What medications should be held prior to abdominal hernia surgery, including anticoagulants (Anti-Coagulants) like warfarin, aspirin, and clopidogrel (Antiplatelet), and nonsteroidal anti-inflammatory drugs (NSAIDs)?

Medication Management Prior to Abdominal Hernia Surgery

For abdominal hernia surgery, aspirin should be continued perioperatively, while clopidogrel and other P2Y12 inhibitors must be stopped 5-7 days before surgery, NSAIDs should be discontinued 5 half-lives preoperatively in bleeding-risk patients, and warfarin should be stopped 5 days before with bridging only for high thrombotic risk patients. 1, 2

Antiplatelet Agents

Aspirin Management

• Continue aspirin (75-325 mg) through surgery for patients on secondary prevention (history of MI, stroke, or cardiovascular disease), as discontinuation increases cardiovascular events three-fold within 7-10 days 1
• Aspirin continuation does not significantly increase bleeding complications in hernia repair, with multiple studies showing safety in both open and laparoscopic approaches 3, 4, 5
• The only increased risk with continued aspirin is mild ecchymosis (bruising), which does not require intervention 5
• Do not stop aspirin unless the patient is on it for primary prevention only and has no cardiovascular risk factors 1

Clopidogrel and P2Y12 Inhibitors

• Stop clopidogrel 5 days before surgery in patients at low thrombotic risk 1, 6, 2
• Stop prasugrel 7 days before surgery due to longer duration of action 1
• Stop ticagrelor 5 days before surgery 1
• The FDA label for clopidogrel specifically states: "When possible, interrupt therapy with clopidogrel for five days prior to surgery with a major risk of bleeding" 2

Dual Antiplatelet Therapy (DAPT) - High Risk Patients

For patients with recent coronary stents or acute coronary syndrome:

• Continue aspirin and consult cardiology before stopping the P2Y12 inhibitor 1, 6
• Drug-eluting stents placed within 6-12 months are high-risk; bare metal stents within 1 month are high-risk 1, 6
• Consider deferring elective surgery until safer to interrupt DAPT 6
• If surgery cannot be delayed, continue aspirin and stop only the P2Y12 inhibitor with cardiology approval 1
• Resume P2Y12 inhibitor within 1-2 days post-operatively if no bleeding complications 6, 2

Anticoagulants

Warfarin Management

• Stop warfarin 5 days before surgery for all patients 1
• Check INR prior to surgery to ensure INR <1.5 1
• Bridging with low molecular weight heparin (LMWH) is only indicated for high thrombotic risk patients, including: 1
  • Mechanical mitral valve
  • Mechanical aortic valve with atrial fibrillation
  • Atrial fibrillation with CHADS-VASc score >5
  • Venous thromboembolism within 3 months
  • Severe thrombophilia (protein C/S deficiency, antiphospholipid syndrome)
• Do not bridge patients with atrial fibrillation and lower CHADS-VASc scores, as bridging increases bleeding risk without reducing thrombotic events 1
• Start LMWH 2 days after stopping warfarin; give last LMWH dose 24 hours before surgery 1
• Resume warfarin evening of surgery with usual dose 1
• One study showed hernia repair can be performed safely with INR <3, though this is not standard practice 7

Direct Oral Anticoagulants (DOACs)

• For low-risk procedures: omit morning dose on day of surgery 1
• For high-risk procedures (hernia repair): take last dose at least 48 hours before surgery 1
• For dabigatran with creatinine clearance 30-50 mL/min: take last dose 72 hours before surgery 1
• Do not use bridging therapy with DOACs 1
• Resume DOAC after adequate hemostasis is achieved 1

NSAIDs

Preoperative Management

• Discontinue NSAIDs for 5 elimination half-lives in patients at bleeding risk 8
• Common NSAIDs and their discontinuation times:
  • Ibuprofen (half-life 2 hours): stop 10 hours before surgery
  • Naproxen (half-life 12-17 hours): stop 3-4 days before surgery
  • Ketorolac (half-life 5-6 hours): stop 24-30 hours before surgery
• NSAIDs should be avoided in patients with: 8, 9
  • Active peptic ulcer disease
  • History of NSAID-associated GI bleeding
  • Concurrent anticoagulation
  • Severe renal impairment
  • Decompensated cirrhosis

Postoperative Use

• IV NSAIDs (such as ketorolac 15-30 mg IV every 6 hours) can be combined with IV acetaminophen for multimodal analgesia postoperatively 8
• Limit ketorolac to maximum 5 days 8
• Use lowest effective dose for shortest duration 8

Critical Timing for Resumption

Restart Medications Post-Surgery

• Aspirin: Resume immediately or within 24 hours post-operatively 1
• Clopidogrel: Resume 1-2 days after surgery if no bleeding complications, preferably within 5 days for high-risk patients 1, 6, 2
• Warfarin: Resume evening of surgery with usual dose 1
• DOACs: Resume after adequate hemostasis 1

Common Pitfalls to Avoid

• Never stop aspirin in patients with recent coronary stents or acute coronary syndrome without cardiology consultation 1, 6
• Do not routinely bridge warfarin in low-risk patients (e.g., atrial fibrillation with CHADS-VASc <5), as this increases bleeding without reducing thrombotic events 1
• Do not bridge DOACs with heparin—this is not indicated and increases bleeding risk 1
• Do not give vitamin K >5 mg to reverse warfarin in high thrombotic risk patients, as this makes re-anticoagulation difficult 1
• Avoid platelet transfusions for antiplatelet reversal, as they do not reduce bleeding and may increase mortality 1