How long should medications be held before surgery?

Perioperative Medication Management Guidelines

For most medications, discontinuation should be based on the medication's half-life, with most medications requiring discontinuation 3-5 half-lives before surgery to minimize perioperative risks while maintaining disease control.

General Principles for Medication Discontinuation

• Most medications should be held for a duration based on their pharmacokinetic properties, particularly their half-life, with the goal of clearing approximately 88% of the drug (achieved after 3 half-lives) 1
• The decision to hold medications must balance the risk of perioperative complications against the risk of disease flare or loss of therapeutic control 1
• Shared decision-making between the patient, surgeon, and prescribing physician is essential, especially for medications treating chronic conditions 1

Medication-Specific Recommendations

Biologics and Disease-Modifying Antirheumatic Drugs (DMARDs)

• For biologics (e.g., adalimumab, infliximab), plan surgery at the end of the dosing cycle 1

  • Example: For adalimumab (dosed every 2 weeks), schedule surgery in week 3
  • Example: For infliximab (dosed every 8 weeks), schedule surgery in week 9
  • Example: For rituximab (dosed every 6 months), schedule surgery in month 7

• JAK inhibitors should be withheld for at least 3 days prior to surgery 1

  • This includes tofacitinib, baricitinib, and upadacitinib
  • This recommendation has been updated from previous guidelines that recommended 7 days 1

• For non-severe SLE patients, withhold mycophenolate mofetil, azathioprine, cyclosporine, and tacrolimus 1 week prior to surgery 1

• For severe SLE patients, continue these medications through surgery to prevent disease flares 1

GLP-1 Receptor Agonists

• For patients taking GLP-1 receptor agonists for weight loss, hold for at least three half-lives before the procedure 1
  • For semaglutide, this would be approximately 3 weeks 1
• For patients taking GLP-1 receptor agonists for diabetes, consult with the treating endocrinologist regarding the risks and benefits of holding the medication 1
• If unable to hold for the recommended period, implement aspiration risk reduction strategies including:
  • Consider postponement of elective procedures
  • Clear fluid diet before pre-operative fasting
  • Prokinetic medications such as metoclopramide 1

Dietary Supplements

• Most herbal supplements should be discontinued 2 weeks before surgery 1
• Supplements affecting blood glucose (e.g., alpha-lipoic acid, chromium, fenugreek) should be held for 2 weeks 1
• Supplements with antiplatelet effects (e.g., garlic, ginkgo, vitamin E) should be held for 2 weeks 1
• Supplements affecting serotonin levels:
  • St. John's wort: hold for 2 weeks 1
  • 5-hydroxytryptophan, L-tryptophan: hold for 24 hours 1

Other Medications

• Phentermine and phentermine-containing medications should be discontinued at least 4 days before procedures requiring anesthesia due to sympathomimetic effects 2
• Ergotamine should be held at least 2 days prior to operation due to potential vasoconstriction and risk of serotonin syndrome 1
• Opioid antagonists:
  • Naltrexone (intramuscular): hold 24-30 days after the last injection 1
  • Naltrexone (oral): hold 3-4 days 1
• Melatonin can be continued as it may provide benefit in the perioperative period 1

Special Considerations

• For patients with difficult-to-control conditions, the risk of disease flare may outweigh the risk of continuing medication 1
• Patients with a history of infections or prosthetic joint infections may benefit from longer medication holds 1
• For medications with multiple effects or drug interactions (e.g., kratom, Garcinia cambogia), discontinuation is strongly recommended 1

Restarting Medications After Surgery

• Restart medications once the risk of postoperative complications (e.g., bleeding, infection) is minimal 1
• For medications affecting coagulation, restart only when the risk of postoperative bleeding is minimal 1
• For immunosuppressive medications, consider the risk of infection at the surgical site before restarting 1

Common Pitfalls to Avoid

• Failing to recognize medications with sympathomimetic properties that require specific washout periods 2
• Stopping medications abruptly when they require tapering (e.g., butalbital should be weaned over 2 weeks if used long-term) 1
• Overlooking the potential for withdrawal symptoms when discontinuing certain medications 1
• Not accounting for drug interactions between perioperative medications and the patient's regular medications 1