When should naproxen (nonsteroidal anti-inflammatory drug) be held prior to surgery?

Perioperative Management of Naproxen

Naproxen should be discontinued 4 days prior to surgery to minimize the risk of perioperative bleeding complications. 1

Mechanism and Bleeding Risk

• Naproxen, like other NSAIDs, has antiplatelet effects that can increase the risk of perioperative bleeding due to its inhibition of platelet aggregation 2
• The antiplatelet effects of NSAIDs are an important consideration in the perioperative setting and require appropriate discontinuation before surgical procedures 2
• Unlike aspirin, which irreversibly inhibits platelet function, naproxen's effects are reversible but still require adequate time for clearance before surgery 1

Timing of Discontinuation

• Naproxen (Aleve, Naprosyn, Anaprox) should be discontinued 4 days before surgery to allow adequate time for its antiplatelet effects to resolve 1
• This timeframe corresponds to approximately five elimination half-lives of the medication, allowing for sufficient clearance from the system 2
• The 4-day discontinuation period for naproxen differs from other NSAIDs, which have varying recommended discontinuation periods:
  • 1 day: Diclofenac (Voltaren), Ibuprofen (Advil, Motrin), Ketorolac (Toradol) 1
  • 2 days: Etodolac (Lodine), Indomethacin (Indocin) 1
  • 6 days: Oxaprozin (Daypro) 1
  • 10 days: Piroxicam (Feldene) 1

Special Considerations

• For patients at high risk of cardiovascular events who are taking naproxen for secondary prevention, the decision to discontinue should carefully weigh thrombotic versus bleeding risks 2
• For minor procedures with minimal bleeding risk (dental, dermatologic, cataract surgery), continuing naproxen may be considered if the cardiovascular risk is significant 2
• For major surgeries or procedures with high bleeding risk, the full 4-day discontinuation period should be strictly followed 1

Resumption After Surgery

• Naproxen can typically be resumed 24-48 hours after surgery when adequate hemostasis has been achieved 3
• Earlier resumption may be appropriate for patients with significant pain needs, as naproxen has demonstrated efficacy in treating postoperative pain while potentially reducing opioid requirements 3, 4
• When restarting naproxen postoperatively, consider the potential for increased bleeding risk if combined with other anticoagulants or antiplatelet medications 2

Potential Pitfalls and Caveats

• Failure to discontinue naproxen appropriately before surgery can lead to excessive intraoperative hemorrhage, postoperative seromas, hematomas, and wound dehiscence 1
• The bleeding risk is further increased when naproxen is combined with anticoagulants or other antiplatelet medications 2
• Patients may not report over-the-counter use of naproxen unless specifically asked, so thorough medication reconciliation is essential 2
• For emergency surgeries when naproxen has not been discontinued, the surgical team should be made aware of the increased bleeding risk 1

Algorithm for Perioperative Naproxen Management

1. For elective surgeries:

   • High bleeding risk procedures: Discontinue naproxen 4 days before surgery 1
   • Low bleeding risk procedures: Consider discontinuing naproxen 2-3 days before surgery 2, 1
   • Minimal bleeding risk procedures (dental, dermatologic): May continue naproxen if cardiovascular risk is significant 2

2. For emergency surgeries:

   • Inform surgical team about naproxen use 1
   • Anticipate potential for increased bleeding 2, 1
   • Consider techniques to minimize bleeding risk 1

3. For postoperative resumption:

   • Resume naproxen 24-48 hours after surgery when hemostasis is adequate 3
   • Consider earlier resumption if pain control is inadequate and bleeding risk is acceptable 3, 4