Pre-Operative Medication Guidelines

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

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 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)

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)

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)

Edoxaban (Lixiana)

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

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

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.

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