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PERIOPERATIVE GUIDELINES – 2019

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

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PERIOPERATIVE MEDICATION GUIDELINES – 2019

DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON Channel Blockers Amlodipine (Norvasc®) Do NOT hold prior to Clevipidine (Cleviprex®) surgery (Cardizem®) (Plendil®) (Dynacirc®) (Cardene®) (Procardia®, Adalat®) (Nimotop®) Verapamil (Calan®, Covera-HS®, Verelan®) Clonidine (Catapres®) Do NOT hold prior to Withdrawal/ surgery rebound effects if held Digoxin (Lanoxin®) Do NOT hold prior to surgery (Diamox) HOLD day of surgery Increases the risk of / Amiloride/ hypovolemia (Moduretic) (Bumex) (Diuril) Chlorthalidone (Thalitone) (Inspra®) Ethacrynic (Edecrin) (Lasix®) Hydrochlorothiazide (Microzide, Esidrix®) (Lozol) (Zaroxolyn) Methazolamide Metolazone (Zaroxoxlyn) (Aldactone) Spironolactone/Hydrochlorothiazide (Aldactazide) Torsemide (Demadex) (Dyrenium) Triamterene / HCTZ (Dyazide, Maxzide) Statins (Lipitor) Do NOT hold prior to Fluvastatin (Lescol) surgery (Mevacor) Pitavastatin (Livalo) Pravastatin (Pravachol) Rosuvastatin (Crestor) (Zocor)

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PERIOPERATIVE MEDICATION GUIDELINES – 2019

RESPIRATORY DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON Bronchodilators Albuterol (ProAir, Proventil, Use on day of surgery Ventolin) Albuterol/Ipratropium (Duoneb, Combivent) /Budesonide (Symbicort) Formoterol/ (Dulera) Ipratropium (Atrovent) Levalbuterol (Xopenex) (Serevent ) Salmeterol/Fluticasone (Advair) Inhaled Beclomethasone (QVAR) Use on day of surgery Flunisolide (AeroBid) Fluticasone (Flovent ) Mometasone (Asmanex) Triamcinolone (Asmacort) 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 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 (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 If no history of CAD Increased risk of (and Aspirin- containing or : bleeding drugs Aspirin/acetaminophen/ Discontinue 5-10 complications (Excedrin®) days prior to Aspirin//caffeine (Fiorinal®) surgery, especially Aspirin/ (Soma for ophthalmologic Compound®) and neurosurgical Aspirin/carisoprodol/ (Soma procedures. compound w/ codeine®) Aspirin/dipyridamole (Aggrenox®) Patients with hx of Aspirin//caffeine CAD or stroke: (Norgesic®) Continue Aspirin, Aspirin/ (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! (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 (Cataflam®, Voltaren®) HOLD day prior to Increased risk for (Lodine®) surgery bleeding and renal (Nalfon®) complications (Ansaid®) (Advil®, Motrin®) Ibuprofen/ (Vicoprofen®) Ibuprofen/Oxycodone (Combunox®) Indomethacin (Indocin®) (Orudis KT®, Oruvail®) (Toradol®) Meclofenamate (Meclomen®) (Ponstel®) (Tolectin®)

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PERIOPERATIVE MEDICATION GUIDELINES – 2019

DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON Long-acting NSAIDs (Dolobid®) At least 3 days prior to Increased risk for Etodolac (Lodine XL®) surgery renal, thrombo- (Mobic®) embolic (Relafen) complications (Aleve®, Anaprox®, Naprosyn®) (Daypro) (Feldene) (Clinoril®) Cox-2 Inhibitors (Celebrex) At least 3 days prior to Increased risk for Nabumetone (Relafen) surgery renal, thrombo- embolic complications MEDICATIONS DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON Long-Acting Patch (Duragesic) Do NOT hold prior to Discontinuation may SR (Exalgo) surgery result in opioid (Dolophine) withdrawal and SR (MS Contin, Kadian, difficulty with Avinza) postoperative pain Morphine SR/ (Embeda) control. Oxycodone SR (Oxycontin) (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) (Nucynta) Opioid / / (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 patch Continue Anesthetic Skeletal Muscle Carisoprodol Soma Continue Relaxant (Skelaxin) AND IMMUNE MEDICATIONS DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON Steroids Do NOT hold prior to Adrenal (Medrol) surgery insufficiency MEDICATIONS DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON Thyroid hormone (Synthroid, Levoxyl) Do NOT hold prior to Dessicated thyroid (Armour Thyroid) surgery MEDICATIONS DRUG LASS DRUGS IN CLASS WHEN TO HOLD REASON Short-Acting 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 (Lantus, Toujeo) Take ½ dose of long Insulin Detemir (Levimir) acting night prior – Insulin Degludec (Tresiba) unless otherwise specified by prescriber Non-Insulin Injections (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/ (Oseni) unless otherwise Linagliptin (Tradjenta) specified by prescriber Pioglitazone (Actos) (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 (Xanax®) Do NOT hold prior to Risk of withdrawal if (Librium®) surgery stopped abruptly; (Valium®) potential for additive effects - (Marplan®) Taper off 2 weeks Drug interactions (MAO) (Nardil®) prior to surgery if (e.g., , Inhibitors (Parnate®) possible meperidine, methadone, (Azilect®) OK to continue ), which could cause a patch (Emsam®) Discontinue at least 10 hypertensive crisis. days prior to surgery if possible Antidepressants – SSRIs and (Celexa®) Do NOT hold prior to Risk of withdrawal if SNRIs (Cymbalta) surgery stopped abruptly (Lexapro®) (Prozac®) (Luvox®) (Paxil®) (Zoloft®) Strattera (®) (Pristiq, Khedezla) Antidepressants - Other (Elavil ) Do NOT hold prior to Risk of withdrawal if (Wellbutrin) surgery stopped abruptly (Norpramin) (Sinequan) (Tofranil) (Remeron) (Serzone) (Pamelor) (Desyrel) 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) (Tegretol) (Klonopin) (Felbatol) (Neurontin) (Keppra) (Lamictal) (Trileptal) (Dilantin) (Lyrica)

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PERIOPERATIVE MEDICATION GUIDELINES – 2019

DRUG CLASS DRUGS IN CLASS WHEN TO HOLD REASON Anticonvulsants continued… (Mysoline) (Gabitril) (Topamax) Valproic Acid (Depakote) (Zonegran) ADHD Drugs () () Do NOT hold prior to No documented (Vyvanse) surgery interaction with (Focalin) (Ritalin, medications Metadate, Concerta, Daytrana patch) ADHD Drugs (non-) (Intuniv) Do NOT hold prior to Risk of rebound surgery if withheld. Sleep Aids (Ambien) May take night before (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 (Prevacid) surgery (Prilosec) Pantoprazole (Protonix) (Aciphex) Histamine H2 blockers (Tagamet) Do NOT hold prior to Reflux prevention Famotidine (Pepcid) surgery Nizatidine (Axid) (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 (Adipex®, Suprenza®) Discontinue at least 7 Risk of hypotension Drug) Phentermine / Topiramate (Qsymia®) days preop that is unresponsive to treatment. Other Medical patch Continue patches patch Herbal Supplements See List Discontinue at least one Risk of bleeding, week preop 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 Poplar Anise Flaxseed Prickly Ash (Northern) Arnica Forskolin Quassia Asafoetida Forsythia Red Clover Aspen Bilberry Gamma linolenic acid Safflower Black Haw German Sarsaparilla Saw palmetto Bladder Wrack (Fucus) Sea buckthorn Bogbean Boldo (Panax, Siberian) Senega Borage Green tea Serrapeptase Bromelain Guggul Swallowroot Buchu Holy Sweet Clover Burdock Honeysuckle Sweet Vernal grass Capsicum Horse Chestnut Sweet Woodruff Carrageenan Tamarind Inositol Nicotinate Chamomile (German and Japanese apricot Tonka Beans Roman) Jiaogulan Chinese prickly ash Cinchona Kudzu Vinpocetine Licorice E Cod oil Meadowsweet Wild Carrot Coltsfoot Wild Lettuce Danshen Methoxylated flavones Willow Bark Deertongue Nattokinase Wintergreen DHA () Yarrow Dong quai Palm oil EPA () 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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