What medications should be stopped before surgery to minimize risks?

Perioperative Management of Antithrombotic Medications

For patients undergoing surgery, antiplatelet and anticoagulant medications should be managed according to specific timing protocols based on the medication type and surgical bleeding risk, with discontinuation of most agents before high-bleeding-risk procedures while maintaining aspirin when possible for patients with high cardiovascular risk.

Antiplatelet Medications

Aspirin

• Low to moderate bleeding risk procedures:

  • Continue aspirin throughout perioperative period for patients with high cardiovascular risk 1
  • For patients taking aspirin without specific medical indications, discontinue until directed by surgical team 1

• High bleeding risk procedures (intracranial, spinal, posterior chamber eye surgery):

  • Discontinue aspirin 7 days before surgery 1, 2

P2Y12 Inhibitors

• Clopidogrel: Discontinue 5 days before elective surgery 1
• Ticagrelor: Discontinue 3-5 days before elective surgery 1
• Prasugrel: Discontinue 7 days before elective surgery 1

Special Considerations for Coronary Stents

• Drug-eluting stents: Delay elective surgery for at least 6 months after placement 3
• Bare metal stents: Delay elective surgery for at least 3 months after placement 1
• For urgent surgery within these timeframes:
  • Continue aspirin throughout perioperative period
  • Consult cardiology for risk assessment and management 1
  • Consider maintaining dual antiplatelet therapy if bleeding risk is acceptable 1

Anticoagulant Medications

Direct Oral Anticoagulants (DOACs)

• Apixaban, Dabigatran, Rivaroxaban:
  • Low bleeding risk procedures: Discontinue 2 days before surgery 1, 4
  • High bleeding risk procedures: Discontinue 3-5 days before surgery 1, 5, 4
  • For patients with renal impairment: Extend discontinuation period (e.g., dabigatran 3-5 days if CrCl <50 mL/min) 5

Warfarin

• Elective surgery: Discontinue 5 days before procedure and check INR (<1.5 is safe for surgery) 1, 2
• High thromboembolic risk patients: Consider bridging with therapeutic LMWH or UFH 1
  • Start bridging 1 day after acenocoumarol interruption or 2 days after warfarin interruption
  • Last dose of LMWH should be administered at least 12 hours before procedure

Postoperative Resumption

• Antiplatelet agents: Resume within 24 hours after surgery if hemostasis is adequate 1, 3
• Anticoagulants:
  • Warfarin: Resume 1-2 days after surgery depending on hemostatic status 1
  • DOACs: Resume 1 day after low-bleeding-risk procedures, 2 days after high-bleeding-risk procedures 4
  • For high bleeding risk: Consider delaying full anticoagulation for 48-72 hours 1

Procedure-Specific Considerations

Cardiac Surgery (CABG)

• Aspirin: Continue throughout perioperative period if possible 1, 6
• Clopidogrel/Ticagrelor: Discontinue for at least 24 hours before urgent CABG 1
• Glycoprotein IIb/IIIa inhibitors: Discontinue 2-4 hours before surgery (eptifibatide/tirofiban) or 12 hours (abciximab) 1

Urological Procedures

• Laser prostate surgery: Can be safely performed with therapeutic INR in high-risk patients 1
• TURP: Associated with increased bleeding risk with anticoagulants/antiplatelets 1
• Prostate biopsy: Can be performed safely on low-dose aspirin with minor increased bleeding risk 1
• Percutaneous nephrolithotomy: Discontinue oral anticoagulants/antiplatelets with bridging as needed 1

Risk Assessment and Multidisciplinary Approach

• For patients with recent coronary stents or high cardiovascular risk, consult with cardiology before discontinuing antiplatelet therapy 1
• For patients with mechanical heart valves or high thromboembolic risk, consider heparin bridging when stopping warfarin 1
• For emergency procedures, consult with hematology/cardiology experts and consider reversal agents if needed 1, 4

Common Pitfalls to Avoid

1. Discontinuing dual antiplatelet therapy within 6 months of drug-eluting stent placement (high risk of stent thrombosis) 1, 3
2. Stopping aspirin in high cardiovascular risk patients for low bleeding risk procedures 1, 3
3. Inadequate bridging for high thromboembolic risk patients 1
4. Delaying resumption of antiplatelet therapy postoperatively (should restart within 24 hours when hemostasis is adequate) 1, 7
5. Using LMWH as replacement for antiplatelet therapy (does not protect against stent thrombosis) 7

By following these medication-specific protocols and considering both bleeding and thrombotic risks, perioperative management of antithrombotic medications can be optimized to improve patient outcomes.