Mercy Hospital
Clinic For Surgical Services and Division of Anesthesia
Preoperative Medication Guidelines
Updated March 2014
Introduction
This policy directing which medications should be taken preoperatively is based upon
recommendations found in the medical literature and upon professional consensus. Both are
informed by the knowledge of how these agents work, their effects on a patient who is fasting
for elective surgery, and their interactions with anesthetic agents. As new pharmaceutical agents
come to the market and as perioperative guidelines from professional organizations change, this
policy will be amended in order to effect the safest and most comfortable experience for the
surgical and procedural patients at Mercy Hospital.
Cardiovascular medications (including antihypertensives)
All of these medications should be taken as scheduled on the morning of surgery except as
noted:
 Diuretics should be held.
o However, beta-blocker/diuretic combinations should be taken (to avoid betablocker withdrawal).
 Angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers
(ARBs) should be continued preoperatively.
o This issue is somewhat controversial, but the literature seems to favor continuing
the drugs. Hypotension that occurs is usually not severe and is controllable. Not
taking the drugs results in hypertension.
o However, ACEI or ARB/diuretic combination products should be held (because the
risk of hypotension is even greater with these combinations).
Hypolipidemic agents
 Statin class drugs should all be continued.
 Niacin, gemfibrozil, and fenobibrate should be held (because of myopathy risk).
 Ezetimibe should also be held (perioperative safety is not clear).
 Agents in the bile sequestrant class should be held. There is no benefit and they may
interfere with absorption of any perioperative oral agents.
Gastrointestinal agents
 Include H2 blockers and proton pump inhibitors.
 These should be continued preoperatively.
Pulmonary agents
 All inhalers and nebulizers should be taken preoperatively per their usual schedule.
 These agents, if used on an as needed (prn) basis, should be brought into the hospital
for possible use perioperatively.
 Leukotriene inhibitors (e.g. montelukast, Singulair) should be continued.
 Corticosteroids should be continued.
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EXCEPTION: Theophylline, which is now uncommonly prescribed, should be held. This
agent has a narrow therapeutic index, and there is no evidence that its preoperative use
decreases pulmonary complications.
Endocrine agents
 Diabetic agents are discussed separately.
 Corticosteroid supplementation agents, prescribed usually for pulmonary and other
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inflammatory conditions should be taken preoperatively. In addition to controlling the
underlying problem, these drugs may have suppressed adrenal function.
Oral contraceptive (OC) recommendations vary according to the surgical risk of venous
thromboembolism (VTE). For lower risk procedures, these agents are generally
continued. Discontinuation for four to six weeks preoperatively is recommended for
patients having procedures at high risk for VTE. However we rarely get to speak to
these patients that far in advance of surgery, and many find discontinuation impractical.
Postmenopausal replacement therapy: Preoperative instructions are the same as for OCs.
Estrogen receptor modulators, taken for breast cancer prophylaxis and osteoporosis (e.g.
tamoxifen, raloxifene): These agents can increase the risk of VTE for high-risk surgery
and ideally should be discontinued. However, for patients who take these agents for
treatment of active breast cancer, this decision must be made in consultation with the
prescribing oncologist. If taken for osteoporosis, discontinuation should be considered
for high-risk procedures.
Thyroid Disease: Medications for the treatment of hypothyroidism should be taken
preoperatively.
Drugs for treatment of osteoporosis: Bisphosphonates (Fosamax, Boniva, alendronate,
etc.) usually will be continued preoperatively. For oral surgery procedures the surgeon
may be temporarily discontinue them for several months prior to the procedure.
Anti-thrombotic agents
 Aspirin, when used for treatment of known cardiovascular conditions, should generally be
continued preoperatively. However we currently leave the decision to the discretion of
the surgeon. In some operations, e.g. some spine, eye, ear, and prostrate procedures,
bleeding outweighs the risk of cardiovascular complications.
 Non-aspirin NSAID agents are not prescribed for management of vascular or coagulation
problems, but they have a lesser effect on platelet activity. Their preoperative
management is left up to the surgeon’s discretion.
 Other anti-platelet agents, such as dipyridamole and clopridogrel (Plavix): Management
of these drugs needs to be coordinated among the surgeon, anesthesiologist,
cardiologist, and hospitalist. Continuation may be necessary but might limit options for
regional anesthesia.
 Warfarin (Coumadin), dabigatran, and other new anticoagulant agents are deferred to
the instructions of the surgeon, subject to review by the anesthesiologist and/or
hospitalist in consultation with a cardiologist, if appropriate. Decisions made by the
hospitalist or surgeon may limit options for regional anesthesia.
 Some of the new anticoagulant drugs (e.g. dabigitran, apixaban, and rivaroxaban) are
irreversible and have prolonged durations of action. Their perioperative management
needs to be acknowledged and addressed by the all practitioners involved in the
preoperative evaluation of the patient.
Psychotropic agents
 Tricyclic and tetracyclic antidepressants should be continued.
 Specific Serotonin Reuptake Inhibitory Agents (SSRIs), such as citalopram or paroxetine,
and Selective Norepinephrine Reuptake Inhibiotors (SNRIs), such as venlafaxine, are to
be continued. (There is some evidence that they may increase bleeding, but
discontinuation can have psychiatric consequences. Should there be consideration to
hold prior to a procedure at high risk for hemorrhage, the prescribing physician must be
involved.)
 MAO Inhibitors: These medications must be noted for the anesthesiologist, because they
interact with commonly used anesthetic drugs. Examples include isocarboxazid,
pargyline, phenelzine, and tranylcypromine. Older literature recommended holding
preoperatively, but this can have disastrous psychiatric consequences. Thus, they should
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be continued, and the anesthesiologist in CSS should be notified.
Mood stabilizers: Lithium and valproate should be taken as scheduled preoperatively.
Antipsychotics should generally be taken preoperatively. They include haloperidol,
risperidone, olanzapine, and ziprasidone. They do present a risk of QT-interval
prolongation, and a preoperative ECG should be considered – consult the CSS
anesthesiologist.
Anti-anxiety drugs should be taken.
Sympathomimetic stimulants (methylphenidate, amphetamine) should be held
preoperatively. There is no adverse effect of holding and they may increase the risk of
hypertension.
Chronic opioid therapy
 All chronic opioids should be taken preoperatively as they normally would be taken.
 Patients taking Suboxone (buprenorphine/naloxone) or Subutex (buprenorphine) require
specific consultation with the anesthesiologist in CSS. Refer to Appendix A, Preoperative
Buprenorphine Management fax, for current recommendations.
 Naltrexone is an opiate agonist used for the management of opiate and alcohol addiction.
It must be withheld for 72 hours prior to any painful surgical procedure, in order to allow
for acute pain management.
 Methadone: Patients taking methadone once daily for opioid abuse treatment must go to
their dispensary and take their methadone prior to coming to the hospital. If they fail to
take their methadone prior to arrival, the surgery should be rescheduled to another day.
Patients taking methadone for chronic pain (usually two or three times daily) should take
their medication on the day of surgery.
Antiepileptic agents
 These should be continued preoperatively.
Antiparkinson agents
 Carbodopa/levodopa should be taken preoperatively. Withdrawal puts patients at risk for
Parkinsonian symptoms.
 Some patients with Parkinson’s Disease are now taking MAO inhibitors (selegiline and
rasagiline). These should be continued, and the CSS anesthesiologist notified. (See
psychotropic agents, above.)
Rheumatologic agents
 The patient’s rheumatologist should generally provide instructions for these agents.
General recommendations are as follows:
 Methotrexate: This is given as once weekly injections. In patients with normal kidney
function dosing in the preoperative week does not need to be changed.
 Sulfasalazine and azathioprine should be held for a week prior to surgery due to risk of
bone marrow suppression.
 Leflunamide: This drug can probably be continued safely.
 Hydroxychloroquine may be continued preoperatively.
 Newer biological agents of the anti-TNF class (Embrel, Remicade, Humira) should be held
several weeks prior to surgery due to the risk of immunosuppression and perioperative
infection.
Gout agents
 Colchicine, allopurinol, and probenicid should all be held on the morning of surgery.
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Diabetic agents
 All oral agents and injectable non-insulin diabetic drugs should be held the morning of
surgery.
 Insulin
o A patient using an insulin pump should be the first case of the day in his or her
surgeon’s list.
o Patients using insulin pumps should leave their pump on their basal rate, take
their blood sugar at least every 1-2 hours prior to arrival at the ACU, and have
apple or other clear juice available to treat hypoglycemia.
 Patients should be told to have whatever glucose containing clear liquid
(e.g. apple juice, any other non-pulp containing juice, or sugar water)
they may need up until 4 hours prior to their surgical time.
 At 4 hours prior, they should stop their clear liquid use, unless they find
that their blood glucose is less than 100 or they feel hypoglycemic. If
this occurs, they should use judicious amounts of clear liquid glucose and
check in early to the Ambulatory Care Unit. They should inform the
receptionist that they are diabetic and need to talk to the nurse ASAP.
The anesthesiologist should be notified immediately.
o Lantus insulin
 Patients should take their usual dose the evening prior and the morning
of surgery UNLESS they report a history of hypoglycemia. If so, consult
the CSS anesthesiologist. (The recommendation then is to reduce both
Lantus doses by 20%.)
 With regards to oral intake instructions and pre-op glucose management,
treat the same as an insulin infusion above.
o Levemir insulin
 The dose the night before surgery should be taken, but it should be held
on the morning of surgery.
 With regards to oral intake instructions and pre-op glucose management,
treat the same as an insulin infusion above.
o Patients on older regimens, such as NPH plus regular insulin
 Consult the CSS anesthesiologist for orders. (Generally, the patient will
hold the regular and take half the NPH on the day of surgery.)
 With regards to oral intake instructions and pre-op glucose management,
treat the same as an insulin infusion above.
Transdermal medications
 Many patients use transdermal (patch) medications for everything from analgesia to
hypertension to Parkinson's disease.
 Patients should be specifically asked if they are using any transdermal medications, and
these drugs should be noted on the medication reconciliation sheet.
 In general these medications should be worn on the day of surgery. However, for
estrogen patches the same recommendations as oral contraceptives apply:
o For lower risk procedures, these agents are generally continued. Discontinuation
for four to six weeks preoperatively is recommended for patients having
procedures at high risk for VTE. However we rarely get to speak to these
patients that far in advance of surgery, and many find discontinuation
impractical.
Drugs for erectile dysfunction
 Phosphodiesterase-5 inhibitors (sildenafil/Viagra®, tadalafil/Cialis®, vardenafil/Levitra®,
avanafil/Stendra®) should be discontinued 24 hours before surgery.
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Herbals and non-vitamin supplements
 These medications are not controlled by the FDA, and their composition is therefore
unregulated. Some have been shown to contain illegal prescription components.
Furthermore, some are known to increase bleeding.
 All of these supplements should be stopped seven days prior to surgery.
Others
 Continue gabapentin, pregabalin, baclofen, and skeletal muscle relaxants (such as
carisoprodol).
David Andrews, MD
Anthony Miller, MD
March 2014
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