Can existing medications be continued after surgery?

Perioperative Medication Management

General Principle for Most Medications

Continue most chronic medications perioperatively, with specific exceptions for antithrombotic agents that require temporary interruption based on bleeding risk. 1

The default approach is medication continuation unless there is a specific reason to stop, as abrupt discontinuation of chronic therapies can precipitate adverse cardiovascular and metabolic events. 1

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Cardiovascular Medications

Beta-Blockers

• Continue beta-blockers in patients already taking them chronically 1
• Stopping beta-blockers perioperatively increases risk of rebound tachycardia, hypertension, and myocardial ischemia 1
• Resume beta-blockers postoperatively guided by clinical circumstances (heart rate, blood pressure) 1
• Critical pitfall: Never start beta-blockers on the day of surgery—this increases mortality risk 1

Statins

• Continue statins in patients currently taking them 1
• Statins reduce perioperative cardiovascular events and should not be interrupted 1
• For vascular surgery patients not on statins, perioperative initiation is reasonable 1

ACE Inhibitors/ARBs

• Continuation of ACE inhibitors or ARBs is reasonable perioperatively 1
• If held before surgery due to hypotension concerns, restart as soon as clinically feasible postoperatively 1
• These agents may cause intraoperative hypotension but stopping them risks rebound hypertension and loss of cardioprotection 1

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Antithrombotic Therapy

Aspirin (ASA)

• Continue aspirin for most surgical procedures 1
• Only stop aspirin ≤7 days before surgery for high-bleeding-risk procedures in confined spaces (intracranial, spinal canal, posterior eye chamber) 1, 2
• For patients requiring aspirin interruption, stop ≤7 days (not 7-10 days) before surgery 1
• Resume aspirin within 24 hours after surgery when hemostasis is achieved 1

P2Y12 Inhibitors (Clopidogrel, Prasugrel, Ticagrelor)

Preoperative interruption timing: 1, 2

• Clopidogrel: Stop 5 days before surgery
• Prasugrel: Stop 7 days before surgery
• Ticagrelor: Stop 3-5 days before surgery

Postoperative resumption: 1

• Resume within 24 hours after surgery when hemostasis is adequate
• For patients with coronary stents, resume as soon as possible to prevent stent thrombosis 1

Dual Antiplatelet Therapy (DAPT) and Coronary Stents

For patients with recent stent placement: 1, 2

• Continue DAPT during urgent surgery within first 4-6 weeks after bare-metal stent or within 6-12 months after drug-eluting stent, unless bleeding risk outweighs stent thrombosis risk 1
• If P2Y12 inhibitor must be stopped, continue aspirin and restart P2Y12 inhibitor as soon as possible postoperatively 1
• For elective surgery with stents placed 6-12 weeks ago, either continue both agents or stop only the P2Y12 inhibitor 7-10 days before surgery 1

Warfarin

• Stop warfarin 5-6 days before surgery to allow INR normalization 1
• Resume warfarin 12-24 hours after surgery (evening of or next day) when hemostasis is established 1
• Bridging anticoagulation with heparin/LMWH may be needed for high-risk patients (mechanical heart valves, recent VTE) 1

Direct Oral Anticoagulants (DOACs)

Dabigatran: 1

• Stop 5 days before major surgery, neuraxial blockade, or in renal dysfunction
• Stop 3 days before other surgeries

Rivaroxaban/Apixaban: 1

• Stop 3 days before major surgery, neuraxial blockade, or in renal dysfunction
• Stop 24-48 hours before other surgeries
• Bridging anticoagulation is NOT required except for recent (<3 months) VTE 1

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Minor Procedures (Dental, Dermatologic, Ophthalmologic)

Continue all antiplatelet therapy without interruption for minor procedures 3, 2

• Evidence shows no increase in major bleeding with continuation of single or dual antiplatelet therapy during minor dental procedures 3
• Local hemostatic measures are sufficient to control bleeding 3
• Critical pitfall: Interrupting DAPT for minor procedures risks catastrophic stent thrombosis with no meaningful bleeding benefit 3

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CABG Surgery Specific Guidance

• Continue aspirin perioperatively for CABG 1
• Stop P2Y12 inhibitors 3-7 days before CABG (clopidogrel 5 days, prasugrel 7 days, ticagrelor 3-5 days) 1
• Resume both aspirin and P2Y12 inhibitor within 24 hours after CABG 1
• Delay resumption if post-CABG thrombocytopenia develops (platelet count <50,000/μL) 1

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Disease-Modifying Agents (Example: Sulfasalazine)

• Resume 24 hours postoperatively for low-to-moderate bleeding risk procedures once oral intake is tolerated 4
• For high bleeding risk procedures, resume 48-72 hours postoperatively 4
• Ensure adequate bowel function before restarting, as sulfasalazine requires intestinal absorption 4
• Do not restart before adequate hemostasis is established 4

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Key Principles

Timing of resumption prioritizes thrombotic risk over bleeding risk: 1, 2

• Most medications should resume within 24 hours postoperatively
• The risk of perioperative MI and stent thrombosis from stopping antiplatelet therapy exceeds surgical bleeding risk for most procedures 2

Common pitfalls to avoid: 1, 2

• Do not routinely use platelet function testing to guide management
• Do not use bridging therapy with glycoprotein IIb/IIIa inhibitors routinely
• Do not stop DAPT within first month after stent placement for elective surgery