileus
Risk of paralytic ileus
Consider ranitidine if patient has
symptomatic acid reflux (see PGD‘Ranitidine for patients undergoing
surgery who are at high risk of reflux’)
Omit on the morning of the operation
Omit on the morning of the operation
IV/IM Hyoscine butylbromide
H2-receptor antagonists
Rantidine
Cimetidine
Lansoprazole
Omeprazole
Pantoprazole
Esomeprazole
Mesalazine
Balsalazide
Sulfasalazine
Senna
Sodium docusate
Lactulose
Reduces the risk of acid
aspiration
Reduces the risk of acid
aspiration
Continue
IV ranitidine
Continue. If the patient takes this on a
when required basis inform them to
take a dose on the morning of the
operation.
Continue
IV ranitidine
Proton pump inhibitors
Aminosalicyclates
Laxatives
Fybogel
Adequate fluid intake needs
to maintained to avoid
intestinal obstruction.
Alternative post-op if unable
to take orally.
Omit morning dose
Phosphate enema
Glycerol suppositories
Omit morning dose
3
BNF 2.Cardiovascular system
BNF Classification
Examples
Risk
Recommendation
Cardiac glycosides
Digoxin
Risks of arrhythmias,
embolism, cardiac failure poor
tissue healing if omitted.
Risk of ventricular arrhythmias
when given with
suxamethonium.
Continue
Thiazides and related
diuretics
Loop diuretics
Bendrofluamethiazide
Indapamide
Furosemide
Bumetanide
Potassium sparing
diuretics and
aldosterone antagonists
Amiloride
Spironolactone
Anti-arrhythmic drugs
Amiodarone
Flecainide
Atenolol
Bisoprolol
Carvedilol
Celiprolol
Labetalol
Metoprolol
Hydralazine
Minoxidil
Beta-blockers
Vasodilator
Centrally acting
antihypertensive
Clonidine
Methyldopa
Moxonidine
Nebivolol
Oxprenolol
Pindolol
Propranolol
Sotalol
Timolol
Alternative post-op if unable
to take orally.
100mcg IV digoxin = 125mcg
oral digoxin tablets.
Liquid 50mcg digoxin
=62.5mcg tablets
Continue
Continue
Tissue damage and reduced
kidney perfusion in immediate
post-op period can lead to
hyperkalaemia.
Reduces the risk of perioperative arrhythmias.
Risk of withdrawal syndromerebound tachycardia, angina,
acute coronary syndrome,
arrhythmias if omitted.
Continue
Risk of hypertension,
tachycardia, MI and stroke if
omitted.
Continue to avoid rebound
symptoms and hypertensive
crisis.
Continue
Continue
Continue
IV diuretics
Max IV rate for
furosemide=4mg/minute
Use IV alternative within the
same class
Give alternative IV betablocker (e.g. Labetalol)
IV alternatives available
Continue
4
BNF 2. Cardiovascular system (Continued)
BNF Classification
Examples
Risk
Recommendation
ACE-inhibitors
Captopril
Perindopril
Cilazapril
Quinalapril
Enalapril
Ramipril
Fosinopril
Trandolapril
Imidapril
Moexipril
Lisinopril
Candesartan
Olmesartan
Eprosartan
Telmisartan
Irbesartan
Valsartan
Losartan
Doxazosin
Terazosin
Isosorbide mononitrate
Isosorbide dinitrate
Risk of hypotension, renal
failure, and reduced cerebral
blood flow.
Omit morning dose
Risk of hypotension and renal
failure
Omit morning dose
Use alternative IV
antihypertensive agent
Hypotension
Continue- improves cardiovascular
stability
Continue
Use alternative IV
antihypertensive agent
Topical (patches), buccal,
sublingual and IV forms
available.
Amlodipine
Diltiazem
Felodipine
Verapamil
Nicorandil
Hypotension
Bradycardia (verapamil)
Risk of angina, acute coronary
syndrome if omitted.
Hypotension
Continue
Cilostazol
Contraindicated in those that
have had surgery in the previous
3 months (predisposition to
bleeding)
Consult with surgical/vascular team.
Manufacturers suggest stopping 2-3
days prior to surgery and restarting
3 months after the operation.
Angiotensin-II receptor
antagonist
Alpha blockers
Nitrates
Calcium-channel
blockers
Potassium-channel
activator
Peripheral vasodilator
Hypotension.
Risk of angina, acute coronary
syndrome if omitted.
Omit morning dose
Alternative post-op if unable
to take orally.
Use alternative IV
antihypertensive agent
Alternative anti-anginals (see
nitrates)
5
BNF 2. Cardiovascular system (Continued)
BNF Classification
Examples
Risk
Recommendation
Aspirin
Haemorrhagic risk
Clopidogrel
Haemorrhagic risk
Dipyridamole
Haemorrhagic risk
It is advisable to stop 7 days prior
to surgery especially for patients that
are likely to bleed but please confirm
with surgeon as it may depend on
type of surgery, and surgeon’s
preference.
Also please be aware of the highrisk patient (e.g.
vascular/TIA/stroke) in whom it may
be advisable to continue. Please
confirm with surgical team in charge.
Seek advice from cardiologist/
surgical team for all cases, unless the
patient is on it for intolerance to
aspirin in which case it needs to be
stopped 7 days prior to surgery.
Please confirm with surgical team in
charge.
Seek advice from surgical team for
all cases.
Anticoagulants
Warfarin
Haemorrhagic risk
Statins
Atorvastatin
Pravastatin
Rosuvastatin
Simvastatin
Antiplatelet drugs
See ‘Guidelines for the management
of anti-coagulation in the perioperative period for elective
surgery’.
Continue
Alternative post-op if
unable to take orally.
The surgical team should
decide when the patient
should be restarted postoperatively.
6
BNF 3. Respiratory
BNF Classification
Examples
Beta-2 antagonist
Salbuatmol
Terbutaline
Salmetrol
Ipratropium bromide
Tiotropium
Continue
Theophylline
Theophylline
Aminophylline
Continue
Corticosteroids
Beclometasone
Fluticasone
Budesonide
Montelukast
Zafirlukast
Carbocysteine
Mecysteine
Continue
Antimuscarinic
brochodilators
Leukotriene receptor
antagonists
Mucolytics
Risk
Recommendation
Continue
Alternative post-op if unable
to take orally.
May need to substitute with
nebulised therapy perioperatively.
May need to substitute with
nebulised therapy perioperatively.
Consider aminophylline
infusion in patients nil by
mouth. Monitor levels closely.
May need to substitute with
nebulised therapy perioperatively.
Continue
Continue
7
BNF 4. Central Nervous System
BNF Classification
Examples
Risk
Recommendation
Hypnotics and
anxiolytics
Abrupt withdrawal may cause confusion, toxic
psychosis, convulsions and withdrawal syndromes.
Continue
Antipsychotic
Diazepam
Nitrazepam
Temazepam
Chlorpromazine
Haloperidol
Clozapine
Risk of acute withdrawal symptoms or relapse.
Risk of arrhythmias.
Associated with thromboembolism
Risk of withdrawal symptoms
Can lower seizure threshold.
Antimanic drugs
Lithium
Abrupt discontinuation of lithium increases the
risk of relapse.
Lithium may prolong the effects of
neuromuscular blocking agents.
Monitor renal function, fluid and electrolyte
function post-operatively.
Continue. Discuss with patients
psychiatrist if concerned.
Discuss with psychiatrist before stopping.
If it is considered appropriate to stop, it
should be stopped 12 hours before
surgery. Patient should receive the next
dose after surgery at the usual time and
at full dose if the patients vital signs are
stable. If clozapine is discontinued for
more than 48 hours it must be re-titrated
beginning at the 12.5mg dose.
Continue but discuss with psychiatrist if
concerned.
Antipsychotic drugs
Tricyclic
antidepressants
SSRIs Antidepressants
Amitriptyline
Clomipramine
Dosulepin
Imipramine
Nortriptyline
Fluoxetine
Citalopram
Escitalopram
Paroxetine
Risk of withdrawal symptoms.
Increase effect of exogenous catecholamines e.g.
adrenaline resulting in arrhythmia.
SSRIs can interact with drugs such as tramadol
and pethidine (which block presynaptic uptake of
serotonin), to precipitate ‘serotonin syndrome’,
which can be fatal.
Alternative post-op
if unable to take
orally.
U&Es and lithium level must be checked
pre-operatively.
Ensure adequate fluid intake during and
after surgery.
Continue
Continue
8
BNF 4. Central Nervous System (continued)
BNF
Classification
Irreversible
MAOIs
antidepressants
Examples
Risk
Recommendation
Phenelzine
Isocarboxazid
Tranylcypromine
Consult with
psychiatrist/
anaesthetist
Reversible
MAOI
antidepressant
Moclobemide
Centrally acting
appetite
suppressants
Sibutramine
CNS excitation and depression when given with
pethidine/ opioid analgesics- avoid concomitant
use and for 2 weeks after stopping MAOI.
Risk of hypertensive crisis when given with
sympathomimetics.
Hazardous interactions between MAOIs and
general anaesthetics.
Risk of hypertensive crisis when given with
sympathomimetics. Possible CNS excitation and
depression when given with pethidine avoid
concomitant use.
Possible CNS excitation and depression when
given with opioid analgesics.
Predisposition to bleeding. Concomitant drugs
that increase risk of bleeding should be used with
caution e.g. aspirin, NSAIDs.
Serotonin syndrome may occur with certain
opioids.
Non-opioid
analgesics
Opioid analgesics
Paracetamol
Nefopam
Fentanyl
Morphine
Buprenorphine
Phenytoin
Sodium Valproate
Carbamazepine
Anti-epileptic
drugs
Alternative post-op if unable to take orally.
Omit on the day
of surgery, only
after discussing
with psychiatrist.
Continue
Continue
Risk of withdrawal symptoms if withdrawn
suddenly.
Discuss with pain
consultant
Abrupt withdrawal should be avoided as it may
precipitate severe rebound seizures.
Continue
Carbamazepine 100mg tabletsCarbamazepine
125mg suppositories.
Sodium Valproate IV Sodium Valproate Oral
Phenytoin 100mg tablets/capsules= Phenytoin
90mg liquid.
Phenytoin IV dose is equivalent to
tablets/capsules.
9
BNF 4. Central Nervous System (continued)
BNF Classification
Drugs for Parkinson’s
disease
Examples
Risk
Recommendation
Levodopa with dopadecarboxylase inhibitors:
Co-careldopa
Co-beneldopa
Dopamine receptor agonists:
Apomorphine
Pergolide
Bromocriptine
Pramipexole
Cabergoline
Roprinirole
Lisuride
Rotigotine
Avoid abrupt withdrawal it may worsen parkinsonian
symptoms
Continue
Avoid abrupt withdrawal.
Continue
COMP inhibitors:
Entacapone
Tolcapone
MAO-B inhibitors:
Selegiline
Rasagiline
Antimuscarinic drugs used in
parkinson’s disease:
Benzhexol (Trihexyphenidyl)
Orphenadrin
Drugs for dementia
Acetylcholinesterase inhibitors:
Donepezil
Galantamine
Rivastigmine
NMDA-receptor antagonist:
Memantine
Alternative post-op
if unable to take
orally.
Avoid concomitant use with metoclopramide.
Risk of toxicity when bromocriptone is given with
isometheptene or phenylpropanolamine.
Entacapone possibly enhances effects of adrenaline
(epinephrine), dobutamine, dopamine and noradrenaline
(norepinephrine).
Hyperpyrexia and CNS toxicity reported when given
with pethidine (avoid concomitant use).
Avoid concomitant use with sympathomimetics.
Avoid abrupt withdrawal.
Antimuscarinics antagonise the effects of
metoclopramide on gastrointestinal activity. Avoid
metoclopramide.
Donepezil possibly enhances the effects of
suxamethonium. Galantamine, rivastigmine enhance the
effects of suxamethonium.
 Donepezil possibly antagonises the effects of nondepolarising muscle relaxants. Rivastigmine enhances the
effect of non-depolarising muscle relaxants.
Increased risk of CNS toxicity when given with
ketamine. Manufacturer recommends avoid concomitant
use.
Continue
Continue
Continue
Continue
Continue
10
BNF 6. Endocrine system
BNF Classification
Examples
Risk
Recommendation
Insulin
Risk of hypoglycaemia in fasted
patients.
Risk of hypoglycaemia in fasted
patients.
See Pre-admission protocol.
Increased risk of acidosis
See Pre-admission protocol.
Consider sliding scale
insulin.
Can delay digestion and absorption of
sucrose and starch therefore restart once
patient resumes normal diet.
Risk of hypoglycaemia in fasted
patients.
Risk of hypoglycaemia in fasted
patients.
See Pre-admission protocol.
Consider sliding scale
insulin.
See Pre-admission protocol.
Consider sliding scale
insulin.
Consider sliding scale
insulin.
Sulphonylureas:
Gliclazide
Glibenclamide
Glimepiride
Glipizide
Biguanides:
Metformin
See Pre-admission protocol.
Alternative post-op if
unable to take orally.
Consider sliding scale
insulin.
Consider sliding scale
insulin.
Drugs for diabetes
Acarbose
Nateglinide
Repaglinide
Thiazolidinediones:
Pioglitazone
Rosiglitazone
See Pre-admission protocol.
11
BNF 6. Endocrine system (continued)
BNF Classification
Examples
Thyroid hormones
Levothyroxine
liothyronine
Carbimazole,
Propylthiouracil
Prednisolone
Dexametasone
Fludrocortisone
Hydrocortisone
Antithyroid drugs
Corticosteroids
Female sex hormones
(combined or
oestrogen-only HRT)
Female sex hormones
(progesterone only)
Premique
Prempak
Premarin
Risk
Recommendation
Alternative post-op if unable
to take orally.
Continue
Continue
Abrupt withdrawal may precipitate
acute adrenal insufficiency
Risk of venous thromboembolism
No increased risk of venous
thromboembolism.
Continue
May need to supplement
dose peri-operatively.
Ensure current and past
steroid use is documented.
Continue
Patients with a family
history/ previous history
of DVT/PE/haematological
blood disorder should be
referred to the surgical
team.
Continue
12
BNF 6. Endocrine system (continued)
BNF Classification
Examples
Risk
Recommendation
Other female sex
hormones
Raloxifene
Risk for venous thrombo-embolic
events that is similar to the reported risk
associated with current use of hormone
replacement therapy.
Anti-androgens
Cyproterone acetate
Thromboembolic events have been
reported in patients using cyproterone.
Patients with previous arterial or venous
thrombotic / thromboembolic events (e.g.
deep vein thrombosis, pulmonary
embolism, myocardial infarction), with a
history of cerebrovascular accidents or
with advanced malignancies are at
increased risk of further thromboembolic
events, and may be at risk of recurrence
of the disease during cyproterone therapy.
Discontinuation should
happen from three days
before the immobilisation
occurs. Therapy should not
be restarted until the
initiating condition has
resolved and the patient is
fully mobile.
Consult with haematology if
patient is high risk otherwise
continue.
Alternative post-op if
unable to take orally.
13
BNF 6. Endocrine system (continued)
BNF Classification
Examples
5 reductase inhibitor
Finasteride
Dutasteride
Desmopressin
Posterior pituitary
hormone
Biphosphonates and
other drugs affecting
bone metabolism
Risk
Recommendation
Alternative post-op if
unable to take orally.
Continue
If and when to stop desmopressin will
depend on the indication for
desmopressin and whether fluids will be
administered to the patient.
Alendronate
Etidronate
Risedronate
Needs to be taken with a full glass of
water. Restart when patient is able to
comply with recommendations.
Strontium
In phase III placebo-controlled studies,
strontium ranelate treatment was
associated with an increase in the annual
incidence of venous thromboembolism
(VTE), including pulmonary embolism.
Ensure adequate preventative measures
are taken post-operatively.
If desmopressin is being
used for haemostatic
indications it should be
continued.
For primary nocturnal
enuresis if no fluids are
required during/ after
surgery desmopressin can be
taken as normal. If fluids are
required, to minimize fluid
retention desmopressin
should not be taken on the
night prior to surgery.
Omit on the morning of the
operation
Consult with haematology if
patient is high risk otherwise
continue.
14
BNF 7. Obstetrics, gynaecology and urinary-tract disorders
BNF Classification
Examples
Risk
Recommendation
Combined hormonal
contraception
Microgynon
Loestrin
Marvelon
Increased risk of venous
thromboembolism
Drugs for urinary
retention
Alfuzosin
Tamsulosin
The administration of general
anaesthetics to patients receiving
alfuzosin can cause profound
hypotension.
There is a theoretical risk of
enhanced hypotensive effect when
tamsulosin is given with anaesthetic
agents.
Consider stopping 4 weeks
before for varicose vein
patients belonging to Barnet
site. Give contraceptive
advice.
Patients with a family
history/ previous history of
DVT/PE/haematological
blood disorder should be
referred to the surgical
team.
Withdraw alfuzosin 24 hours
before surgery.
Drugs for urinary
incontinence
Oxybutynin
Tolterodine
Alternative post-op if
unable to take orally.
Continue
15
BNF 8. Malignant disease and immunosuppression
BNF Classification
Examples
Risk
Recommendation
Hormone antagonists
Oestrogen receptor
antagonist (e.g.
Tamoxifen)
Increased risk of thromboembolic
event. A 2-3-fold increase in the risk
for VTE has been demonstrated in
healthy tamoxifen-treated women.
For patients being treated
for infertility, tamoxifen
should be stopped at least 6
weeks before surgery or
long-term immobility (when
possible) and re-started only
when the patient is fully
mobile.
Surgery and immobility:
Tamoxifen treatment should only be
stopped if the risk of tamoxifeninduced thrombosis clearly
outweighs the risks associated with
interrupting treatment. All patients
should receive appropriate
thrombosis prophylactic measures.
Alternative post-op if
unable to take orally.
For patients with breast
cancer discuss with surgical
team and oncology team.
Patient should be advised to report
sudden breathlessness and any pain
in the calf of one leg,
Aromatase inhibitors
Anti-androgen
(Gonadorelin analogues)
Anastrazole
Letrozole
Exemestane
Bicalutamide
Flutamide
(see above for
cyproterone acetate)
Continue
Continue
16
BNF 10. Musculoskeletal and joint diseases
BNF
Classification
Examples
Risk
Recommendation
Ibuprofen
Diclofenac
Etodolac
Indometacin
Meloxicam
Naproxen
Nabumetone
Non selective NSAIDs inhibit COX-1 which
Selective inhibitors
of COX-2:
Celecoxib
Etoricoxib
Lumiracoxib
Penicillamine
Does not inhibit COX-1 therefore platelet
Consider stopping for procedures with a high
risk of bleeding e.g. revision of a joint and
back surgery. Please confirm with surgeon.
Stop ibuprofen, mefenamic acid, diclofenac,
indometacin the day before surgery.
Stop naproxen and etodolac 3 days before
the surgery.
Stop nabumetone and meloxicam 5 days
before surgery.
Continue
blocks the formation of thromboxane A2,
resulting in thromboxane-dependent aggregation
which prolongs bleeding.
NSAIDs
Drugs
suppressing the
rheumatic
disease process
Cytokine
inhibitors
Gout
Skeletal muscle
relaxants
Hydroxychloroquine
Azathioprine
Leflunomide
Sulfasalazine
Etanercept
Infliximab
Adalimumab
Anakinra
Allopurinol
Baclofen, dantrolene
Alternative
post-op if
unable to
take orally.
aggregation is not affected.
Potential for disruption of collagen synthesis
and delay in wound healing.
Continue
May delay wound healing
May affect wound healing
Continue
Consult with surgical team
Consult with surgical team
Continue
May increase the risk of infection or healing
complications.
Consult with surgical team
Serious side-effects can occur on abrupt
Continue
Continue
withdrawal
17
Herbal Medication
Herb
Echinacea
Ephedra
Garlic
Gingko
Ginseng
Kava
St John’s Wort
Valerian
Risk
Allergic reactions
Reduced effectiveness of immunosuppressive
drugs
Impaired wound healing
Increased risk of infection
Risk of MI and stroke with halothane
Ventricular arrhythmias
Haemorrhagic risk especially in combination
with other anti-platelet drugs.
 Haemorrhagic risk especially in combination
with other anti-platelet drugs.
Hypoglycaemia
 Haemorrhagic risk
Decreased anticoagulative effect of warfarin.
Possible increase sedation with anaesthetics.
Interaction with a number of drugs including
warfarin and steroids
Increased sedative effect with anaesthetics.
Withdrawal symptoms may develop during
post-operative period, which can be treated with
benzodiazepines.
Recommendation
Stop all herbal medications 2 weeks prior to surgery
18