Pre-Operative Medication Guidelines

Sent on behalf of Dr. J Huang - July 25, 2024

Pre-Operative Medication Guidelines

Antiplatelet Medications: ASA, clopidogrel, ticagrelor, prasugrel

Antiplatelet Agent	When to STOP before surgery
*ASA*	No Need to Stop
Clopidogrel (Plavix) Ticagrelor (Brilinta)	Hold for 6 full days, LAST DOSE 7 days before surgery
Prasugrel (Effient)	Hold for 7 full days, LAST DOSE 8 days before surgery

Parenteral Anticoagulants: low molecular weight heparin, unfractionated heparin, fondaparinux

Anticoagulant	When to STOP before surgery
VTE Prophylaxis Doses
*Enoxaparin 40 mg sc qhs* *Enoxaparin 30 mg sc qhs*	LAST DOSE 1 day before surgery
Heparin 5000 units sc BID	LAST DOSE 1 day before surgery
Therapeutic anticoagulation
*Enoxaparin 1.5 mg/kg sc daily* *(preferred time is 1000h)*	LAST DOSE 1000h 1 day before surgery If the patient has been receiving doses at 2200h: · Do NOT give a dose the evening before surgery · Give last dose in the evening of 2 days before surgery OR convert patient to 1 mg/kg BID dosing and follow guideline for enoxaparin 1mg/kg sc BID
*Enoxaparin 1 mg/kg sc BID*	LAST DOSE 2 days before surgery
*Fondaparinux*	LAST DOSE at 1000h 2 days before surgery

Oral Anticoagulants: warfarin, dabigatran, apixaban, rivaroxaban, edoxaban

Oral Anticoagulant

When to STOP before surgery

Warfarin (Coumadin)

If NO bridging required (low thrombosis risk patients):

Hold warfarin for 5 full days, LAST DOSE 6 days before surgery

If bridging is required (high thrombosis risk patients):

1. Hold warfarin for 5 full days, LAST DOSE 6 days before surgery

2. Start enoxaparin 3 days before OR at a dose of 1.5 mg/kg sc daily in the morning (for patients with normal renal function)

3. LAST DOSE of enoxaparin to be given 1 day before surgery

Criteria for bridging may include: DVT less than 3 months ago, prosthetic mitral heart valves, high risk aortic valves (previous TIA/stroke, atrial fibrillation, severe LV dysfunction), cardiac thrombus presumed to be present less than 3 months

Direct Oral Anticoagulants (DOACs)

No overlapping is required between DOACs and LMWH

Start therapeutic LMWH or IV heparin only If DOAC is held for longer than the following stated days

Dabigatran (Pradaxa)

Determine patient’s renal function ( eGFR, mL/min/1.73²)

Renal Function (eGFR, mL/min/1.73²)		Hold dose
Equal or greater than 80 mL/min/1.73²		3 days before surgery
50 - 70 mL/min/1.73²		4 days before surgery
30 – 49 mL/min		5 days before surgery

In patients with severe renal dysfunction (CrCl less than 30 mL/min) who are generally ineligible for DOACs, peri-operative management is unclear.

Apixaban (Eliquis)

Determine patient’s renal function ( eGFR, mL/min/1.73m²)

Dose	Renal Function ( eGFR, mL/min/1.73m²)	Hold dose
5 mg BID		3 days before surgery
2.5 mg BID	Equal or greater than 30 mL/min/1.73m²	2 days before surgery
2.5 mg BID	Less than 30 mL/min/1.73m²	3 days before surgery

In patients with severe renal dysfunction (CrCl less than 30 mL/min) who are generally ineligible for DOACs, peri-operative management is unclear.

Rivaroxaban (Xarelto)

Dose			Hold dose
20 mg once daily			4 days before surgery
10 mg once daily			3 days before surgery

Edoxaban (Lixiana)

Determine patient’s renal function (eGFR, mL/min/1.73m²)

Dose	Renal Function ( eGFR, mL/min/1.73m²)	Hold dose
60 mg once daily	Equal or greater than 30 mL/min/1.73m²	4 days before surgery
60 mg once daily	Less than 30 mL/min/1.73m²	5 days before surgery
30 mg once daily	Equal or greater than 30 mL/min/1.73m²	2 days before surgery
30 mg once daily	Less than 30 mL/min/1.73m²	3 days before surgery

Anti-hypertensives: beta blockers, ACEis, ARBs, Entresto, CCBs, vasodilators, diuretics, MRAs, alpha agonists, alpha blockers, vasodilators, nitrates, direct rening inhibitors

Antihypertensive Agent

When to STOP before surgery

Beta blockers:

Atenolol, acebutolol, bisoprolol, carvedilol Metoprolol, nadolol, nebivolol, pindolol, propranolol, sotalol, timolol

CONTINUE on the morning of surgery (prevents POAF)

RAAS Inhibitors:

ACE-Inhibitors:

Ramipril, perindopril, fosinopril, lisinopril, quinapril, trandolapril, enalapril, cilazapril, benazepril, captopril

ARBs:

Candesartan, eprosartan, irbesartan, losartan, , olmesartan, telmisartan, valsartan

ARB/Neprilysin Inhibitor:

Sacubitril/valsartan (Entresto)

Direct Renin Inhibitor:

Aliskerin (Rasilez)

LAST DOSE day before surgery.

(Risk of vasoplegia post-op)

Diuretics:

Amiloride, chlorthalidone, furosemide, hydrochlorothiazide, indapamide, metolazone,

MRAs:

Eplerenone, spironolactone

HOLD on the morning of surgery

Alpha blocker:

Doxazosin, terazosin,

Alpha 2 agonists:

Clonidine, methyldopa

Calcium channel blockers:

Amlodipine, diltiazem, felodipine, nifedipine, verapamil

Nitrates:

Isosorbide dinitrate, nitroglycerin patch

Vasodilators:

Hydralazine

CONTINUE on the morning of surgery

Anti-hyperglycemic agents: Insulins, metformin, SGLT2is, GLP1s, DPP4is, sulfunylureas, acarbose, thiazolidinediones

· For outpatients: Refer to RADAR clinic if A1C >8.5% and surgery more than one week away

*Consensus with Endocrinology and Diabetes Educators

Antidiabetic Agent

When to STOP before surgery

Insulin

Long-acting e.g:

Glargine (Basaglar, Lantus, Toujeo)

Degludec (Tresiba)

Detemer (Levemer)

Intermediate-acting e.g:

Humulin N

Novolin ge NPH

Mixed insulin e.g:

Humalog Mix25

Humalog Mix40

Humulin 30/70

Novomix30

Short-acting e.g:

Aspart (Novorapid, Trurapi, Fiap)

Lispro (Humalog, Admelog)

Glulisine (Apidra)

Humulin R

Novolin ge Toronto

· Insulin pump: Consult Endocrinology

· Type I diabetes: Consult Endocrinology

· Long-acting basal or intermediate insulin: Give 75% of patient’s usual dose the night before AND on the morning of surgery

· Mixed insulins: HOLD on the morning of surgery

· Short-acting meal insulin: HOLD on the morning of surgery

SGLT2 inhibitors

canagliflozin (Invokana)

Dapagliflozin (Forxiga

Empagliflozin (Jardiance)

Canagliflozin/Metformin (Invokamet)

Empagliflozin/Metformin (synjardy)

Empagliflozin/Linagliptin (Giyxambi)

Dapagliflozin/Metformin (Xigduo)

Dapagliflozin/Saxagliptin (Qtern)

Ertugliflozin (Steglatto)

Ertugliflozin/Metformin (Segluromet)

Ertugliflozin/Sitagliptin (Steglujan)

(HOLD for 3 full days before and on morning of surgery. LAST DOSE 4 days before surgery - Risk of euglycemic DKA)

Metformin

Sulfonylureas:

Gliclazide (Diamicron), glyburide, glimepiride (Amaryl)

DPP4 inhibitors:

Linagliptin (Trajenta),

sitagliptin (Januvia), saxagliptin (Onglyza)

Thiazolidinediones;

Rosiglitazone,

pioglitazone (Actos)

Alpha-glucosidase Inhibitor: Acarbose

Meglitinides:

Repaglinide (Gluconorm), nateglinide (Starlix)

HOLD on the morning of surgery

(Consider holding longer in renal dysfunction or AKI)

GLP1 agonist:

Semaglutide (Ozempic, Rybelsus)

Dulaglutide (Trulicity)

Liraglutide (Viktoza, Saxenda)

Tirzepatide (Mounjaro)

Glargine/Lixisenatide (Soliqua®)

HOLD for ALL IN PATIENTS

(Risk of delayed gastric emptying and pulmonary aspiration during anesthesia)

· Weekly dosing: semaglutide sc (Ozempic), dulaglutide (Trulicity), Trizapatide (Mounjaro)

o If for weight loss: HOLD for 3 weeks preop if time allows

o If for diabetes: SKIP one dose preop

· Daily dosing: semaglutide po (Rybelsus), liraglutide (Viktoza or Saxenda), Soliqua

o HOLD for 2 days before surgery (last dose 3 days preop)

For Type 2 DM: If HbA1C > 8.5% and NOT taking insulin, refer to RADAR clinic preoperatively.

If no HbA1C available, please order one in PAC and refer to RADAR clinic as necessary.

Disease Modifying Agents DMARDs and Biologics:

**Consider risk of discontinuing therapy (disease flare-up) VS continuing therapy (increased risk of SSIs and wound healing) **

DMARD Agent	When to STOP before surgery
Leflunomide	HOLD 2 weeks before surgery and resume 1-2 weeks after surgery
Methotrexate	Consider holding 1 week before surgery and resume 1-2 weeks after surgery (e.g. in elderly and renal dysfunction when higher chance of build up occur)
Hydroxychloroquine	Continue with no interruption
Sulfasalazine	Continue with no interruption (consider holding 1 day before and resume 3 days after surgery)
Biologics Agent	When to STOP before surgery (Generally, hold 2-3 half-lives) before surgery and restart in 2-4 weeks when good wound healing achieved with no evidence of infection
TNF-alpha inhibitors	· *Adalimumab* (q2 weeks injection): HOLD for 3 weeks · Etanercept (weekly injection) : HOLD for 2 weeks; Last dose 3 weeks before surgery · Golimumab (monthly injection): HOLD for 6 weeks (skip one injection) · Infliximab (q 4-8 weeks injection) : HOLD for 8 weeks · Certolizumab (monthly injection): HOLD for 6 weeks · Tocilizumab o SC injection: HOLD for 3 weeks o IV injection: HOLD for 4 weeks
*Rituximab*	Plan surgery at the end of cycle
Abatcept	SC injection: HOLD 1 week IV injection: HOLD 1 month