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peri_operative_medication_management [2026/04/09 03:20] – Scott Larsonperi_operative_medication_management [2026/04/09 03:30] (current) – Scott Larson
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 ====== Peri-Operative Medication Management ====== ====== Peri-Operative Medication Management ======
-FIXME+
 ====Cardiovascular and Hypertensive Medication==== ====Cardiovascular and Hypertensive Medication====
   * Beta Blockers- continue through surgery    * Beta Blockers- continue through surgery 
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   * Ranexa (ranolazine)- can take day of surgery   * Ranexa (ranolazine)- can take day of surgery
  
-===GI agents===+====GI agents====
   * H2 Blockers and PPIs- continue through surgery   * H2 Blockers and PPIs- continue through surgery
  
-===Pulmonary===+====Pulmonary====
   * Metered dose inhalers- continue through surgery   * Metered dose inhalers- continue through surgery
   * Theophylline- stop the night before surgery   * Theophylline- stop the night before surgery
   * Leukotriene inhibitors (zileuton, zafirlukast, montelukast)- continue through surgery   * Leukotriene inhibitors (zileuton, zafirlukast, montelukast)- continue through surgery
  
-===Endocrine=== +====Endocrine==== 
-==Glucocorticoids==+===Glucocorticoids===
   * Patients taking glucocorticoids < 3 weeks or daily dose prednisone equivalent < 5mg or taking chronic every other day therapy are unlikely to need stress doses, continue usual meds through surgery   * Patients taking glucocorticoids < 3 weeks or daily dose prednisone equivalent < 5mg or taking chronic every other day therapy are unlikely to need stress doses, continue usual meds through surgery
   * Patient with daily dose > 5mg or treated with > 5mg/day for > 3 weeks in the past year need stress dosing.   * Patient with daily dose > 5mg or treated with > 5mg/day for > 3 weeks in the past year need stress dosing.
  
-==Diabetic Medications==+===Diabetic Medications===
   * Hold sulfonylureas, metformin and other oral agents on day of surgery (if risk of hypotension or need IV contrast, hold metformin for 48 hours).   * Hold sulfonylureas, metformin and other oral agents on day of surgery (if risk of hypotension or need IV contrast, hold metformin for 48 hours).
   * SGL T2 Inhibitors (dapagliflozin, empagliflozin, ertugliflozin) -- hold for 3 days prior to surgery (5 days for bariatric surgery)   * SGL T2 Inhibitors (dapagliflozin, empagliflozin, ertugliflozin) -- hold for 3 days prior to surgery (5 days for bariatric surgery)
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       * Sitagliptin (Januvia), Saxagliptin (Ongliza), Linagliptin (Tradjenta), Alogliptin (Nesina)       * Sitagliptin (Januvia), Saxagliptin (Ongliza), Linagliptin (Tradjenta), Alogliptin (Nesina)
  
-==Hormone Medications==+====Hormone Medications====
   * Oral Contraceptives   * Oral Contraceptives
     * Low risk surgery for VTE can continue     * Low risk surgery for VTE can continue
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   * Thyroid Medication-continue to take   * Thyroid Medication-continue to take
  
-===Medications Affecting Homeostasis=== +====Medications Affecting Homeostasis==== 
-==Antiplatelet Agents==+===Antiplatelet Agents===
   * Patient at high risk for CV event and low risk for complications if bleeding occurs—continue ASA (call surgeon if any questions)   * Patient at high risk for CV event and low risk for complications if bleeding occurs—continue ASA (call surgeon if any questions)
   * Stop ASA 7 days prior to surgery where bleeding would be catastrophic (e.g. intracranial, spinal, urological procedures) or where patient is low risk for CV event   * Stop ASA 7 days prior to surgery where bleeding would be catastrophic (e.g. intracranial, spinal, urological procedures) or where patient is low risk for CV event
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   * Stop Brilinta(ticagrelor) x 5 days   * Stop Brilinta(ticagrelor) x 5 days
  
-==Other Antiplatelet Agents==+===Other Antiplatelet Agents===
   * Stop cilostazol(Pletal) x 5 days   * Stop cilostazol(Pletal) x 5 days
   * Stop dipyridamole x 2 days   * Stop dipyridamole x 2 days
   * Stop Aggrenox (aspirin/dipyridamole) x 7 days   * Stop Aggrenox (aspirin/dipyridamole) x 7 days
  
-==NSAID==+===NSAID===
   * Stop 7 days prior to surgery.    * Stop 7 days prior to surgery. 
   * Celebrex (celecoxib), if needed can consider to continue through surgery as little effect on platelets (elevated CV mortality)   * Celebrex (celecoxib), if needed can consider to continue through surgery as little effect on platelets (elevated CV mortality)
  
-==Anticoagulation==+===Anticoagulation===
   * Follow anticoagulation bridging protocol if prescribed by surgeon, PCP or anticoagulation clinic.   * Follow anticoagulation bridging protocol if prescribed by surgeon, PCP or anticoagulation clinic.
   * Coumadin (warfarin)   * Coumadin (warfarin)
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   * SPINAL OR EPIDURAL ANESTHESIA—hold Factor Xa inhibitors or Direct Thrombin Inhibitor 72 hours minimum before procedure.   * SPINAL OR EPIDURAL ANESTHESIA—hold Factor Xa inhibitors or Direct Thrombin Inhibitor 72 hours minimum before procedure.
  
-===Psychiatric Medications===+====Psychiatric Medications====
   * TCA—continue through surgery   * TCA—continue through surgery
   * SSRIs—may affect platelet function, generally continue   * SSRIs—may affect platelet function, generally continue
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   * Phendimetrazine-Stop 7 days before surgery   * Phendimetrazine-Stop 7 days before surgery
  
-===Chronic Opioid Therapy===+====Chronic Opioid Therapy====
   * Continue through surgery   * Continue through surgery
   * For patients on high dose narcotics, consider Pain Management consultation for management postoperatively   * For patients on high dose narcotics, consider Pain Management consultation for management postoperatively
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   * Naltrexone—Hold for 3 days for opioid addiction. Hold for 5 days for other dx, i.e. weight loss   * Naltrexone—Hold for 3 days for opioid addiction. Hold for 5 days for other dx, i.e. weight loss
  
-===Neurological Medications===+====Neurological Medications====
   * Seizure medication—continue through surgery   * Seizure medication—continue through surgery
   * Muscle relaxants-see under psych meds. Continue throughout surgery   * Muscle relaxants-see under psych meds. Continue throughout surgery
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     * Pyridostigmine-continue as ordered, give day of surgery     * Pyridostigmine-continue as ordered, give day of surgery
  
-===Rheumatologic Medications===+====Rheumatologic Medications====
  
-==Non-biologic DMARDS==+===Non-biologic DMARDS===
  
   * Sulfasalazine, azathioprine, mycophenolate (Cellcept), cyclophosphamide—consider holding one week prior to surgery due to neutropenia   * Sulfasalazine, azathioprine, mycophenolate (Cellcept), cyclophosphamide—consider holding one week prior to surgery due to neutropenia
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   * Nonacetylated NSAIDs (i.e. salsalate) have no effect on platelets and can continue through surgery   * Nonacetylated NSAIDs (i.e. salsalate) have no effect on platelets and can continue through surgery
  
-==Biologic DMARDS==+===Biologic DMARDS===
   * Best to discuss with Rheumatology and/or Surgeon for guidance of management in the Perioperative period.   * Best to discuss with Rheumatology and/or Surgeon for guidance of management in the Perioperative period.
   * Hold for 2-3 half-lives before surgery—restart with wound closure ~ 2 weeks after surgery. Consult with rheumatology if any questions about medication management.   * Hold for 2-3 half-lives before surgery—restart with wound closure ~ 2 weeks after surgery. Consult with rheumatology if any questions about medication management.
  
-=TNF Blockers=+===TNF Blockers===
  
   * Etanercept (Enbrel)—t ½ 3.5-5.5d, hold 7-10 days prior to surgery   * Etanercept (Enbrel)—t ½ 3.5-5.5d, hold 7-10 days prior to surgery
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   * Golimumab (Simponi)—t ½ 14d, hold 4 weeks prior to surgery   * Golimumab (Simponi)—t ½ 14d, hold 4 weeks prior to surgery
  
-=PDE-4 Inhibitor=+===PDE-4 Inhibitor===
  
   * Apremilast (Otezla) - t ½ 6-9 hrs, hold 3 days prior and resume when stitches are out   * Apremilast (Otezla) - t ½ 6-9 hrs, hold 3 days prior and resume when stitches are out
  
-=T cell costimulator=+===T cell costimulator===
  
   * Abatacept (Orencia)—t ½ 13d, hold 4 weeks prior to surgery   * Abatacept (Orencia)—t ½ 13d, hold 4 weeks prior to surgery
  
-=Interleukins antagonist=+===Interleukins antagonist===
  
   * Tocilizumab (Actemra)—t ½ 11-13d, hold 3 weeks prior to surgery   * Tocilizumab (Actemra)—t ½ 11-13d, hold 3 weeks prior to surgery
   * Anakinra (Kineret)—t ½ 4-6 hrs, hold 1 day prior to surgery   * Anakinra (Kineret)—t ½ 4-6 hrs, hold 1 day prior to surgery
  
-=B cell depleting agent and other biological modifiers=+===B cell depleting agent and other biological modifiers===
  
   * Rituximab (Rituxan)—t ½ 18 d, hold 4 weeks prior to surgery   * Rituximab (Rituxan)—t ½ 18 d, hold 4 weeks prior to surgery
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   * Upadacitinib (Rinvoq)- t ½ 8-14hrs, ok to continue through surgery for low-risk procedure (per Dr. Knibbe)   * Upadacitinib (Rinvoq)- t ½ 8-14hrs, ok to continue through surgery for low-risk procedure (per Dr. Knibbe)
  
-==Gout Medications==+====Gout Medications====
  
   * Hold colchicine, allopurinol and probenecid on day of surgery   * Hold colchicine, allopurinol and probenecid on day of surgery
  
-===Immunosuppressants for transplant===+====Immunosuppressants for transplant====
  
   * Continue through surgery   * Continue through surgery
   * If patient is on an mTOR inhibitor (sirolimus or everolimus), recommend discussion with nephrology prior to surgery as these can cause post-op wound healing issues, seromas and lymphoceles.   * If patient is on an mTOR inhibitor (sirolimus or everolimus), recommend discussion with nephrology prior to surgery as these can cause post-op wound healing issues, seromas and lymphoceles.
  
-11.  Hematology/Oncology Medication-Best to discuss IN ADVANCE OF SURGERY with Hematologist and surgeon for guidance during perioperative period. +====Hematology and Oncology Medications==== 
 +  * Best to discuss IN ADVANCE OF SURGERY with Hematologist and surgeon for guidance during perioperative period.
   * Palbociclib (Ibrance)-- can cause neutropenia, dosed 3 weeks on/1 week off to allow ANC to recover. May need to be held before surgery and up to 1 week after to allow for healing but needs to be discussed with oncologist MUCH PRIOR to surgery to coordinate   * Palbociclib (Ibrance)-- can cause neutropenia, dosed 3 weeks on/1 week off to allow ANC to recover. May need to be held before surgery and up to 1 week after to allow for healing but needs to be discussed with oncologist MUCH PRIOR to surgery to coordinate
   * Anastrozole (Arimidex), tamoxifen, letrozole, exemestane (Aromasin)-- hold 1 day prior to surgery and day of surgery due to risk for clotting. Should be held up to 1 week after surgery depending on mobility   * Anastrozole (Arimidex), tamoxifen, letrozole, exemestane (Aromasin)-- hold 1 day prior to surgery and day of surgery due to risk for clotting. Should be held up to 1 week after surgery depending on mobility
  
-12.  Parathyroid Hormone Analogs+====Parathyroid Hormone Analogs====
  
   * Teriparatide (Forteo) and other similar osteoporosis agents are ok to continue through surgery.   * Teriparatide (Forteo) and other similar osteoporosis agents are ok to continue through surgery.
  
-13.  PDE Inhibitors (i.e. sildenafil)+====PDE Inhibitors (i.e. sildenafil)====
  
   * If for ED, hold for 24 hrs prior to surgery. Continue if for pulmonary HTN.   * If for ED, hold for 24 hrs prior to surgery. Continue if for pulmonary HTN.
  
-14. Herbal Medications+====Herbal Medications====
   * CBD oil should also be held for 1 week prior to surgery.    * CBD oil should also be held for 1 week prior to surgery. 
   * Stop ALL herbal supplements for 1 week prior to surgery.   * Stop ALL herbal supplements for 1 week prior to surgery.