What medications should be avoided preoperatively in a patient undergoing surgery, particularly those with conditions like diabetes or hypertension?

Preoperative Medication Management

SGLT2 inhibitors (e.g., Jardiance, Farxiga) must be stopped one day before surgery, while NSAIDs should be discontinued 1-10 days preoperatively depending on the specific agent, and ACE inhibitors/ARBs may be held on the day of surgery—but beta blockers and clonidine must never be stopped abruptly due to risk of rebound hypertension and adverse cardiovascular events. 1

Critical Medications to Discontinue

SGLT2 Inhibitors (Highest Priority)

• Stop SGLT2 inhibitors (empagliflozin, dapagliflozin, canagliflozin) the day before surgery to prevent euglycemic diabetic ketoacidosis, which can occur even with normal glucose levels and carries significant mortality risk 1
• This applies to all patients taking SGLT2 inhibitors regardless of indication (diabetes, heart failure, or chronic kidney disease) 1
• Provide specific "sick-day rules" instructions for postoperative recovery, including signs of DKA and when to resume the medication 1

NSAIDs (Variable Timing Based on Half-Life)

• Stop NSAIDs preoperatively based on drug half-life to prevent excessive bleeding complications: 2, 3, 4
  • 1 day before surgery: Diclofenac (Voltaren), Ibuprofen (Advil, Motrin), Ketorolac (Toradol) 4
  • 2 days before surgery: Etodolac (Lodine), Indomethacin (Indocin) 4
  • 4 days before surgery: Meloxicam (Mobic), Naproxen (Aleve, Naprosyn), Nabumetone (Relafen) 4
  • 6 days before surgery: Oxaprozin (Daypro) 4
  • 10 days before surgery: Piroxicam (Feldene) 4
• NSAIDs should never be used immediately before or after coronary artery bypass graft (CABG) surgery due to increased cardiovascular risk 2, 3
• Patients with longer NSAID half-lives experience more postoperative bleeding complications, particularly gastrointestinal bleeding and hypotension 5

ACE Inhibitors and ARBs (Controversial but Recommended)

• Consider discontinuing ACE inhibitors and ARBs 24 hours before major noncardiac surgery to reduce risk of intraoperative hypotension and composite outcomes (death, stroke, myocardial injury) 1
• Recent cohort evidence demonstrates patients who stopped these medications 24 hours preoperatively had better outcomes than those continuing until surgery 1
• However, this remains controversial with limited randomized trial data 1

Metformin in High-Risk Patients

• Stop metformin immediately in patients with foot gangrene, tissue necrosis, or acute infection due to risk of metformin-associated lactic acidosis (MALA) with 30-50% mortality 6
• In patients with stable renal function (GFR >60), metformin can generally continue, but hold if acute kidney injury develops perioperatively 6

Sulfonylureas

• Hold sulfonylureas (e.g., Amaryl, glyburide) on the morning of surgery due to hypoglycemia risk with NPO status and surgical stress 6
• Resume only after stable oral intake is established postoperatively 6

Medications That Must NEVER Be Stopped Abruptly

Beta Blockers (Critical Warning)

• Continue beta blockers in all patients currently taking them chronically—abrupt discontinuation is potentially harmful and associated with rebound hypertension, tachycardia, and adverse cardiovascular events 1
• Beta blockers should be continued until surgery and resumed as soon as possible postoperatively 1
• Never start beta blockers on the day of surgery in beta blocker-naïve patients 1

Clonidine

• Never discontinue clonidine abruptly perioperatively due to severe rebound hypertension risk 1
• If patient cannot take oral medications, consider parenteral alternatives to maintain alpha-2 agonist therapy 1

GLP-1 Receptor Agonists (New Evidence)

• Continue GLP-1 receptor agonists (semaglutide, liraglutide, tirzepatide) through the perioperative period with appropriate risk mitigation strategies 1
• Perform full risk assessment for aspiration risk and implement protective techniques (rapid sequence induction, cricoid pressure consideration) 1
• Despite concerns about delayed gastric emptying, current multidisciplinary consensus supports continuation rather than discontinuation 1

Antiplatelet Agents (Context-Dependent)

Aspirin

• Continue aspirin perioperatively in most patients unless bleeding risk substantially exceeds thrombotic risk 7
• Aspirin monotherapy does not require discontinuation for most non-cardiac surgeries 7
• For cardiac surgery with cardiopulmonary bypass, consider stopping aspirin 7 days preoperatively in low-risk patients 8

Clopidogrel (Plavix)

• Stop clopidogrel at least 5-7 days before elective surgery to allow platelet function recovery 7
• Exception: Patients with recent drug-eluting stent placement (<12 months) face 10% risk of major vascular events if antiplatelet therapy is withdrawn prematurely 7
• In urgent surgery after recent stent placement, delay if possible but do not exceed critical time windows 8

Diuretics

• Hold diuretics on the day of surgery to prevent intraoperative hypovolemia and hypotension 9
• Resume in the postoperative period once volume status is stable 9

Long-Acting Sedatives

• Avoid long-acting sedative premedication within 12 hours of surgery as it impairs immediate postoperative recovery, mobility, and oral intake 1
• If anxiolysis is necessary, use short-acting intravenous agents (fentanyl with small incremental midazolam or propofol) titrated carefully by anesthesia 1

Key Clinical Pitfalls to Avoid

• Do not defer surgery solely for uncontrolled hypertension unless SBP ≥180 mmHg or DBP ≥110 mmHg 1
• Do not assume all diabetes medications can continue—SGLT2 inhibitors and sulfonylureas require specific perioperative management 1, 6
• Do not restart ACE inhibitors/ARBs immediately postoperatively if patient is hypotensive—delaying resumption has been associated with increased 30-day mortality in some studies 10
• Do not combine multiple antiplatelet agents with NSAIDs without recognizing exponentially increased bleeding risk 4, 5
• Do not provide generic "continue all home medications" instructions—each drug class requires individualized perioperative planning 1