Should NSAIDs Be Stopped Prior to Surgery?
For most surgical procedures, NSAIDs should be discontinued 1-10 days preoperatively depending on the specific drug's half-life, with longer-acting agents requiring earlier cessation to minimize bleeding risk. 1
Drug-Specific Discontinuation Timeline
The timing of NSAID cessation varies significantly based on pharmacokinetics 1:
Short-acting NSAIDs (stop 1 day before surgery):
Intermediate-acting NSAIDs (stop 2-4 days before surgery):
- Etodolac (Lodine) - 2 days 1
- Indomethacin (Indocin) - 2 days 1
- Meloxicam (Mobic) - 4 days 1
- Naproxen (Aleve, Naprosyn) - 4 days 1, 3
- Nabumetone (Relafen) - 4 days 1
Long-acting NSAIDs (stop 6-10 days before surgery):
Bleeding Risk Considerations
NSAIDs increase perioperative bleeding through platelet inhibition, with risk amplified by:
- Longer drug half-lives (>6 hours show more complications) 4
- Concurrent anticoagulant or antiplatelet therapy (2.5x increased severe bleeding risk) 5
- Patient factors including older age, poor health, and bleeding history 2
The American Academy of Family Physicians emphasizes that naproxen's antiplatelet effects require appropriate discontinuation before surgical procedures 3. However, recent evidence suggests the bleeding risk may be overstated for certain procedures 6.
Procedure-Specific Exceptions
Minor procedures where continuation may be acceptable:
- Dental extractions (can be performed safely with local hemostatic measures) 5
- Dermatologic procedures (patients with normal bleeding time can continue therapy) 7
- Cataract surgery 5
For these low-bleeding-risk procedures, continuing NSAIDs may be reasonable if cardiovascular thrombotic risk is significant 3.
Postoperative Resumption
NSAIDs are recommended postoperatively for multimodal analgesia when bleeding risk permits:
- Strong evidence supports combining NSAIDs with opioids to reduce morphine consumption, sedation, nausea/vomiting, and ileus 5
- Both non-selective NSAIDs and COX-2 inhibitors show equivalent analgesic efficacy 5
- COX-2 selective agents may carry lower bleeding risk than non-selective NSAIDs 6
Critical Contraindications
Do not use NSAIDs perioperatively in patients with:
- Renal insufficiency (creatinine clearance <50 mL/min) 5
- Active renal hypoperfusion 5
- History of atherothrombosis (peripheral artery disease, stroke, MI) - avoid COX-2 inhibitors entirely 5
- Recent coronary stent placement (postpone elective surgery if possible) 8
Common Pitfalls
Avoid these errors:
- Failing to ask about over-the-counter NSAID use during medication reconciliation 3
- Not accounting for increased risk when NSAIDs are combined with anticoagulants (including therapeutic-dose enoxaparin, rivaroxaban, or warfarin) 5, 3
- Assuming all NSAIDs require the same discontinuation period 1
- Continuing NSAIDs beyond 7 days postoperatively in patients with atherothrombosis 5
High-Risk Surgery Considerations
For procedures with high bleeding risk (major orthopedic, abdominal, thoracic surgery, spinal fusion), the decision to discontinue NSAIDs should weigh thrombotic versus bleeding risks 5, 1. Spine surgeons specifically need awareness that medical consultants may underestimate bleeding complications (excessive intraoperative hemorrhage, seromas, hematomas, wound dehiscence) if NSAIDs are not stopped appropriately 1.