Several medications are reviewed for use & disuse perioperatively.
Choose agent(s) for management
Antiplatelet (aspirin, clopidogrel, etc)
Direct oral anticoagulant (DOAC)
General principles of periop mgmt
General principles (students, residents)
External links to web & app resources
iPRO's MAPPP
MAQI2 Anticoag Toolkit U-Mich
ASRA's Coags (reg-neuraxial)
Two independent apps have offered more comprehensive mgmt guidance on these medications for years.
- iPRO's MAPPP (managing anticoag in the periprocedure period), includes antiplatelet
- Univ. Michigan's MAQ12 Anticoagulation Toolkit, anticoag-only
ASRA Coags (American Society Regional Anesthesia) covers the unique risks involved in neuraxial and regional anesthesia, and ASRA has no web version.
The ACC 2024, ADA 2024, and ICSI 2020 guidelines offer the following recommendations for the management of insulins and diabetic medications around surgery.
Note: SGLT-2's and GLP-1's (and GLP-1/GIP) are covered separately because they are no longer indicated only for diabetes.
Oral meds:
- metformin continuation is reasonable to maintain glycemic control (ACC 2a, C)
- do not administer oral hypoglycemics preoperatively (ICSI strong, low) except for metformin (ACC above)
- DPP-4 inhibitors (e.g. sitagliptin) can be continued perioperatively, if patient desires (ICSI strong, low). But ICSI adds that since they work on glucose for absorption in the GI tract, the agents are safe but unnecessary since surgical patients are NPO
Insulins:
- long-acting insulins (e.g. glargine) may be decreased to 75-80% of usual dose the night before and/or day of surgery (ADA)
- intermediate-acting insulins (NPH) used BID can be decreased to 50% usual dose the night before and/or day of surgery (ADA)
- adjust insulin pump basal rates based upon type of diabetes and clinical judgement, ADA does offer that cutting basal pump rates down by 25% starting the evening before surgery achieves glycemic goals while reducing hypoglycemia (ADA)
- short-acting, sliding scale insulin should be used to treat high blood glucose values in patients holding their normal diabetic medications (ICSI strong, low; ADA)
General guidance:
- individualized diabetes mgmt plans should be formulated prior to surgery so as to avoid glycemic extremes (ICSI strong, low)
- glycemic control should be directed at achieving blood glucose levels between 140-180 mg/dL and not be directed at more intensive goal targets (80-110 mg/dL) (ICSI strong, high)
- ACC notes that no evidence supports an A1c goal before surgery or delaying surgery to achieve one. ACC does support attention to perioperative glucose control.
Further ICSI pointers:
- mild hyperglycemia is preferable to hypoglycemia
- details of insulin recommendations influenced by insulin sensitivity of patient, timing of procedure, length of procedure, and how long patient will need to be NPO following procedure
Guidance on this topic has evolved recently.
Out of concern for delayed GI emptying and risk of aspiration, initial recommendations for GLP-1 agonists (semaglutide, liraglutide) were to hold these agents perioperatively essentially for the duration of their half-lives (1+ day for daily agents, 1+ week for weekly agents).
However, the American Society of Anesthesiologists (ASA), joined by multiple other specialties, issued a new multisociety guildeline in late 2024, modifying previous guidance significantly. Two large cohort studies show no increased risk of aspiration pneumonia for patients on GLP-1's. Thus they recommend continuing or withholding GLP-1 agents according to the risk of significant delayed GI emptying. They recommend consideration of this issue based upon 3 steps.
1) Is risk of delayed GI emptying increased? Yes or no based upon following:
- current GI symptoms suggesting delayed gastric emptying; recent dose increases, higher doses, and weekly meds
- medical conditions beyond GLP-1 usage, which may also delay gastric emptying
2) Choose GLP-1 mgmt plan based on delayed gastric emptying risk above and shared decision-making:
- Continue GLP-1 preoperatively if there is no concern for delayed gastric emptying
- If elevated risk of delayed gastric emptying exists:
a. recommend liquid diet for at least 24 h before procedure with usual recommended fasting protocol, or
b. discontinue the GLP-1 for the duration of their half-lives (1+ day for daily agents, 1+ week for weekly agents), and consider bridging glycemic control measures
3) On the day of procedure, reassess for delayed gastric emptying and mitigate risk if clinical concern:
- Proceed with procedure as planned if there is no concern for delayed gastric emptying
- If elevated risk of delayed gastric emptying exists:
a. consider point-of-care gastric ultrasound and/or
b. consider rapid sequence induction of general anesthesia, if appropriate
c. minimize procedure cancellation when possible
Thus far, no guidance (guidelines, package insert) distinguishes the relatively unique GLP-1/GIP combination agonist agent tirzepatide from other GLP-1 agents. Until specific evidence and guidance emerges to say differently, treat tirzepatide like other weekly GLP-1 medications.
SGLT-2 inhibitors (per FDA March 2020) are associated in case reports with euglycemic DKA. FDA recommends stopping dapagliflozin, empagliflozin, and canagliflozin 3 days before surgery, ertugliflozin 4 days before surgery, managing sugars in the interim, and not resuming until patient is tolerating full diet and patient no longer has risks for ketoacidosis, ACC and ADA agree with the FDA recommendations (ACC 1, C).
How large is this risk? One cohort study (Mehta Endo Pract '22) found a DKA rate of 0.17% and 1.1% for non-emergent and emergent surgeries, respectively, in a cohort of 2,183 procedures on 1,307 patients. Another cohort study (Dixit JAMA Surg '25) looked only at emergency surgeries, finding 3.5% vs. 3.8% for SGLT2 users vs. non-users, respectively, among 34,671 diabetic patients.
ACE's and ARB's can cause transient hypotension but there has long been controversy in absence of optimal RCT evidence regarding whether clinical outcomes are worsened. The POISE-3 RCT has settled this showing no difference in outcomes continuing or withholding ACE's & ARB's, see below.
Thus ACC takes a permissive approach with level 2 recommendations, leaning towards discontinuation in most patients but leaning towards continuation in those with a compelling special indication for ACE-ARB like HFrEF:
- withholding ACE's and ARBs used for HTN mgmt 24 hours before elevated risk surgery may be beneficial to limit intraoperative hypotension (2b, B)
- continuing chronic ACE's and ARBs used for stability of HFrEF is reasonable (2a, B)
The POISE-3 RCT (Annals Int Med '23) randomized 7,490 patients to withholding or continuing an ACE-ARB perioperatively. Among a wide range of primary and secondary 30-day outcomes, there were no differences in outcomes with a hypertension-avoidance strategy (continue ACE-ARB) vs. a hypotension-avoidance strategy (withhold ACE-ARB).
A second large RCT (Legrand JAMA '24) confirmed these findings, showing no difference in mortality or post-op complications with continuation vs. discontinuation of ACE-ARB's. Intraoperative hypotension was greater in the continuation group, but was notably common in both groups, at 54% and 41% for continuation and discontinuation.
Note that anesthesiologists care about intraoperative hypotension and overall outcomes. The recent outcomes evidence may only somewhat allay concerns. There may be strong opinions about perioperative ACE's and ARB's in your community.
Guidance on handling buprenorphine (and buprenorphine/naloxone a.k.a Suboxone) peri- and post-operatively is evolving. Guidelines suggest several options:
For major surgical interventions,
1) Continue buprenorphine at the patient's maintenance dose and administer full opiate agonist agents peri- and post-op for additional pain relief like morphine and hydromorphone (Kohan, Reg Anesth Pain Med 2021). In theory, this shouldn't work, with buprenorphine blocking the agonists, but it does work. Every guideline making this recommendation notes you may have to use higher than usual doses of opiate agonists to overcome the buprenorphine. But what little evidence there is on dosing suggests maybe standard doses may be sufficient (Hitt, Anesth 2025).
2) Decrease any high-dose buprenorphine to 8-12 mg qDay so as to permit other opiate agonists to work and use peri- and post-op full agonists for pain.
For lower levels of anticipated pain, such as outpatient procedures,
1) Continue buprenorphine at the patient's maintenance dose, but break the total daily dose into 3-4 smaller more frequent doses. Although used mainly for its craving/withdrawal-suppression effect of 24+ hours duration, Buprenorphine also has a shorter pain-relieving effect on the order of 6-8 hours duration. Thus for mild-to-moderate pain, buprenorphine itself can be used when dosed more frequently.
Here's what not to do.
Do NOT discontinue buprenorphine altogether preop. Why even mention an option that shouldn't be an option? Because this option used to be the original recommendation starting 2 decades ago (2004), to discontinue buprenorphine altogether in favor of peri & post-op exclusive use of strong opiate agonists. All current guidelines have withdrawn this recommendation. Evidence has confirmed risks of withdrawal and precipitated withdrawal come from stopping and later resuming buprenorphine around surgery.
Ideally, management would be coordinated with the patient's opiate use disorder prescriber and/or hospital pain management experts.
ACC says:
- patients chronically on beta-blockers should stay on beta-blockers perioperatively (I, B)
- for patients with a new indication for beta- blocker therapy, it may be reasonable to begin beta-blockers long enough in advance to assess safety and tolerability and respond with dose titrations, optimally > 7 days before surgery (11b, B)
- in patients without a need for beta-blocker therapy, beta-blockers should not be started on the day of surgery due to increased stroke and mortality harm (3, B)
What happened to the enthusiasm for perioperative beta-blockade? Several RCTIs initially created excitement that periop beta- blockade could protect patients from the risk of myocardial ischemia. But ACC reviews that some of those early trials included stopping chronic beta-blockers rather than initiating them anew, thus making beta-blockade look artificially favorable. Then the POISE trial gave untitrated fairly high-dose beta-blockade on the day of surgery, yielding cardiac benefit but stroke harm, which dampened overall enthusiasm. Furthermore, the scientific integrity of some work in this field has been called into question. Thus the ACC recommendations above which were once strongly favorable are now more tempered.
ACC says:
- patients on statins should continue (l, B)
- perioperative initiation of statin for those not on one is recommended for those with standard hyperlipidemia and cardiac risk guideline-based clinical indications (1, B)
The safety (if not outright benefit) of periop statins is important to note because in the early days of statins even up to the early 2000's, statin package inserts raised concerns about perioperative use.
ESA offers the following guidance.
- Patients chronically treated with TCAs should undergo cardiac eval [details unstated] (D).
- Antidepressant for chronically depressed patients should not be discontinued (B).
- Discontinuation of SSRI perioperatively is not recommended (D).
- Irreversible MAOIs should be discontinued at least 2 weeks prior to anaesthesia. In order to avoid relapse of underlying disease, medication should be changed to reversible MAOIs (D).
- The incidence of postoperative confusion is significantly higher in schizophrenic patients if medication was discontinued prior to surgery. Thus, antipsychotic medication should be continued in patients with chronic schizophrenia perioperatively (B).
- Lithium should be discontinued 72 h prior to surgery. It can be restarted if the patient has normal ranges of electrolytes, is haemodynamically stable and able to eat and drink. Blood levels of lithium should be controlled within 1 week (D).
- For minor surgery under local anaesthesia, continuation of lithium therapy can be considered (D).
When to stop (per ICSI 2014):
Non-COX selective
- shorter half-life agents (ibuprofen, indomethacin, etc.): stop 1 day before surgery
- longer half-life agents (naproxen, sulindac, etc.): stop 3 days before surgery
COX-2 selective agents (celecoxib): stop 2 days before surgery, mainly due to concern for renal effects
With NSAIDs primarily cleared by the kidneys, recommendations above might be adjusted (lengthened) in CKD patients. But CKD patients should not be taking NSAIDs, so perhaps this proviso won't arise often.
It is commonly advised that NSAIDs be stopped 7-14 days before surgery. But this is due to the misconception that NSAIDs inhibit platelets like aspirin. Aspirin irreversibly inhibits platelets, thus aspirin needs to be stopped long enough prior to surgery for the lifecycle of platelet production to replace old inhibited platelets with new ones. However, NSAIDs inhibit platelet function reversibly, and thus they only need to be discontinued long enough for roughly 5 half-lives of the agent so that it and its platelet inhibitory impact are cleared. It may not be worth arguing with physicians who demand a lengthy discontinuation period for NSAIDs, but patients should rest assured that inadvertent NSAID use closer to surgery is not an indication to postpone their procedure.
Systemic QI -antagonists are typically used for BPH and HTN. However, they can complicate cataract surgery by causing intraoperative floppy iris syndrome (IFIS), characterized by sudden intraoperative iris prolapse and pupil constriction. IFIS increases both the difficulty and the risk of cataract surgery. Tamsulosin is associated with higher rates of IFIS than other a-blockers. Few outside of ophthalmology know of this condition.
Stopping the a-blocker does not reduce the risk of IFIS. But having cataract surgery before starting a-blocker, avoiding Tamsulosin, and certainly alerting eye surgeons to a-blocker use before surgery are all recommended (ASCRS & AAO).
ACC reviews the evidence and concludes that perioperative alpha-2 agonists (i.e. clonidine) for prevention of cardiac events are not recommended (3, B)
Use of perioperative CCBIs fall into two general questions: (1) for those not on one, should CCBIs be initiated perioperatively; and (2) for those already on one, should CCBIs be withheld perioperatively.
Regarding initiation, ACC reports:
- no clear support for perioperative initiation of CCBIs
Regarding withholding, ACC reports:
- no clear support for perioperative withholding of CCB's, noting potential for hypotension for the dihydropyridine agents and for bradycardia for the non- dihydropyridine agents
The Society for Perioperative Assessment and Quality Improvement (SPAQI) has a consensus statement reviewing what is known about preoperative management of surgical patients using supplements. Much of the clinical considerations are disease-oriented. Many concerns seem hypothetical. But they are willing to offer recommendations to continue or discontinue medications (and for how long) prior to surgery on 83 different herbals, vitamins, and supplements. Directly check the reference (Cummings, Mayo Clin Proc 2021) to view any of their 83+ recommendations which are too numerous to include here.
Two organizations have published guidance on perioperative cannabis. The American Society of Regional Anesthesia (ASRA) and Pain Medicine has a consensus guideline of 2023 in which they assembled evidence to make statements and recommendations on 9 questions. They cite evidence about cardiovascular and hemodynamic alterations and elevated MI risk after smoking cannabis. Except for FDA-approved cannabinoids used in conjunction with cancer treatment, they do not endorse use of cannabis at all. Their caveats around cannabis include:
- cannabis can impair cognition and the ability to offer informed consent to surgery, indicating delay of surgery
- smoked cannabis should delay surgery at least 2 hours to avoid the acute hemodynamic and pulmonary alterations and MI risk
- there is insufficient evidence to recommend an amount of time of abstinence or surgical delay for cannabis consumed via other non-smoking routes
The other recommendations come from the Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement (Mayo Clin Proc 2021) on patients using dietary supplements. They are more willing to make definitive recommendations, citing much of the same concerns as ASRA with fewer pathophysiology details. They recommend:
- elective surgery should preferably not occur within 3 days of cannabis use, and ideally abstinence should be 2 weeks to reduce airway irritability in those who smoke
- their recommendations do not apply to FDA-approved cannabinoids used for recognized indications such as chemotherapy nausea or rare epilepsy syndromes.
Perioperative GI meds
The same American Society of Anesthesiology (ASA) guideline of 2017 (Anesth 126, 3, pg 376) offering guidance on perioperative food and drink also made recommendations regarding perioperative GI meds, at least as focused on the issue of preventing pulmonary aspiration. The recommendations are pretty permissive and probably won't change how you manage patients.
Gastric Acid Secretion Blockade:
- PPI's, H2B's may be preoperatively administered to patients at increased risk of aspiration
- do not routinely administer such meds for the purpose of preventing pulmonary aspiration in patients without increased risk
Antacids:
- antacids may be preoperatively administered to patients at increased risk of aspiration, only use non-particulate antacids
- do not routinely administer such meds for the purpose of preventing pulmonary aspiration in patients without increased risk
Antiemetics:
- antiemetics may be preoperatively administered to patients at increased risk of post-op nausea and vomiting
- do not routinely administer such meds for the purpose of preventing post-op nausea and vomiting in patients without increased risk of pulmonary aspiration
Anticholinergics:
- do not administer anticholinergics preoperatively for the purpose of preventing pulmonary aspiration
Perioperative Food and Drink
The American Society of Anesthesiology has two recent guidelines (2017, 2023) focused on recommendations about oral intake of solid and liquid nutrition prior to surgery, ever with an eye towards minimizing the risk of aspiration.
Clear Liquids*:
- may be ingested by healthy adults and children for up to 2 hours before procedures
- clear liquids should not include alcohol
- evidence insufficient regarding whether clear liquids may include protein
- use clinical judgement in those with coexisting GI disorders which might delay gastric emptying
- studies supporting clear liquids generally administered appx. 400 cc up to 2 hours before anesthesia
Breast Milk:
- for otherwise healthy neonates and infants, breast milk may be ingested up to 4 hours before procedures
Infant Formula:
- for otherwise healthy neonates and infants, infant formula may be ingested up to 6 hours before procedures
Solids and Non-human Milk:
- a light meal or nonhuman milk may be ingested up to 6 hours before procedure
- additional fasting time (≥8 hrs) may be needed for fried foods, fatty foods, or meat
* What are examples of "clear liquids"? Examples of clear liquids include, but are not limited to, water, and fruit juices without pulp, carbonated beverages, carbohydrate rich nutritional drinks, clear tea, and black coffee
Refs: Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents... Anesth 2017;126(3):376-393. 2023 American Society of Anesthesiologists Practice Guidelines for
Preoperative Fasting... Modular Update of the 2017 American Society of Anesthesiologist Practice Guidelines for Preoperative Fasting. Anesth 2023;138:132-151.
Anticoagulant & antiplatelet guidance has become so complicated over the years that in previous versions of this app (through 4.0) I had given up on trying to master it, instead offering general principles and directing you to other excellent apps. However, now the guidance seems more clear and unified by ACCP in 2022 and ACC in 2024, so I'm adding that guidance back into this app as of version 4.1. I'm still not pleased with clarity on antiplatelet agent mgmt, so send feedback and ideas if you have any.