How soon should a patient with no significant medical history stop taking naproxen (nonsteroidal anti-inflammatory drug) before undergoing surgery?

Timing of Naproxen Discontinuation Before Surgery

Stop naproxen 4 days before surgery to allow adequate clearance of its antiplatelet effects and minimize perioperative bleeding risk. 1, 2

Pharmacologic Rationale

Naproxen has reversible antiplatelet properties with a half-life of 7 to 15 hours, which is longer than many other NSAIDs. 1 This extended half-life necessitates a longer preoperative discontinuation period compared to shorter-acting NSAIDs like ibuprofen (which requires only 1 day). 2

• The American College of Chest Physicians guidelines specifically note that naproxen falls into the intermediate half-life category (7-15 hours) among NSAIDs. 1
• Unlike aspirin or clopidogrel, which irreversibly inhibit platelet function and require 7-10 days of interruption, naproxen's reversible mechanism allows for shorter discontinuation periods. 1

Evidence-Based Discontinuation Timeline

The 4-day preoperative discontinuation window for naproxen is supported by spine surgery literature and reflects the drug's pharmacokinetic profile. 2

• Stop naproxen at least 4 days before surgery for major procedures with significant bleeding risk. 2
• This timing allows for complete elimination of the antiplatelet effect while minimizing the period without anti-inflammatory coverage. 1

Comparison with Other NSAIDs

The discontinuation timeline varies significantly among NSAIDs based on their half-lives: 2

• 1 day preoperatively: Ibuprofen, diclofenac, ketorolac
• 2 days preoperatively: Etodolac, indomethacin
• 4 days preoperatively: Naproxen, meloxicam, nabumetone
• 6 days preoperatively: Oxaprozin
• 10 days preoperatively: Piroxicam

Postoperative Resumption

Resume naproxen 24-48 hours after surgery once adequate hemostasis is achieved. 1

• Naproxen has demonstrated significant efficacy in treating postoperative pain and can help reduce opioid requirements. 3
• Studies show naproxen does not demonstrate increased bleeding rates when used appropriately in the postoperative period. 3

Critical Considerations and Pitfalls

Patients frequently fail to report over-the-counter NSAID use, making thorough medication reconciliation essential. 4

• Many patients do not consider naproxen (available as Aleve) a "real medication" and may not disclose its use without direct questioning. 4
• Combining naproxen with antiplatelet agents (aspirin, clopidogrel) or anticoagulants significantly increases bleeding risk and may require longer discontinuation periods or alternative management strategies. 1, 4
• For minor procedures with minimal bleeding risk (dental procedures, minor dermatologic procedures, cataract surgery), continuing naproxen may be acceptable if pain control is critical, though this should be discussed with the surgical team. 1

Special Populations

For patients with cardiovascular disease taking both aspirin and naproxen: 1

• Stop naproxen 4 days preoperatively while continuing aspirin in moderate-to-high cardiovascular risk patients. 1, 4
• The 2022 American College of Chest Physicians guidelines note that postoperative NSAID use may impair the cardioprotective effects of aspirin, which should be considered when planning postoperative analgesia. 1