PERIOPERATIVE MEDICATION GUIDELINES – 2019

ANTIHYPERTENSIVES
DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON
Angiotensin Converting Benazepril / amlodipine (Lotrel) HOLD Day of Surgery Potential
Enzyme (ACE) Inhibitors Benazepril (Lotensin) (Do NOT hold day of Hypotension intra-
Benazepril / HCTZ (Lotensin HCT) surgery for cataract op risk
Captopril (Capoten®) patients)
Captopril / HCTZ (Capozide)
Enalapril (Vasotec®)
Enalapril / HCTZ (Vaseretic)
Fosinopril (Monopril)
Fosinopril / HCTZ (Monopril HCT)
Lisinopril (Prinivil®, Zestril®)
Lisinopril / HCTZ (Prinzide or
Zestoretic)
Moexipril (Univasc)
Moexipril / HCTZ (Uniretic)
Perindopril (Aceon)
Quinapril (Accupril)
Quinapril / HCTZ (Accuretic)
Ramipril (Altace)
Trandolapril (Mavik)
Trandolapril/verapamil (Tarka)
Angiotensin Receptor Azilsartan (Edarbi) HOLD Day of Surgery Potential
Blockers (ARB) Candesartan (Atacand) (Do NOT hold day of Hypotension intra-
Candesartan/HCTZ (Atacand HCT) surgery for cataract op risk
Eprosartan (Teveten) patients
Eprosartan/HCTZ (Teveten HCT)
Irbesartan (Avapro)
Irbesartan / HCTZ (Avalide)
Losartan (Cozaar)
Losartan / HCTZ (Hyzaar)
Olmesartan (Benicar)
Olmesartan / HCTZ (Benicar HCT)
Telmisartan (Micardis)
Telmisartan/HCTZ (Micardis HCT)
Valsartan (Diovan)
Valsartan / HCTZ (Diovan HCT)
Beta Blockers Acebutolol (Sectral) Do NOT hold prior to Withdrawal/rebound
Atenolol (Tenormin) surgery effects if held
Betaxolol (Kerlone)
Bisoprolol (Zebeta)
Carvedilol (Coreg)
Metoprolol (Lopressor, Toprol XL)
Nadolol (Corgard)
Nebivolol (Bystolic)
Penbutolol (Levatol)
Pindolol (Visken)
Propranolol (Inderal)
Sotalol (Betapace)

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 PERIOPERATIVE MEDICATION GUIDELINES – 2019

DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON

Calcium Channel Blockers Amlodipine (Norvasc®) Do NOT hold prior to
Clevipidine (Cleviprex®) surgery
Diltiazem (Cardizem®)
Felodipine (Plendil®)
Isradipine (Dynacirc®)
Nicardipine (Cardene®)
Nifedipine (Procardia®, Adalat®)
Nimodipine (Nimotop®)
Verapamil (Calan®, Covera-HS®,
Verelan®)
Clonidine Clonidine (Catapres®) Do NOT hold prior to Withdrawal/
surgery rebound effects if
held
Digoxin Digoxin (Lanoxin®) Do NOT hold prior to
surgery
Diuretics Acetazolamide (Diamox) HOLD day of surgery Increases the risk of
Amiloride hypokalemia /
Amiloride/Hydrochlorothiazide hypovolemia
(Moduretic)
Bendroflumethiazide
Bumetanide (Bumex)
Chlorothiazide (Diuril)
Chlorthalidone (Thalitone)
Eplerenone (Inspra®)
Ethacrynic acid (Edecrin)
Furosemide (Lasix®)
Hydrochlorothiazide (Microzide,
Esidrix®)
Indapamide (Lozol)
Metolazone (Zaroxolyn)
Methazolamide
Methyclothiazide
Metolazone (Zaroxoxlyn)
Spironolactone (Aldactone)
Spironolactone/Hydrochlorothiazide
(Aldactazide)
Torsemide (Demadex)
Triamterene (Dyrenium)
Triamterene / HCTZ (Dyazide,
Maxzide)
Statins Atorvastatin (Lipitor) Do NOT hold prior to
Fluvastatin (Lescol) surgery
Lovastatin (Mevacor)
Pitavastatin (Livalo)
Pravastatin (Pravachol)
Rosuvastatin (Crestor)
Simvastatin (Zocor)

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 PERIOPERATIVE MEDICATION GUIDELINES – 2019

RESPIRATORY MEDICATIONS
DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON
Bronchodilators Albuterol (ProAir, Proventil, Use on day of surgery
Ventolin)
Albuterol/Ipratropium (Duoneb,
Combivent)
Formoterol/Budesonide (Symbicort)
Formoterol/Mometasone (Dulera)
Ipratropium (Atrovent)
Levalbuterol (Xopenex)
Salmeterol (Serevent )
Salmeterol/Fluticasone (Advair)
Inhaled Steroids Beclomethasone (QVAR) Use on day of surgery
Flunisolide (AeroBid)
Fluticasone (Flovent )
Mometasone (Asmanex)
Triamcinolone (Asmacort)
ANTICOAGULANTS
DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON
Direct Thrombin Inhibitors Dabigatran (Pradaxa®) Do not discontinue Increased risk of
without consulting bleeding
prescribing physician complications. No
spinal or epidural
within seven days
of last
dose.
Factor XA Inhibitor Fondaparinux (Arixtra) Do not discontinue Increased risk of
Apixaban (Eliquis ) without consulting bleeding
Rivaroxaban (Xarelto) prescribing physician complications.
Heparin SQ Heparin SQ At least 4 hours prior to Increased risk of
surgery bleeding
complications.
Low molecular weight Dalteparin (Fragmin) Enoxaparin 24 hrs prior to surgery if Increased risk of
heparin (Lovenox) on full anticoagulant bleeding; No
dose (1 mg/kg), 12 hrs spinal or epidural
prior to surgery if on within 12 hrs of
DVT prophylaxis dose prophylaxis dose
(0.5 mg/kg) (0.5 mg/kg) and
24 hrs of
therapeutic dose
(1 mg/kg)
Warfarin Warfarin (Coumadin) Do not Increased bleeding
discontinue risk.
without
consulting
prescribing physician

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 PERIOPERATIVE MEDICATION GUIDELINES – 2019

DRUGS CLASS DRUGS IN CLASS WHEN TO HOLD REASON

Aspirin Aspirin If no history of CAD Increased risk of
(and Aspirin- containing or stroke: bleeding
drugs Aspirin/acetaminophen/caffeine Discontinue 5-10 complications
(Excedrin®) days prior to
Aspirin/butalbital/caffeine (Fiorinal®) surgery, especially
Aspirin/carisoprodol (Soma for ophthalmologic
Compound®) and neurosurgical
Aspirin/carisoprodol/codeine (Soma procedures.
compound w/ codeine®)
Aspirin/dipyridamole (Aggrenox®) Patients with hx of
Aspirin/orphenadrine/caffeine CAD or stroke:
(Norgesic®) Continue Aspirin,
Aspirin/oxycodone (Percodan®) including day of surgery
if at all possible. Need
to consult with surgeon
if neuro/ spine/
ophthalmologic
surgery.
Anti-Platelet Drugs Clopidogrel (Plavix) Do NOT discontinue Increased risk of
without explicit bleeding
Prasugrel (Effient®) instructions from complications
prescribing physician!
Ticagrelor (Brilinta®) Must be documented
by prescribing physician
Ticlopidine (Ticlid) on form N-372 (Request
for Preoperative
Cardiac Evaluation)
Cilostazol (Pletal®) HOLD 4 days preop

Dipyridamole (Persantine®) HOLD 2 days preop

Diipridamole/Aspirin (Aggrenox®) HOLD 7 days preop

Short-acting NSAIDs Diclofenac (Cataflam®, Voltaren®) HOLD day prior to Increased risk for
Etodolac (Lodine®) surgery bleeding and renal
Fenoprofen (Nalfon®) complications
Flurbiprofen (Ansaid®)
Ibuprofen (Advil®, Motrin®)
Ibuprofen/Hydrocodone (Vicoprofen®)
Ibuprofen/Oxycodone (Combunox®)
Indomethacin (Indocin®)
ketoprofen (Orudis KT®, Oruvail®)
ketorolac (Toradol®)
Meclofenamate (Meclomen®)
Mefenamic Acid (Ponstel®)
Tolmetin (Tolectin®)

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 PERIOPERATIVE MEDICATION GUIDELINES – 2019

DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON

Long-acting NSAIDs Diflunisal (Dolobid®) At least 3 days prior to Increased risk for
Etodolac (Lodine XL®) surgery renal, thrombo-
Meloxicam (Mobic®) embolic
Nabumetone (Relafen) complications
Naproxen (Aleve®, Anaprox®,
Naprosyn®)
Oxaprozin (Daypro)
Piroxicam (Feldene)
Sulindac (Clinoril®)
Cox-2 Inhibitors Celecoxib (Celebrex) At least 3 days prior to Increased risk for
Nabumetone (Relafen) surgery renal, thrombo-
embolic
complications
OPIOID PAIN MEDICATIONS
DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON
Long-Acting Opioids Fentanyl Patch (Duragesic) Do NOT hold prior to Discontinuation may
Hydromorphone SR (Exalgo) surgery result in opioid
Methadone (Dolophine) withdrawal and
Morphine SR (MS Contin, Kadian, difficulty with
Avinza) postoperative pain
Morphine SR/Naltrexone (Embeda) control.
Oxycodone SR (Oxycontin)
Oxymorphone (Opana ER)
Short-Acting Opioids Hydrocodone Do NOT hold prior Discontinuation may
Hydrocodone/Acetaminophen to surgery result in opioid
(Hycet, Lorcet, Lortab, Norco, withdrawal and
Vicodin, Zydone) difficulty with
Hydrocodone/Ibuprofen (Vicoprofen) Switch patient postoperative pain
Hydromorphone (Dilaudid) from Aspirin and control.
Hydromorphone ER (Exalgo) Ibuprofen
Morphine containing drugs
Oxycodone (Roxicodone) one week preop.
Oxycodone/Acetaminophen
(Percocet, Endocet, Roxicet)
Oxycodone/Aspirin (Percodan,
Endodan)
Propoxyphene/Acetaminophen
(Darvocet)
Propoxyphene/Aspirin (Darvon)
Tapentadol (Nucynta)
Opioid Agonist/ Buprenorphine/Naloxone (Suboxone) Should be transitioned May cause
Antagonists Buprenorphine patch (Butrans) to alternative difficulty with
Naltrexone (Vivitrol, ReVia, Depade) medication 1-2 weeks postoperative pain
prior to elective control, high
surgery by the opioid
prescribing requirements.
physician.

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 PERIOPERATIVE MEDICATION GUIDELINES – 2019

DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON

Topical local Lidocaine patch Continue
Anesthetic
Skeletal Muscle Carisoprodol Soma Continue
Relaxant Metaxalone (Skelaxin)
STEROID AND IMMUNE MEDICATIONS
DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON
Steroids Prednisone Do NOT hold prior to Adrenal
Methylprednisolone (Medrol) surgery insufficiency
THYROID MEDICATIONS
DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON
Thyroid hormone Levothyroxine (Synthroid, Levoxyl) Do NOT hold prior to
Dessicated thyroid (Armour Thyroid) surgery
DIABETES MEDICATIONS
DRUG LASS DRUGS IN CLASS WHEN TO HOLD REASON
Short-Acting Insulin Regular Insulin (Humulin, Novolin) Hold day of surgery –
Insulin Aspart (Novolog) unless otherwise
Insulin Glulisine (Apidra) specified by prescriber
Insulin Lispro (Humalog)
Intermediate- Acting Insulin Insulin NPH (Humulin N, Novolin N)
Humulin 70/30
Humalog 50/50
Humalog 75/25
Novolin 70/30
Novolog 70/30
Long-Acting Insulin Insulin Glargine (Lantus, Toujeo) Take ½ dose of long
Insulin Detemir (Levimir) acting night prior –
Insulin Degludec (Tresiba) unless otherwise
specified by prescriber
Non-Insulin Injections Exenatide (Byetta, Bydureon) Per regimen unless
Linagliptin (Tradjenta) otherwise specified by
Pramlintide (Symlin) prescriber
Liraglutide (Victoza)
Dulaglutide (Trulicity)
Oral Diabetic Drugs Alogliptin (Nesina) Hold day of surgery –
Alogliptin/Pioglitazone (Oseni) unless otherwise
Linagliptin (Tradjenta) specified by prescriber
Metformin
Pioglitazone (Actos)
Rosiglitazone (Avandia)
Saxagliptin (Onglyza)
Saxagliptin/Metformin ER (Kombiglyze
XR)
Sitagliptin (Januvia)
Sitagliptin/Metformin ER (Janumet)

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 PERIOPERATIVE MEDICATION GUIDELINES – 2019

CNS AGENTS
DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON
Benzodiazepines Alprazolam (Xanax®) Do NOT hold prior to Risk of withdrawal if
Chlordiazepoxide (Librium®) surgery stopped abruptly;
Diazepam (Valium®) potential for
additive
effects
Antidepressants - Isocarboxazid (Marplan®) Taper off 2 weeks Drug interactions
Monoamine Oxidase (MAO) Phenelzine (Nardil®) prior to surgery if (e.g., ephedrine,
Inhibitors Tranylcypromine (Parnate®) possible meperidine,
methadone,
Rasagiline (Azilect®) OK to continue tramadol), which
could cause a
Selegiline patch (Emsam®) Discontinue at least 10 hypertensive crisis.
days prior to surgery if
possible
Antidepressants – SSRIs and Citalopram (Celexa®) Do NOT hold prior to Risk of withdrawal if
SNRIs Duloxetine (Cymbalta) surgery stopped abruptly
Escitalopram (Lexapro®)
Fluoxetine (Prozac®)
Fluvoxamine (Luvox®)
Paroxetine (Paxil®)
Sertraline (Zoloft®)
Strattera (Atomoxetine®)
Desvenlafaxine (Pristiq, Khedezla)
Antidepressants - Other Amitriptyline (Elavil ) Do NOT hold prior to Risk of withdrawal if
Bupropion (Wellbutrin) surgery stopped abruptly
Desipramine (Norpramin)
Doxepin (Sinequan)
Imipramine (Tofranil)
Mirtazapine (Remeron)
Nefazodone (Serzone)
Nortriptyline (Pamelor)
Trazodone (Desyrel)
Lithium Lithium (Eskalith, Lithonate) Do NOT hold prior to
surgery
Acetyl- cholinesterase Donazepil (Aricept) Do NOT hold prior to
Inhibitors Galantamine (Razadyne) surgery
(for Alzheimer’s) Rivastigmine (Exelon)
Tacrine (Cognex)
Anticonvulsants Carbamazepine (Tegretol)
Clonazepam (Klonopin)
Felbamate (Felbatol)
Gabapentin (Neurontin)
Levetiracetam (Keppra)
Lamotrigine (Lamictal)
Oxcarbazepine (Trileptal)
Phenytoin (Dilantin)
Pregabalin (Lyrica)

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 PERIOPERATIVE MEDICATION GUIDELINES – 2019

DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON

Anticonvulsants continued… Primidone (Mysoline)
Tiagabine (Gabitril)
Topiramate (Topamax)
Valproic Acid (Depakote)
Zonisamide (Zonegran)
ADHD Drugs (Stimulants) Dextroamphetamine (Adderall) Do NOT hold prior to No documented
Lisdexamfetamine (Vyvanse) surgery interaction with
Dexmethylphenidate (Focalin) anesthesia
Methylphenidate (Ritalin, medications
Metadate, Concerta, Daytrana
patch)
ADHD Drugs (non-stimulant) Guanfacine (Intuniv) Do NOT hold prior to Risk of rebound
surgery hypertension if
withheld.
Sleep Aids Zolpidem (Ambien) May take night before
Eszopiclone (Lunesta) surgery
Restless legs Ropinirole (Requip) Continue
Pramipexole (Mirapex)
REFLUX MEDICATIONS
DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON
Proton Pump Inhibitors Esomeprazole (Nexium) Do NOT hold prior to Reflux prevention
Lansoprazole (Prevacid) surgery
Omeprazole (Prilosec)
Pantoprazole (Protonix)
Rabeprazole (Aciphex)
Histamine H2 blockers Cimetidine (Tagamet) Do NOT hold prior to Reflux prevention
Famotidine (Pepcid) surgery
Nizatidine (Axid)
Ranitidine (Zantac)
Particulate Antacids Gaviscon HOLD day of surgery Risk of particulate
Maalox aspiration
OTHER DRUGS
DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON
Appetite Suppressant (Diet Phentermine (Adipex®, Suprenza®) Discontinue at least 7 Risk of hypotension
Drug) Phentermine / Topiramate (Qsymia®) days preop that is
unresponsive to
treatment.
Other Medical Estrogen patch Continue
patches Nicotine patch
Herbal Supplements See List Discontinue at least one Risk of bleeding,
week preop blood pressure
problems, slow
awakening from
anesthesia, etc.

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 PERIOPERATIVE MEDICATION GUIDELINES – 2019

Herbals and Dietary Supplements with the Potential to Increase Bleeding

Agrimony Fenugreek Peony
Andrographis Feverfew Policosanol
Angelica Fish oil Poplar
Anise Flaxseed Prickly Ash (Northern)
Arnica Forskolin Quassia
Asafoetida Forsythia Red Clover
Aspen Garlic Resveratrol
Bilberry Gamma linolenic acid Safflower
Black Haw German Sarsaparilla Saw palmetto
Bladder Wrack (Fucus) Ginger Sea buckthorn
Bogbean Ginkgo Biloba Selenium
Boldo Ginseng (Panax, Siberian) Senega
Borage Green tea Serrapeptase
Bromelain Guggul Swallowroot
Buchu Holy basil Sweet Clover
Burdock Honeysuckle Sweet Vernal grass
Capsicum Horse Chestnut Sweet Woodruff
Carrageenan Horseradish Tamarind
Celery Inositol Nicotinate Tiratricol
Chamomile (German and Japanese apricot Tonka Beans
Roman) Jiaogulan Turmeric
Chinese prickly ash Krill Oil Vanadium
Cinchona Kudzu Vinpocetine
Clove Licorice Vitamin E
Cod liver oil Meadowsweet Wild Carrot
Coltsfoot Melatonin Wild Lettuce
Danshen Methoxylated flavones Willow Bark
Deertongue Nattokinase Wintergreen
DHA (docosahexaenoic acid) Onion Yarrow
Dong quai Palm oil
EPA (eicosapentaenoic acid) Pantethine
Epimedium Passion Flower
Evening primrose oil Pau d’Arco
Evodia

It is recommended that patients discontinue herbal supplements at least one week

prior to surgery.

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