FMLH Preoperative Guidelines

Preoperative Medication Management

DEPARTMENT OF ANESTHESIOLOGY
Recommended Perioperative Medication Management
The following medications SHOULD BE CONTINUED up to and including the day of surgery
(Instruct patients to take with a small sip of water):
1. Alzheimers medications
2. Anti-anxiety and psychiatric medications
Be aware that with short acting SSRIs, SNRIs (e.g. Paxil, Zoloft, Luvox, Effexor) withdrawal symptoms may
manifest even with one omitted dose.
3. Antidepressants
Except MAO inhibitors see list below
(Patients taking MAO inhibitors should have a High Risk Anesthesia Consultation)
4. Anti-hypertensive medications (anything ending in-olol)
Cardioselective beta blockers (that are more likely
to block beta-1 receptors rather than beta-2
receptors) include:

Acebutolol (Sectral )

Atenolol (Tenormin )

Beta blockers that also block alpha receptors

include:

Betaxolol (Kerlone , Betoptic )

Carvedilol (Coreg , Coreg CR )

Bisoprolol (Zebeta )

Labetalol (Trandate ).

Esmolol (Brevibloc )

Metoprolol (Lopressor , Toprol-XL ).

Nebivolol (Bystolic )
Beta blockers with intrinsic sympathomimetic activity
(ISA) include:

Acebutolol (Sectral )

Carteolol (Ocupress )

Penbutolol (Levatol )

Pindolol (Visken ).

Beta blockers that are non-selective, do not have

ISA, and do not block alpha receptors include:

Levobunolol (Betagan )

Metipranolol (OptiPranolol )

Nadolol (Corgard )

Propranolol (Inderal , Inderal LA, InnoPran

XL )

Sotalol (Betapace , Sorine )

Timolol (Betimol , Blocadren , Istalol ,

Timoptic ).

4A. Other Anti-Hypertensive Agents and Cardiac Medications. (i.e. hydralazine, nitrates, calcium channel
blockers, digoxin, alpha antagonists)
5. Anti-seizure medications
6. Antivirals and retrovirals
7. Asthma medications (inhalers and nebulizers please USE on the morning prior to arrival)
8. Birth control pills
Updated June 2012
Ellinas, Lauer, Manley, Woehlck

FMLH Preoperative Guidelines

Preoperative Medication Management

The following medications SHOULD BE CONTINUED up to and including the day of surgery
(Instruct patients to take with a small sip of water):
9. COX-2 inhibitors (check with surgeon if there is concern about new bone growth/healing)
10. Cardiac medications- see Other Anti-Hypertensive Agents and Cardiac Medications above
11. Eye drops
12. Heartburn or anti-reflux medications (e.g. Prilosec, Zantac)
13. Immunosuppressants (e.g. azathioprine, cyclosporine, rapamune, methotrexate, Remicade, Humira, Enbrel) do not stop any immunosuppressant medications without speaking with the prescribing physician. Patients
with organ transplants should be continued on immunosuppressants. Patients taking these medications for other
diseases (i.e. rheumatoid arthritis, crohn's) may have them discontinued perioperatively only AFTER a discussion of
risks/benefits between the surgeon and the prescribing physician has taken place.
14. Opioids (e.g. morphine, oxycodone or oxycontin, fentanyl patch)
15. Rheumatologic medications (e.g. allopurinol)
16. Statins (e.g. simvastatin, rosuvastatin)
17. Steroids (oral and inhaled)
18. Thyroid medications (e.g. levothyroxine)

Updated June 2012

Ellinas, Lauer, Manley, Woehlck

FMLH Preoperative Guidelines

Preoperative Medication Management

The following medications should be DISCONTINUED prior to surgery:

1. ACE inhibitors (angiotensin converting enzyme inhibitors, anything ending in -pril) hold on day of surgery
Benazepril (Lotensin)
Captopril (Capoten)
Enalapril (Vasotec)
Fosinopril (Monopril)
Lisinopril (Prinivil, Zestril)
Quinapril (Accupril)
Ramipril (Altace)
Trandolapril (Mavik)

2. ARBs (angiotensin II receptor blockers, anything ending in -artan) hold on day of surgery
Candesartan (Atacand)
Eprosartan (Teveten)
Irbesartan (Avapro or Avalide-combo with HCTZ)
Losartan (Cozaar or Hyzaar-combo with HCTZ)
Olmesartan (Benicar or Benicar HCT-combo with HCTZ)
Telmisartan (Micardis)
Valsartan (Diovan)

3. Antiplatelet agents (Plavix, clopidogrel, ticlopidine, Ticlid, prasugrel, Effient, ticagrelor, Brilinta) please refer to
FMLH Algorithm for Management of Perioperative Antiplatelet Therapy. Discuss with prescribing physician.
For aspirin-see SPECIAL SITUATIONS at the end of the document. If patient does not have cardiac or carotid stents,
stop 7 days prior to surgery

4. Bisphosphonates hold on day of surgery

5. Coumadin if normal coagulation is required, discontinue 5 days before surgery will need to check PT and
PTINR preop. Discuss with prescribing physician and consider bridging therapy.

6. Dabigatran length to hold depends on renal function and risk of bleeding. If possible, discontinue PRADAXA 1
to 2 days (CrCl 50 mL/min) or 3 to 5 days (CrCl <50 mL/min) before invasive or surgical procedures because of the
increased risk of bleeding. Consider longer times for patients undergoing major surgery, spinal puncture, or placement
of a spinal or epidural catheter or port, in whom complete hemostasis may be required. Discuss with prescribing
physician and consider bridging therapy.

7. Diuretics hold on day of surgery

8. Heparin patients receiving either UFH or LMWH should have their doses held for 12 hours preop if taking
prophylactic dosing and 24 hours if taking therapeutic dosing

9. Herbal supplements and Vitamin E-containing multivitamins discontinue 7 days prior to surgery
10. Insulin please refer to FMLH protocol for insulin management (see below). Order finger stick on arrival on day
of surgery. Please note that if the surgical start time is delayed, the anesthesiologist assigned to the case needs to be
contacted regarding blood sugar monitoring and IV placement.
Patient with insulin pumps should continue their basal rate ONLY.
FMLH protocol for pre-procedure insulin management:
1. Hold short acting insulin (e.g. Humalog, Novolog, Regular)
2. NPH: give of usual dose
3. Pre-mixed insulin (eg. Humulin or Novolog mix 70/30) give 1/3 of usual dose
4. Insulin Glargine (Lantus): give usual dose.
5. Insulin Detemir (Levemir): give usual dose.
Updated June 2012
Ellinas, Lauer, Manley, Woehlck

FMLH Preoperative Guidelines

Preoperative Medication Management

The following medications should be DISCONTINUED prior to surgery:

11. Iron hold on day of surgery
12. MAO inhibitors patient may need special instructions consider Anesthesiology Consultation preop
List of MAOIs
Pharmaceutical Drugs
o Nonselective MAO-A/MAO-B Inhibitors
o Hydrazines
Benmoxin (Nerusil, Neuralex)
Hydralazine (Apresoline)
Iproclozide (Sursum)
Iproniazid (Marsilid, Iprozid,
Ipronid, Rivivol, Propilniazida)
Isocarboxazid (Marplan)
Isoniazid (Laniazid, Nydrazid)
Mebanazine (Actomol)
Nialamide (Niamid)
Octamoxin (Ximaol, Nimaol)
Phenelzine (Nardil, Nardelzine)
Pheniprazine (Catron)
Phenoxypropazine (Drazine)
Pivalylbenzhydrazine (Tersavid)
Procarbazine (Matulane,
Natulan, Indicarb)
Safrazine (Safra)
o Non-Hydrazines
Caroxazone (Surodil,
Timostenil)
Echinopsidine (Adepren)
Furazolidone (Furoxone,
Dependal-M)
Linezolid (Zyvox, Zyvoxam,
Zyvoxid)
Tranylcypromine (Parnate,
Jatrosom)
o Selective MAO-A Inhibitors
Brofaromine (Consonar)
Metralindole (Inkazan)
Minaprine (Cantor)
Moclobemide (Aurorix, Manerix)
Pirlindole (Pirazidol)
Toloxatone (Humoryl)
o Selective MAO-B Inhibitors
Lazabemide (Pakio, Tempium)
Pargyline (Eutonyl)
Rasagiline (Azilect)

o
o
o
o
o

Selegiline (Deprenyl, Eldepryl,

Emsam)
Selective MAO-A Inhibitors
Resveratrol (found in skin of red
[14]
grapes)
Berberine (found in many herbs
[15]
like Goldenseal)
Nonselective MAO-A/MAO-B Inhibitors
Curcumin (found in turmeric)
Harmala alkaloids (found in
tobacco, syrian rue, passion
flower, ayahausca, and Tribulus
terrestris)
Harmine, Harmaline,
Tetrahydroharmine,
Harmalol, Harman,
Norharman, etc
Rhodiola Rosea (active
consituent(s) unknown)
Selective MAO-B inhibitors
Catechin (found in the tea plant,
cocoa, and cat's claw)
Desmethoxyyangonin (found in
kava)
Epicatechin (also found in the
tea plant, cocoa, and cat's claw)
Fo-Ti (active constituent(s)
unknown)
Hydroxytyrosol (found in olive
oil)
Piperine (found in pepper)
Unknown Selectivity
Liquorice (active constituent(s)
unknown)
Myristicin (found in nutmeg, parsley, and
dill)
Siberian Ginseng (active constituent(s)
unknown)
Yerba Mate (active constituent(s)
unknown)
Yohimbe (active constituent(s) unknown

Updated June 2012

Ellinas, Lauer, Manley, Woehlck

FMLH Preoperative Guidelines

Preoperative Medication Management

The following medications should be DISCONTINUED prior to surgery:

MAO Inhibitors
Research Compounds
Nonselective MAO-A/MAO-B Inhibitors
o Hydrazines
o Metfendrazine
Selective MAO-A Inhibitors
o Amiflamine
o Bazinaprine
o Befloxatone
o Befol
o Cimoxatone
o Clorgyline

o
o
o
o
o
o
o
o
o
o

Esuprone
Methylene Blue
Sercloremine
Tetrindole
Tyrima
Selective MAO-B Inhibitors
D-Deprenyl
Ladostigil
Milacemide
Mofegiline

Various tryptamine and phenethylamine/amphetamine derivatives such as ET, MT, amphetamine (itself),
methamphetamine, MDMA, 4-MTA, PMA, 2C-T-7, and 2C-T-21 may also have weak to strong MAOI effects at high
doses. Many other unlisted hydrazines like hydrazine (itself), monomethylhydrazine, and phenylhydrazine have some
MAOI properties as well.
14. NSAIDS discontinue 7 days before surgery
15. Oral diabetic agents hold on day of surgery
16. Premarin hold on day of surgery
17. Rivaroxaban hold min 24 hrs prior to surgical procedure. Discuss with prescribing physician and consider
bridging therapy.
18. Direct Renin Inhibitor-hold on day of surgery
Aliskiren (Tekturna)
19. Viagra or similar drugs hold 24 hours preop.

Updated June 2012

Ellinas, Lauer, Manley, Woehlck

FMLH Preoperative Guidelines

Preoperative Medication Management

SPECIAL SITUATIONS--ASPIRIN

Updated June 2012

Ellinas, Lauer, Manley, Woehlck