Perioperative Medication Management

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Andrew Morton
8 years ago
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1 CARDIOVASCULAR Beta blockers (metoprolol, atenolol, others) Should be continued until and including the day of Ace inhibitors (ACEI) & Angiotensin receptor blockers (ARB) (captopril, lisinopril, losartan, candesartan, others) These should be continued until the day before the, but discontinued on the day of the. This applies to patients booked for general anesthesia. Patients booked for MAPS should continue these medications until and including the day of the. The following are possible indications (especially if more than 1 apply to any given patient) to hold ACEI & ARBs hrs prior to surgery: Patients on multiple anti-htn meds, Patients with well controlled BP General anesthesia planned Lengthy surgery planned Procedures involving significant blood loss or fluid shifts Calcium channel blockers (nifedipine, diltiazem, others) Nitrates (nitroglycerin, isosorbide, others) Alpha-2 agonists (clonidine, others) Aspirin (See guidelines for Management of platelet therapy) Should be discontinued at least one week prior to the planned Continue these drugs unless the risk of bleeding outweighs the risk of thrombosis. If reversal of platelet inhibition is necessary then drugs such as aspirin and clopidogrel must be stopped 7 days prior to surgery. Do NOT stop these drugs in patients having vascular surgery or cataract surgery with topical or general anesthesia. Do NOT discontinue antiplatelet drugs in patients who have drug-eluting coronary stents (DES) until they have completed 12 months of anti-platelet therapy unless the patient, surgeon and cardiologist have discussed the risks of discontinuation. The same applies to patients with bare-metal stents (BMS) until they have completed 1 month of antiplatelet therapy.

Patients booked for MAPS should continue these medications until and including the day of the.

2 Aspirin or aspirin containing products (Stop 2 weeks prior to surgery) Alka Seltzer Anacin Ascriptin Aspergum Bayer Bufferin Ecotrin Easprin Empirin Excedrin Generic Aspirin Measurin Midol Synalgos Zorprin Clopidogrel (plavix) [See guidelines for Management of platelet therapy] Should be discontinued at least one week prior to the planned, unless specifically stated otherwise by the surgical service. Continue Plavix unless the risk of bleeding outweighs the risk of thrombosis. If reversal of platelet inhibition is necessary then Plavix must be stopped 7 days prior to surgery. Do not stop Plavix in patients having vascular surgery or cataract surgery with topical or general anesthesia. Do NOT discontinue Plavix in patients who have drug-eluting coronary stents (DES) until they have completed 12 months of anti-platelet therapy unless the patient, surgeon and cardiologist have discussed the risks of discontinuation. The same applies to patients with bare-metal stents (BMS) until they have completed 1 month of antiplatelet therapy. Oral anticoagulants (warfarin, coumadin) Should be discontinued at least 5 days prior to the planned, unless specifically stated otherwise by the surgical service IMPORTANT NOTE FOR ALL PATIENTS ON BLOOD THINNERS If you have had an MI, stroke/tia (ministroke), CAD, angioplasty with/without stent placement, Bypass surgery, Atrial fibrillation, carotid surgery, or blood clot (in the leg or lung) check with your primary care physician or cardiologist before stopping ASA or blood thinners. Blood thinners / Antiplatelet Coumadin / warfarin Dipyridamole / persantine Plavix / clopidorel Pletal / cilostazol Ticlid / ticlopidine Danaparoid (Orgaran) Lovenox / enoxaprarin Fragmin / dalteparin Innohep-Tinzaparin Orgaran / danaparoid Heparin Enoxaprarin (Lovenox) Dalteparin (Fragmin) Tinzaparin Diuretics (furosemide, hydrochlorothiazide, others) Should be taken until the day before the, but discontinued the day of the HCTZ or triamterene should be CONTINUED DOS when taken for hypertension

service. Continue Plavix unless the risk of bleeding outweighs the risk of thrombosis. If reversal of platelet inhibition is necessary then Plavix must be stopped 7 days prior to surgery.

3 Cardiac rhythm management medications (digoxin, beta-blockers, quinidine, amiodarone, others) Statins (atorvastatin, simvastatin, others) Cholesterol lowering medications Should be taken until the day before the, but discontinued the day of the CENTRAL NERVOUS SYSTEM MEDICATIONS Anticonvulsants (phenytoin, tegretol, others) Antidepressants (imipramine, sertraline, others) Monoamine oxidase inhibitors (very rarely used) Do not stop abruptly, check with Primary Care physician about stopping meds, medication may need to be weaned or substituted Should be discontinued at least 2 full weeks prior to the planned Antianxiety medications (diazepam, lorazepam, others) Antipsychotics (haloperidol, risperdal, others) Lithium Antiparkinson drugs (sinemet, others) Recreational drugs (marijuana, cocaine, others) Should be discontinued as soon as possible prior to any planned elective VITAMINS/ NUTRITIONAL SUPPLEMENTS Over the counter vitamins Stop days prior to surgery, unless otherwise directed by surgeon

inhibitors (very rarely used) Do not stop abruptly, check with Primary Care physician about stopping meds, medication may need to be weaned or substituted Should be discontinued at least 2 full weeks

4 Included ALL mega dose vitamins, Vitamin E, anti-oxidants, fish oils Herbal/Alternative preparations Should be discontinued at least one full week prior to the planned surgical procedure Diet Medications (prescribed, OTC, Herbal Should be discontinued at least one full week prior to the planned surgical procedure Diet Supplements (Check with Primary Care physician about stopping) i.e., Protein Drinks Diet Drinks (SlimFast, etc.) (This does not mean TPN, Tube Feeding, Ensure, etc. - Do as directed by surgery or anesthesia team) PULMONARY MEDICATIONS Asthma medications (theophylline, inhaled steroids, others) COPD medications (theophylline, ipratropium, inhaled steroids, others) Pulmonary hypertension medications (sildenafil, prostacyclin, others) ENDOCRINE Insulin All insulin preparations should be taken at the usual dosages for the entire day preceding the planned For all patients, discontinue all regular insulins on DOS. Type 2 diabetics should take none or up to ½ dose of long-acting or combination (70/30 preparations) insulins on DOS. Type 1 diabetics should take a small amount (usually 1/3) of their usual AM longacting insulin (e.g. lente or NPH) the DOS. Patients with an insulin pump should continue their basal rate ONLY. Oral Diabetic Medications Should be taken until the day before the, but discontinued the day of the

) (This does not mean TPN, Tube Feeding, Ensure, etc.

5 Thyroid medications (synthroid, dessicated thyroid, propylthiouracil, others) Steroids (prednisone, cortef, others) Oral contraceptives RENAL Phosphate binders, renal vitamins, iron, erythropoietin, others Should be taken until the day before the, but discontinued the day of the GYNECOLOGY/ UROLOGY Prostate medications (terazosin, tamsulozsin, others) Hormonal medications Oral contraceptives ANALGESICS Opiate containing analgesics (vicodin, tylox, methadone, others), without exception Non-steroidal anti-inflammatory compounds (ibuprofen, naproxen, others) Should be discontinued at least 5 days prior to the planned surgical procedure GASTOINTESTINAL Gastroesophageal reflux (GERD) medications (ranitidine, omeprazole, others) Antiemetics (ondansetron, metaclopramide, others)

Oral contraceptives ANALGESICS Opiate containing analgesics (vicodin, tylox, methadone, others), without exception Non-steroidal anti-inflammatory compounds (ibuprofen, naproxen, others) Should

6 AUTOIMMUNE MEDICATIONS Autoimmune medications Continue methotrexate on DOS unless risk of acute renal failure Discontinue etanercept (Enbral) 2 weeks prior to surgery Discontinue infliximab (Remicade) 6 weeks prior to surgery Discontinue adalimumab (Humira) 8 weeks prior to surgery Medications for Ulcerative Colitis (Rowasa/Pentasa/Asacol; Sulfasaladine/azulfidine) Check with primary care physician to see if you can stop these medications OTHER MEDICATIONS Eye drops Continue on DOS Topical Medications (ointments or creams) Continue on DOS

prior to surgery Medications for Ulcerative Colitis (Rowasa/Pentasa/Asacol; Sulfasaladine/azulfidine) Check with primary care physician

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