Perioperative Medication Management on Day of Surgery
Direct Answer
Most chronic medications should be continued on the morning of surgery, with specific exceptions for medications that significantly increase surgical risk or have problematic perioperative interactions. The decision depends on the medication class and individual patient factors, prioritizing prevention of withdrawal, disease exacerbation, and maintenance of hemodynamic stability 1, 2.
Medications to CONTINUE on Day of Surgery
Cardiovascular Medications
- Beta-blockers must be continued in all patients already taking them to prevent severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 3, 2.
- Statins should be continued without interruption, as discontinuation is potentially harmful 2.
- Clonidine must be continued to avoid rebound hypertension and other withdrawal complications 2.
Pain Medications
- Chronic opioid agonists should be continued on the morning of surgery to prevent withdrawal and maintain pain control 3, 1.
- Acetaminophen should be continued including the day of surgery 3.
- Butorphanol, nalbuphine, and pentazocine should be continued as they act synergistically with full mu agonists rather than blocking them 3.
- Buprenorphine management requires individualization based on daily dose, indication (pain vs. dependency), relapse risk, and expected postoperative pain, but current evidence supports continuation in most cases 3.
Psychiatric Medications
- Antidepressants (SSRIs, SNRIs, TCAs) should be continued to avoid withdrawal syndrome, though monitoring for serotonin syndrome is essential when combined with other serotonergic agents 2, 4.
Rheumatologic Medications
- Conventional DMARDs (methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, apremilast) should be continued through surgery 1, 2.
- Glucocorticoids should be continued at the current daily dose rather than administering supraphysiologic "stress doses" 1.
Muscle Relaxants
- Tizanidine should be continued preoperatively including the day of surgery 1.
Medications to HOLD on Day of Surgery
Diabetes Medications
- SGLT2 inhibitors must be discontinued 3-4 days before surgery due to euglycemic ketoacidosis risk 3, 1, 2.
- Metformin should be withheld on the day of surgery 3.
- Basal insulin should be reduced to half of NPH dose or 75-80% of long-acting analog dose on the morning of surgery 3.
Headache Medications
- Triptans should be held on the day of operation due to potential serotonin syndrome risk with perioperative medications and multiple drug-drug interactions involving CYP metabolism 3, 1.
- Ergotamine should be held at least 2 days prior to operation due to risk of severe hypertensive response when combined with local anesthetics and epinephrine, plus prolonged vasoconstriction 3.
Rheumatologic Medications
- Biologic DMARDs should be withheld prior to surgery, with surgery planned after the next dose is due 1, 2.
- JAK inhibitors (tofacitinib, baricitinib, upadacitinib) should be held for at least 3 days prior to surgery 1, 2.
Muscle Relaxants
- Methocarbamol should be held on the day of surgical procedure 3.
- Orphenadrine should be held on the day of operation due to anticholinergic effects and cardiovascular instability risk 3.
- Butalbital should be held on the day of surgery, though if used long-term it requires a 2-week taper rather than abrupt discontinuation to avoid withdrawal 3.
Anticoagulation
- ACE inhibitors and ARBs may be held on the day of surgery due to increased risk of intraoperative hypotension requiring vasopressor support, though this remains controversial 2.
Critical Perioperative Considerations
Timing of Medication Administration
- Long-acting sedatives should not be used within 12 hours of surgery as they impair immediate postoperative recovery, mobility, and oral intake 3.
- Short-acting anxiolytics may be used carefully by anesthesiologists to facilitate epidural or spinal placement with minimal residual effect 3.
Monitoring Requirements
- Monitor for serotonin syndrome when combining SSRIs/SNRIs with opioids (especially tramadol, meperidine, fentanyl), triptans, or other serotonergic agents 3, 2, 4.
- Monitor blood glucose at least every 2-4 hours while NPO and dose with short- or rapid-acting insulin as needed 3.
Restarting Medications Postoperatively
- Withheld rheumatologic medications should be restarted once the wound shows evidence of healing, sutures/staples are out, and there's no significant swelling, erythema, drainage, or infection (typically ~14 days) 1.
- SGLT2 inhibitors should be restarted once eating and drinking normally, usually 24-48 hours after surgery 1.
Common Pitfalls to Avoid
- Never abruptly discontinue medications with withdrawal potential (beta-blockers, clonidase, chronic opioids, benzodiazepines, baclofen) as this leads to significant morbidity including rebound hypertension, seizures, and cardiovascular events 1, 5.
- Do not continue SGLT2 inhibitors through surgery despite general principle of continuing chronic medications, as the ketoacidosis risk is substantial even with normal glucose levels 1, 2.
- Avoid initiating beta-blockers on the day of surgery in patients not already taking them, as this increases postoperative mortality and stroke risk 3.
- Do not use long-acting sedatives for preoperative anxiolysis as they delay recovery and impair postoperative function 3.
- Recognize that 71% of medication errors involve high-risk medications (antithrombotics, anticoagulants, antihypertensives) that can cause serious perioperative complications 6.