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Here is a comprehensive, up-to-date reference on drugs to hold or stop before surgery, synthesized from the 2024 AHA/ACC Perioperative Cardiovascular Guidelines, WakeMed 2025 Perioperative Medication Guidelines, Froedtert Perioperative Medication Management Guidelines, and the European Society of Medicine perioperative review.
Drugs to Stop Before Surgery - 2024/2025 Guidelines
1. ANTICOAGULANTS
| Drug | When to Stop | Notes |
|---|---|---|
| Warfarin | 5 days before | Check INR; bridge therapy may be needed for high-thromboembolic risk |
| Apixaban (Eliquis) | 48 hrs (low bleed risk); 72 hrs (high bleed risk) | Adjust for renal impairment |
| Rivaroxaban (Xarelto) | 24-48 hrs | Renal-adjust |
| Dabigatran (Pradaxa) | 2-4 days | Longer if CrCl < 50 mL/min |
| LMWH (enoxaparin) | 24 hrs before; last therapeutic dose 24 hrs prior | Prophylactic dose: 12 hrs |
2. ANTIPLATELET AGENTS
| Drug | When to Stop | Notes |
|---|---|---|
| Aspirin (non-cardiac indication) | 7-10 days before | Especially for neuro, spine, ophthalmologic procedures |
| Aspirin (history of CAD/stroke) | Do NOT stop - continue including day of surgery | Consult surgeon first |
| Clopidogrel (Plavix) | At least 5 days before | May continue for peripheral artery/carotid surgery |
| Prasugrel (Effient) | At least 7 days before | |
| Ticagrelor (Brilinta) | 3-5 days before | Resume 24 hrs post-procedure |
| Dipyridamole | At least 2 days before | |
| Aspirin/Dipyridamole ER (Aggrenox) | 7-10 days before |
Important - Coronary Stents: Delay elective surgery and continue dual antiplatelet therapy (DAPT) until the minimum recommended stent duration is complete.
3. DIABETES MEDICATIONS
| Drug | When to Stop | Notes |
|---|---|---|
| All oral antidiabetics (metformin, glipizide, glyburide, pioglitazone, saxagliptin, etc.) | Day of surgery - do NOT take | Risk of hypoglycemia and (for metformin) lactic acidosis if contrast is used |
| SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin, ertugliflozin) | 3 days before surgery | Risk of euglycemic diabetic ketoacidosis (euDKA) - critical and often missed |
| Long-acting insulin (detemir/glargine/degludec) | Take usual dose (reduce by 20% if hypoglycemic episodes) | Toujeo/Tresiba dose reduction must happen 3 days in advance |
| GLP-1 agonists (semaglutide, liraglutide) | 1 week before surgery (weekly dosing); 1 day before (daily dosing) | Risk of delayed gastric emptying causing aspiration |
4. NSAIDS
| Drug | When to Stop |
|---|---|
| Ibuprofen, naproxen, diclofenac | 7 days before |
| Celecoxib and other COX-2 inhibitors | 7 days before |
| Aspirin-containing combinations (Percodan, etc.) | Switch 1 week pre-op |
5. CARDIOVASCULAR DRUGS
| Drug | Action | Reason |
|---|---|---|
| ACE inhibitors / ARBs (lisinopril, enalapril, losartan, valsartan) | Hold day of surgery (or evening before if evening-dosed) | Risk of refractory intraoperative hypotension |
| Diuretics | Hold day of surgery | Electrolyte imbalance, volume depletion |
| Beta-blockers | Continue - do NOT stop | Abrupt withdrawal causes rebound hypertension, tachycardia, MI risk |
| Statins | Continue - do NOT stop | Abrupt discontinuation increases cardiovascular events |
| Digoxin | Continue, check levels | Narrow therapeutic window |
| Calcium channel blockers | Generally continue |
6. PSYCHIATRIC AND CNS DRUGS
| Drug | Action | Reason |
|---|---|---|
| MAO Inhibitors (phenelzine, tranylcypromine, isocarboxazid) | Taper off 2 weeks before if possible | Risk of hypertensive crisis with ephedrine, meperidine, methadone |
| SSRIs / SNRIs / antidepressants | Do NOT hold | Risk of withdrawal syndrome; notify anesthesia team |
| Tricyclic antidepressants (amitriptyline, imipramine) | Discuss with team; discontinue if depression mild and arrhythmia risk high | FDA package labeling advises stopping before elective surgery when possible |
| Lithium | Do NOT hold | |
| Benzodiazepines | Do NOT hold | Abrupt withdrawal risk is severe |
| Antiepileptics / anticonvulsants | Do NOT hold | Seizure risk |
| ADHD stimulants (Adderall, Ritalin) | Do NOT hold | No documented anesthesia interaction |
| Antipsychotics | Generally continue |
7. RHEUMATOLOGY / IMMUNOSUPPRESSANTS
| Drug | Action | Notes |
|---|---|---|
| Non-biologic DMARDs (methotrexate, hydroxychloroquine, leflunomide, sulfasalazine) | Continue | |
| Biologic DMARDs (adalimumab, infliximab, etanercept, rituximab, tocilizumab) | Stop; schedule surgery at END of dosing cycle | Restart only after wound healing (~2 weeks post-op) |
| JAK inhibitors (tofacitinib, baricitinib, upadacitinib) | Stop at least 3-7 days before surgery | Tofacitinib: 7 days |
| Corticosteroids | Continue (use "stress dose" if applicable) | Adrenal insufficiency risk if abruptly stopped |
8. HORMONAL / OTHER DRUGS
| Drug | When to Stop | Reason |
|---|---|---|
| Oral contraceptives / HRT (estrogen) | 4 weeks before major surgery | VTE risk |
| SERMs (raloxifene, tamoxifen) | 4 weeks before major surgery | VTE risk |
| Herbal supplements (ginkgo, garlic, ginseng, St. John's Wort, fish oil, vitamin E) | 1-2 weeks before | Bleeding, drug interactions, cardiovascular effects |
| Phentermine (appetite suppressant) | At least 7 days before | Risk of treatment-resistant hypotension |
| Non-statin lipid agents (fibrates, niacin, bile sequestrants, ezetimibe) | Day before surgery | Long-term agents; safe to hold short-term |
| PDE5 inhibitors (sildenafil, tadalafil) | 24-48 hrs before | Interaction with intraoperative vasopressors |
| Naltrexone | Hold before surgery | Blocks opioid receptors needed for postoperative pain control |
| PPIs / H2 blockers | Continue - use on day of surgery | Aspiration pneumonia prevention |
| Bronchodilators / inhaled steroids | Use on day of surgery | Perioperative bronchospasm prevention |
| Oral chemotherapy | Consult oncologist | Individualized decisions |
Key "Always Continue" Drugs (Do NOT Stop)
- Beta-blockers
- Statins
- Antiepileptics
- Antipsychotics
- SSRIs/SNRIs/antidepressants
- Benzodiazepines
- Thyroid medications (levothyroxine)
- PPIs / H2 blockers
- Inhaled asthma medications
- Anti-Parkinson drugs
- Opioids (continuation prevents withdrawal)
- Guanfacine (rebound hypertension risk)
Special Considerations (2024 AHA/ACC)
Per the 2024 AHA/ACC Perioperative Cardiovascular Guidelines, the management of perioperative antiplatelet and anticoagulant therapy is individualized based on:
- The patient's thromboembolic risk (e.g., recent stent, mechanical heart valve, AF with high CHA2DS2-VASc)
- The surgical bleeding risk (high = neurosurgery, urologic; low = dermatology, cataract)
- Whether bridging therapy with LMWH is warranted
Disclaimer: These are general evidence-based guidelines. Always individualize management based on the specific patient, procedure type, and anesthesia team's protocol. Patients on anticoagulation for high-risk conditions (mechanical valves, recent stents) require specialist input before stopping any therapy.
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