Prescribed medications (including pre-medication) can be taken up until induction of anaesthesia with a small drink of water (less than 30 mL) EXCEPT IN THE FOLLOWING CIRCUMSTANCES:

1. Do not administer if there are specific directions to hold one or many medications for a patient (e.g. “hold” beside drugs on the patient’s drug chart or anaesthesiologist note on pre-assessment sheet);
2. Do not administer if the patient is unable to swallow oral medication (fasting for surgery is not in itself a reason to withhold medication):
3. If the drug belongs to the drug classes below- CHECK WHAT TO DO .  The table below is not exhaustive.
   • Where there is concern , refer the patient to the anaesthesiologist, surgeon or prescribing team for a decision on an individual basis.
   • Inform anaesthesiologist if any drug in the table below was given even though it should have been held.

If the drug belongs to the drug classes below- CHECK WHAT TO DO.

Otherwise, if not in the table, prescribed medications (including pre-medication) can be taken up until induction of anaesthesia with a small drink of water (less than 30 mL)

Generic examples

Brand examples

Recommendation

CARDIOVASCULAR SYSTEM,   ANTICOAGULATION

Anticoagulants (Oral)

Assess individually in advance of surgery; usually held.
Warfarin may require bridging, however DOACs do not. Refer to chapter 11 .

Dabigatran

Edoxaban

Rivaroxaban

Antiplatelets

Aspirin

Nu-Seals Aspirin

Nuprin

Aspirin 75mg usually continued.

Assess individually in advance of surgery: refer to chapter 2 .

For dipyridamole discuss with prescribing consultant.

Clopidogrel

Plavix

Dipyridamole

Persantin, Asasantin Retard

Prasugrel

Efient

ACE Inhibitors

Capoten, Capozide, Capto-Co

Hold on morning of surgery

Innovace, Innozide

Zestril, Zestoretic, Carace Plus, Acerycal

Coversyl, Coversyl Plus

Ramilo, Tritace, Triapin

Trandolapril

Gopten, Odrik, Tarka

Angiotensin II Antagonists (and combination with neprilysin inhibitor)

Hold on morning of surgery

Atacand, Atacand Plus

Teveten, Teveten Plus

Aprovel, CoAprovel

Cozaar, Cozaar-Comp

Valsartan/Sacubitril

Entresto

Renin Inhibitors

Aliskerin

Rasilez, Rasilez HCT

Hold on morning of surgery

Beta-Blockers

Continue on morning of surgery

Atecor, Atecor CT

Bisocor, Bisop

Sotalol

Sotacor, Sotoger

Calcium Channel Blockers

Verapamil

Loop and Thiazide Diuretics

Continue on morning of surgery

Xipamide

Diurexan

Potassium Sparing Diuretics

Triamterene

Dytac, Frusene, Kalspare, Triam-Co, Dyazide

Hold on morning of surgery

Peripheral Vasodilator

Cilostazol

Pletal

Hold for 5 days pre-surgery

Antiarrhymthic

Continue and inform anaesthesiologist .
Potential for bradycardia unresponsive to atropine, hypotension,
disturbances of conduction and decreased cardiac output if general anaesthesia is used.

Dronedarone

Multaq

If the drug belongs to the drug classes below- CHECK WHAT TO DO.

Otherwise, if not in the table, prescribed medications (including pre-medication) can be taken up until induction of anaesthesia with a small drink of water (less than 30 mL)

Generic examples

Brand examples

Recommendation

DIABETES

Insulins

All injectable insulins - See section 6.1.2 of the Guide, or Adult Diabetes Chart

Sodium-Glucose Co-Transporter 2 Inhibitors (SGLT-2 inhibitors)

Hold for 72 hours prior to surgery. See section 6.1.2 of the Guide, or Adult Diabetes Chart

Ertugliflozin

Steglatro, Stegluromet, Steglujan

Other Hypoglycaemic Agents

Hold all oral hypoglycaemics and non-insulin injections on morning of surgery.
See section 6.1.2 of the Guide, or Adult Diabetes Chart

Vildagliptin

Eucreas

If the drug belongs to the drug classes below- CHECK WHAT TO DO.

Otherwise, if not in the table, prescribed medications (including pre-medication) can be taken up until induction of anaesthesia with a small drink of water (less than 30 mL)

CENTRAL NERVOUS SYSTEM

Lithium

Priadel, Camcolit

Continue – but inform anaesthesiologist & monitor electrolytes and fluid balance closely.
Take a lithium level before surgery – see TDM section XVII .
Surgery-related electrolyte disturbance or reduced renal function may precipitate lithium toxicity.
Maintain adequate fluid intake. Avoid other nephrotoxins, e.g. NSAIDs. If stopping, discuss with Psychiatry including restart plan.

Clozapine

Clozaril, Denzapine

Hold on the morning surgery. Restart normal dose post-operatively if vital signs are normal.
If discontinued for more than 48 hours, must be re-titrated; contact Pharmacy or Psychiatry for advice.

Benzodiazepines

Continue. High dose only: inform anaesthesiologist

CNS Stimulants

Hold for 24 hours before surgery, restart when patient is stable.

Methylphenidate-avoid pethidine or tramadol (risk of serotonin syndrome)

Lisdexamfetamine

Tyvense

Mono-Amine Oxidase Inhibitors (MAOI)

Hold for 2 weeks before surgery, or hold on morning of surgery & inform Anaesthesiologist . Patient’s psychiatrist and anaesthesiologist should consider as early as possible, preferably at least 2 weeks prior to surgery. Risk of psychiatric relapse if discontinued. Option to switch to reversible MAOI (e.g. moclobemide) or continue and use alternative anaesthetic technique.  Potentially fatal interactions with pethidine, potential hypertensive crisis with inotropes.
Tranylcypromine and phenelzine should not be used with opioids and phenelzine can cause hypotension with spinal anaesthesia, potentiate inotropes and sympathomimetics and potentiate antihypertensives and CNS depressants.

Tranylcypromine

Reversible MAOI

Moclobemide

Manerix

Hold for 24 hours before surgery, and inform anaesthesiologist

Tricyclic/ Tetracyclic antidepressants

Continue – but inform anaesthesiologist .

Caution with pethidine use.

Increased risk of arrhythmias and hypotension during anaesthesia.
Risk of serotonin syndrome if clomipramine or amitriptyline administered with pethidine or tramadol.
May result in exaggerated response to sympathomimetic agents. Inform anaesthesiologist if any queries.

Trimipramine

Surmontil

Selective Serotonin Reuptake Inhibitors (SSRIs), and similar antidepressants

Continue & inform anaesthesiologist - avoid pethidine or tramadol (risk of serotonin syndrome).

Sertraline

Lustral

Serotonin and Noradrenaline Reuptake Inhibitors (SNRIs)

Continue & inform anaesthesiologist - avoid pethidine or tramadol (risk of serotonin syndrome).

Venlafaxine

Efexor

Multimodal activity with similar activity to SSRIs

Vortioxetine

Brintellix

Continue & inform anaesthesiologist - avoid pethidine or tramadol (risk of serotonin syndrome).

Alzheimer’s Disease Treatment

Inform anaesthesiologist & hold for 24 hours before surgery unless advised otherwise .
Can prolong the effects of depolarizing neuromuscular blockers such as suxamethonium. Restart as soon as possible post-op.

Rivastigmine

Exelon

Donepezil

Aricept

Continue, as prolonged interruptions in therapy result in sustained & irreversible cognitive decline. Inform anaesthesiologist.
Can prolong effects of depolarizing neuromuscular blockers such as suxamethonium & antagonise effect of non-depolarising muscle relaxants.

Parkinson’s Disease Treatment: MAO-B Inhibitor

Continue & inform anaesthesiologist - avoid pethidine and tramadol (risk of serotonin syndrome).

NB: Ensure all Parkinson’s medicines are given before surgery

Rasagiline

Azilect

Opioid Therapy

Continue AND ensure documentation is complete - anaesthesiologist must have access to current information including current dose

Tramadol

Tradol, Zydol

Opioid Maintenance Program

Methadone

Phymet, Pinadone

Give dose at least 2hrs before surgery.

Anaesthesiologist must be informed of the DOSE and VOLUME that has been administered.

Buprenorphine & Naloxone

Suboxone

Continue AND ensure documentation is complete - anaesthesiologist must have access to current information including current dose

Alpha-2 Receptor Agonists

Clonidine

Continue AND inform anaesthesiologist

NSAIDs

Continue AND inform anaesthesiologist

If the drug belongs to the drug classes below- CHECK WHAT TO DO.

Otherwise, if not in the table, prescribed medications (including pre-medication) can be taken up until induction of anaesthesia with a small drink of water (less than 30 mL)

IMMUNE SYSTEM

Immunosuppressants

Continue

If surgeon or prescribing team are concerned RE risk of infection (implants involved etc), depending on the indication,
it may be stopped 1 week prior to operation. (Do not stop in transplant patients)

Sulfasalazine

Salazopyrin

Leflunomide

Arava

Advice as per DMARDs above, but if stopping, stop 2 weeks prior to operation.

Methotrexate

Advice as per DMARDs above. Continue, but not on morning of surgery.
If the weekly dose will therefore be missed, it can be given 24-48 hours postoperatively (48 hours if contrast involved) once renal function is normal.

Give the dose on the usual day the following week.

Cytokine modulators

Biologic agents

Stop prior to surgery and schedule surgery at the end of the dosing cycle, if feasible.
Resume medications a minimum 14 days after surgery in the absence of wound healing problems,
surgical site infection or systemic infection. Check with patient for their individual dosing interval (general dosing intervals below).

For non-rheumatology patients on immunomodulators undergoing surgery, discuss with prescribing team prior to holding or restarting post-surgery.

Dosing Interval

Janus Kinase Inhibitors

Withhold for 3 days prior to surgery.

Resume medications a minimum 14 days after surgery in the absence of wound healing problems, surgical site infection or systemic infection.For non-rheumatology patients on immunomodulators undergoing surgery, discuss with prescribing team prior to holding or restarting post-surgery.

Corticosteroids (Systemic  outes only)

Continue oral steroids preoperatively as normal (additional IV hydrocortisone may also be indicated on induction of anaesthesia:
see section 6.4 of the Guide).

Triamcinolone

Kenalog, Adcortyl

If the drug belongs to the drug classes below- CHECK WHAT TO DO.

Otherwise, if not in the table, prescribed medications (including pre-medication) can be taken up until induction of anaesthesia with a small drink of water (less than 30 mL)

OTHER DRUG CLASSES

HRT and oral contraceptives

For Major Surgery >45 minutes with high thrombosis risk or prolonged immobilisation:

Hold HRT, OCP for 4 weeks pre-operatively

For minor surgery <45 minutes with:

- No other VTE risk factors – Continue HRT, OCP

- Other VTE risk factors (see section 11.1 )– continue HRT, but hold OCP for 4 weeks pre-operatively

See sections 9.5 and 9.6 for more details

Note: Progesterone-only methods can be continued perioperatively

Note: Transdermal HRT can be continued perioperatively

Consider stopping 4-6 weeks before surgery where prolonged immobilisation is likely.

Therapeutic doses > 5 mg:

Consider stopping 4-6 weeks before surgery where prolonged immobilisation is likely.

Tamoxifen

Nolvadex-D, Tamox

For breast cancer, continue with thromboprophylaxis.

For other indications, hold for 6 weeks pre-operatively

Raloxifene

Evista

Hold for 72 hours pre-operatively

Herbal medicines and supplements

Hold for two weeks pre-operatively

Strontium

Protelos

Hold for two weeks pre-operatively

Possesses mild anticoagulant activity.

For high-risk and intermediate-risk spinal procedures: Hold for 5 days pre-operatively. Can be resumed 24 hours after the procedure.

Anion exchange resins

Hold for 24 hours before surgery

Colestyramine

Questran