What medications should be held prior to surgery?

From the Guidelines

Medications that should be held prior to surgery include anticoagulants, antiplatelet medications, non-steroidal anti-inflammatory drugs (NSAIDs), certain diabetes medications, and herbal supplements. The decision to hold these medications is based on the need to balance the risk of bleeding and thromboembolic events with the risk of withholding necessary medications. Key medications to consider holding include:

• Warfarin, which should be discontinued 5-7 days prior to surgery 1
• Direct oral anticoagulants like apixaban and rivaroxaban, which should be discontinued 48-72 hours prior to surgery
• Clopidogrel, which should be discontinued at least 5 days before surgery for elective CABG and at least 24 hours before surgery for urgent CABG 2, 3
• Aspirin, which may be continued in some cases, such as for cardiac patients, but should be discontinued 7-10 days prior to elective procedures in other cases 2, 3
• NSAIDs, which should be stopped 3-7 days before surgery to reduce bleeding risk 1
• Certain diabetes medications like metformin, which should be held 24-48 hours before procedures requiring contrast dye to prevent lactic acidosis
• Herbal supplements such as ginkgo biloba, garlic, ginseng, and St. John's wort, which should be discontinued 1-2 weeks before surgery due to potential bleeding risks and drug interactions
• ACE inhibitors and ARBs, which are typically held 24 hours before surgery to prevent intraoperative hypotension 4 It's essential to note that the specific timing for medication discontinuation varies based on the procedure type, patient's medical condition, and the medication's half-life, so patients should always follow their surgeon's or anesthesiologist's personalized instructions during preoperative evaluation.

From the FDA Drug Label

Do not take an NSAID medicine: if you had an asthma attack, hives, or other allergic reaction with aspirin or any other NSAID medicine for pain right before or after heart bypass surgery NSAID medicines should never be used right before or after a heart surgery called a "coronary artery bypass graft (CABG)." Prior to Surgery Advise patients to inform physicians and dentists that they are receiving heparin before any surgery is scheduled

The following medications should be held prior to surgery:

• NSAIDs (e.g. naproxen, ibuprofen, aspirin) especially before heart bypass surgery or coronary artery bypass graft (CABG)
• Heparin (inform physicians and dentists before any surgery is scheduled) 5 6

From the Research

Medications to be Held Prior to Surgery

The following medications may need to be held prior to surgery due to their potential to increase the risk of bleeding or interact with anesthesia:

• Antiplatelet agents:
  • Aspirin 7, 8, 9, 10
  • Clopidogrel 7, 8, 9, 10
  • Prasugrel 7, 8, 10
  • Ticagrelor 7, 8, 9, 10
• Anticoagulants:
  • Warfarin 8, 9
  • Bivalirudin 7
  • Unfractionated heparin 7
  • Enoxaparin 7
  • Fondaparinux 7
  • Rivaroxaban 7
• Other medications:
  • Amphetamines may not need to be stopped before surgery, but this should be determined on a case-by-case basis 11

Considerations for Holding Medications

When deciding which medications to hold prior to surgery, the following factors should be considered:

• The type of surgery and the risk of bleeding associated with it
• The patient's medical history and current medications
• The potential risks and benefits of holding or continuing each medication
• The availability of alternative medications or treatments

Specific Medication Considerations

• Aspirin and other antiplatelet agents may need to be held 7-10 days prior to surgery to minimize the risk of bleeding 7, 8, 9, 10
• Warfarin and other anticoagulants may need to be held 3-5 days prior to surgery to minimize the risk of bleeding 8, 9
• Amphetamines may not need to be stopped before surgery, but this should be determined on a case-by-case basis 11