Perioperative Medication Management

General Principles for Medication Management

Medication management should be based on the specific medication's risk profile, potential for withdrawal, and impact on surgical outcomes, as recommended by the American College of Physicians 1, 2, 3
The American Academy of Orthopaedic Surgeons suggests continuing medications where abrupt discontinuation could lead to withdrawal or disease exacerbation (e.g., opioids, certain muscle relaxants, and most chronic disease medications) 1, 4
The American College of Rheumatology recommends withholding medications that significantly increase surgical risks (e.g., certain biologics, JAK inhibitors, SGLT2 inhibitors) 3, 5, 6
Consider pharmacokinetics and pharmacodynamics when determining timing of medication cessation, as advised by the American Society of Anesthesiologists 7, 8

The American Pain Society recommends continuing opioid agonists on the morning of surgery to prevent withdrawal and maintain pain control 4
The American Academy of Neurology suggests continuing tizanidine preoperatively, including the day of surgery 2
The American College of Rheumatology advises continuing conventional DMARDs (e.g., methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, and apremilast) through surgery 3, 5
The American College of Rheumatology recommends continuing glucocorticoids at the current daily dose rather than administering supraphysiologic doses 3, 5

The American College of Rheumatology suggests withholding biologics prior to surgery and planning surgery after the next dose is due 3, 5, 7
The American College of Rheumatology recommends withholding JAK inhibitors (e.g., tofacitinib, baricitinib, upadacitinib) for at least 3 days prior to surgery 7
The American Society of Anesthesiologists advises withholding SGLT2 inhibitors the day before and day of surgery to reduce the risk of ketoacidosis 6, 8
The American Headache Society recommends withholding triptans on the day of operation due to potential serotonin syndrome risk with perioperative medications 1

The American Academy of Orthopaedic Surgeons suggests tapering rather than abrupt discontinuation for medications with significant withdrawal potential (e.g., baclofen, carisoprodol) 1, 2
The American College of Rheumatology recommends restarting withheld rheumatologic medications once the wound shows evidence of healing, sutures/staples are out, and there's no significant swelling, erythema, drainage, or infection (typically ~14 days) 3, 5
The American Diabetes Association advises restarting SGLT2 inhibitors once eating and drinking normally (usually 24-48 hours after surgery) 6, 8

The American College of Physicians warns that abrupt discontinuation of medications with withdrawal potential can lead to significant morbidity 1, 2
The American Society of Anesthesiologists cautions that continuing SGLT2 inhibitors through surgery increases the risk of ketoacidosis, especially with prolonged fasting 6, 8
The American College of Rheumatology advises that failure to restart medications in a timely manner can lead to disease flares 3, 5

The American Diabetes Association, as published in Diabetes Care, recommends discontinuing SGLT2 inhibitors 3-4 days before surgery, unlike furosemide which does not carry the same risks and can be continued 9

The Association of Anaesthetists, as published in Anaesthesia, recommends continuing chronic medications that don't increase surgical risk for patients undergoing day-case surgery to maintain physiological stability 10, 11
The American Heart Association, as published in Hypertension, recommends continuing medications that control heart failure or hypertension for perioperative hemodynamic stability 12