What medications should be continued before surgery?

Perioperative Medication Management

Most chronic medications should be continued through the morning of surgery, with specific exceptions for ACE inhibitors/ARBs (consider holding), antiplatelet agents (timing depends on indication), and certain diabetes medications.

Cardiovascular Medications

Beta-Blockers

• Continue beta-blockers perioperatively in all patients already taking them 1, 2
• Abrupt discontinuation is potentially harmful and can precipitate severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 1, 2
• The FDA label for metoprolol explicitly states that chronically administered beta-blocking therapy should not be routinely withdrawn prior to major surgery 2
• Do NOT initiate beta-blockers on the day of surgery in beta-blocker-naive patients 1

ACE Inhibitors and ARBs

• Discontinuation perioperatively may be considered due to increased risk of intraoperative hypotension requiring vasopressor support 1
• If continued, patients must be hemodynamically stable with good renal function and normal electrolytes 3
• A randomized study demonstrated that patients who continued ARBs had significantly more hypotensive episodes (mean 2±1 vs 1±1 episodes), longer duration of hypotension (8±7 vs 3±4 minutes), and greater vasopressor requirements 4
• If held, restart as soon as clinically feasible postoperatively 1

Statins

• Continue statins perioperatively without interruption 1
• Discontinuation is potentially harmful and not recommended 1

Clonidine and Alpha-2 Agonists

• Continue clonidine perioperatively - abrupt discontinuation is potentially harmful 1
• Do NOT initiate alpha-2 agonists for cardiac event prevention 1

Antiplatelet Therapy

Aspirin

• Continue aspirin in patients on secondary prevention (established cardiovascular disease) 1, 3
• May discontinue 7-10 days before surgery for primary prevention only, if bleeding risk exceeds cardiac risk 3
• Initiate aspirin within 6 hours postoperatively if not given preoperatively 1

P2Y12 Inhibitors (Clopidogrel, Ticagrelor, Prasugrel)

• For elective surgery: Discontinue clopidogrel and ticagrelor at least 5 days before surgery; prasugrel at least 7 days 1
• For urgent surgery: Discontinue at least 24 hours before to reduce major bleeding 1
• Critical exception - recent PCI with stents: Continue dual antiplatelet therapy and delay surgery if possible for 30 days after bare-metal stent, 6-12 months after drug-eluting stent 1
• Restart P2Y12 inhibitor as soon as possible postoperatively 1

Diabetes Medications

GLP-1 Receptor Agonists (Semaglutide, Liraglutide, etc.)

• Continue GLP-1 agonists through surgery 1
• Implement full aspiration risk assessment and mitigation strategies (rapid sequence induction, cricoid pressure consideration) 1
• This represents the most current 2025 multidisciplinary consensus, reversing prior recommendations to hold these medications 1

SGLT-2 Inhibitors (Empagliflozin, Dapagliflozin, etc.)

• Omit SGLT-2 inhibitors the day before and day of surgery due to euglycemic ketoacidosis risk 1

Insulin

• Continue basal insulin at reduced dose (typically 50% of usual NPH dose) or use insulin infusion for tight control 1
• Target postoperative glucose <180 mg/dL to reduce infection risk 1

Psychiatric Medications

Antidepressants (SSRIs, SNRIs, TCAs)

• Continue all antidepressants perioperatively to avoid withdrawal 5, 6
• Monitor for serotonin syndrome if multiple serotonergic agents used 5

MAO Inhibitors

• Continue MAOIs using MAOI-safe anesthetic techniques (avoid indirect-acting vasopressors, meperidine, dextromethorphan) 6
• Modern practice supports continuation rather than discontinuation 6

Weight Loss Medications

Phentermine

• Discontinue phentermine at least 4 days before surgery due to sympathomimetic effects causing both hyperadrenergic responses and paradoxical refractory hypotension 7

Antirheumatic Medications

Conventional DMARDs

• Continue methotrexate and hydroxychloroquine through surgery 1
• Hold mycophenolate, azathioprine, cyclosporine, tacrolimus for 1 week before surgery in non-severe SLE 1

Biologic DMARDs

• Plan surgery at the end of the dosing cycle (e.g., month 7 for rituximab dosed every 6 months; week 3 for adalimumab dosed every 2 weeks) 1

JAK Inhibitors

• Hold tofacitinib, baricitinib, upadacitinib for at least 3 days before surgery 1

Pain Medications

Opioids and Buprenorphine

• Continue chronic opioid therapy perioperatively to avoid withdrawal 1

Migraine Medications

• Continue ergotamine derivatives but hold at least 2 days before surgery 1
• Continue triptans but hold on day of surgery 1
• Continue CGRP antagonists (erenumab, fremanezumab, galcanezumab) throughout perioperative period 1

Critical Threshold for Surgery Delay

Consider deferring elective surgery if blood pressure ≥180/110 mmHg 1