Should all medications be withheld on the day of surgery?

Perioperative Medication Management: What to Withhold on Day of Surgery

Not all medications should be withheld on the day of surgery. Medication management should be based on the specific medication's risk profile, potential for withdrawal, and impact on surgical outcomes. 1

General Principles for Medication Management

• Continue medications where abrupt discontinuation could lead to withdrawal or disease exacerbation (e.g., opioids, certain muscle relaxants, and most chronic disease medications) 1
• Withhold medications that significantly increase surgical risks (e.g., certain biologics, JAK inhibitors, SGLT2 inhibitors) 1
• Consider pharmacokinetics and pharmacodynamics when determining timing of medication cessation 1

Medications to Continue on Day of Surgery

Analgesics

• Opioid agonists: Continue on the morning of surgery to prevent withdrawal and maintain pain control 1
• Ergotamine: Hold at least 2 days prior to operation due to risk of vasoconstriction and potential interactions with anesthetics 1
• Tizanidine: Continue preoperatively including the day of surgery 1

Rheumatologic Medications

• Conventional DMARDs: Continue methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, and apremilast through surgery 1
• Glucocorticoids: Continue current daily dose rather than administering supraphysiologic doses 1
• For severe SLE patients: Continue mycophenolate mofetil, azathioprine, cyclosporine, tacrolimus, anifrolumab, and voclosporin 1

Medications to Withhold on Day of Surgery

Rheumatologic Biologics and JAK Inhibitors

• Biologics: Withhold all biologics prior to surgery and plan surgery after the next dose is due 1
• JAK inhibitors (tofacitinib, baricitinib, upadacitinib): Withhold for at least 3 days prior to surgery 1
• For non-severe SLE: Withhold mycophenolate mofetil, azathioprine, cyclosporine, tacrolimus, belimumab, and rituximab 1

Muscle Relaxants

• Cyclobenzaprine: Hold on day of operation due to anticholinergic effects and potential interactions with anesthetics 1
• Metaxalone: Hold on day of operation due to CNS effects 1
• Carisoprodol: Hold on day of operation; consider tapering if time permits 1

Migraine Medications

• Triptans: Hold on the day of operation due to potential serotonin syndrome risk with perioperative medications 1
• Butalbital: Hold on day of operation; for long-term users, wean slowly over 2 weeks if possible 1

Diabetes Medications

• SGLT2 inhibitors: Withhold the day before and day of surgery to reduce risk of ketoacidosis 1
• Metformin: Withhold during periods of restricted food and fluid intake to reduce risk of lactic acidosis 2
• GLP-1 receptor agonists: For weekly dosed GLP-1 RAs, consider withholding for 1 week pre-operatively; for daily dosed, withhold on day of procedure 1

Special Considerations

• Risk of withdrawal: For medications with significant withdrawal potential (e.g., baclofen, carisoprodol), tapering rather than abrupt discontinuation is recommended 1
• Restart timing: For withheld rheumatologic medications, restart once wound shows evidence of healing, sutures/staples are out, and there's no significant swelling, erythema, drainage, or infection (typically ~14 days) 1
• Diabetes medications: For SGLT2 inhibitors, restart once eating and drinking normally (usually 24-48 hours after surgery) 1

Common Pitfalls to Avoid

• Abrupt discontinuation of medications with withdrawal potential can lead to significant morbidity 1
• Continuing SGLT2 inhibitors through surgery increases risk of ketoacidosis, especially with prolonged fasting 1
• Withholding all medications unnecessarily can lead to disease exacerbation and complications 3, 4
• Failure to restart medications in a timely manner can lead to disease flares 1

Remember that these recommendations are based on elective surgeries and may need modification for emergency procedures, where the risk-benefit analysis may differ 1, 5.