What medications should be stopped before surgery?

Medications to Stop Before Surgery

For most surgeries, aspirin should be continued perioperatively, while P2Y12 inhibitors (clopidogrel, ticagrelor, prasugrel) and NSAIDs must be stopped at specific intervals based on their pharmacokinetics, with anticoagulants requiring 3-5 days of discontinuation before elective procedures. 1, 2

Antiplatelet Agents

Aspirin

• Continue aspirin (75-325 mg daily) through the perioperative period for most surgeries, including cardiac procedures, as the thrombotic risk of discontinuation outweighs bleeding risk 2, 1
• Stop aspirin only for high bleeding-risk surgeries where bleeding occurs in closed spaces: intracranial neurosurgery, spinal canal surgery, or posterior chamber eye surgery 2, 1
• When discontinuation is necessary, stop 5-7 days before surgery to allow complete platelet turnover 1
• Resume aspirin 12-24 hours postoperatively when hemostasis is achieved 2, 1

Clopidogrel

• Stop 5 days before elective surgery to allow restoration of platelet function 2, 3
• The FDA label specifically states: "Discontinue 5 days prior to elective surgery that has a major risk of bleeding" 3
• For urgent surgery, can be stopped 24 hours before if bleeding risk is acceptable 2
• Resume within 12-24 hours postoperatively when hemostasis permits 2, 1

Ticagrelor

• Stop 3-5 days before elective non-cardiac surgery (shorter than traditional 7-10 days due to reversible platelet inhibition) 4, 2
• For CABG specifically, discontinue at least 5 days before surgery 4
• For urgent CABG, stop at least 24 hours before to reduce major bleeding 4
• Resume within 24 hours after surgery when hemostasis is achieved 4

Prasugrel

• Stop 7 days before surgery to allow complete platelet function restoration 2, 1
• Resume postoperatively when bleeding risk is acceptable 2

NSAIDs

General NSAIDs

• Stop for 5 elimination half-lives of the specific medication before surgery 1
• Specific timing by drug:
  • Ibuprofen, Ketorolac, Diclofenac: 1-2 days before surgery 1, 5
  • Naproxen: 2-4 days before surgery 1, 5
  • Meloxicam: 4 days before surgery 5
  • Piroxicam: 10 days before surgery 1, 5
• NSAIDs should be avoided in patients with preexisting renal disease, heart failure, or cirrhosis 1
• Avoid NSAIDs in patients taking anticoagulants due to 3-6 fold increased GI bleeding risk 1

Anticoagulants

Warfarin

• Stop 4-5 days before surgery to allow INR normalization (target INR <1.5) 2, 1
• For low thrombotic risk patients, no bridging therapy is needed 2
• For high thrombotic risk patients, bridge with therapeutic-dose heparin or LMWH when INR falls below therapeutic range 2
• Resume 12-24 hours postoperatively when bleeding risk is acceptable 2

Novel Oral Anticoagulants (NOACs)

• Rivaroxaban: stop 3 days before surgery 2, 1
• Dabigatran: stop 2-5 days before surgery depending on renal function and bleeding risk 2, 1
• Apixaban: stop 2 days before surgery 5
• For minor bleeding-risk procedures, NOACs do not require modification 2, 1

Critical Considerations for Patients with Coronary Stents

This is the highest-risk scenario where premature antiplatelet discontinuation can be fatal:

• Delay elective surgery for at least 1 month after bare-metal stent (BMS) placement 2
• Delay elective surgery for at least 6 months after drug-eluting stent (DES) placement 2, 4
• Within these timeframes, dual antiplatelet therapy (DAPT) should not be interrupted unless bleeding risk is life-threatening 1
• If surgery cannot be delayed and DAPT must be interrupted, continue aspirin and stop only the P2Y12 inhibitor, restarting it within 5 days postoperatively 2
• Never stop both antiplatelet agents simultaneously in stent patients unless bleeding risk is life-threatening 2
• Mandatory cardiology consultation when urgent surgery is required within these timeframes 2, 1

Surgery-Specific Bleeding Risk Stratification

High Bleeding Risk (Stop All Antiplatelet/Anticoagulant Agents)

• Intracranial neurosurgery 2, 1
• Spinal canal surgery 2, 1
• Posterior chamber eye surgery 2, 1

Moderate Bleeding Risk (Continue Aspirin, Stop P2Y12 Inhibitors)

• Coronary artery bypass grafting 2
• Major abdominal surgery 2
• Orthopedic surgery 2

Low Bleeding Risk (Continue All Antiplatelet Agents)

• Dental procedures 1, 2
• Minor dermatologic procedures 1
• Cataract surgery 1
• Ureteroscopy 1

Critical Pitfalls to Avoid

• Do not use heparin bridging as a substitute for antiplatelet therapy in stent patients—it does not prevent stent thrombosis 2
• Do not routinely bridge low-risk patients on warfarin—this increases bleeding without reducing thrombotic events 2
• Do not stop aspirin in patients with recent MI or stroke unless absolutely necessary for high bleeding-risk surgery 1
• Do not combine NSAIDs with anticoagulants without GI prophylaxis due to dramatically increased bleeding risk 1
• The thrombotic risk of preoperative antiplatelet withdrawal overwhelms any benefit of regional or neuraxial blockade 6

Resumption of Therapy Postoperatively

• Aspirin: resume within 12-24 hours when hemostasis is achieved (maximal effect within minutes) 2, 1
• Clopidogrel: resume within 12-24 hours (maximal effect in 4-5 days with maintenance dose, or 12-15 hours with loading dose) 2, 1
• Ticagrelor: resume within 24 hours (maximal effect within 2 hours) 4, 1
• Warfarin: resume 12-24 hours postoperatively when bleeding risk is acceptable 2