Medications | Perioperative Medication Management - Adult/Pediatric - Inpatient/Ambulatory
Appendices
Perioperative Medication Management Appendix (Medication Management Table)
Perioperative Medication Management Appendix (Cardiac Stent Algorithim)
Perioperative Medication Management Appendix (Methylene Blue Serotonin Syndrome)
Perioperative Medication Management Appendix (Aminolevulinic acid and Phototoxicity)
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Perioperative Medication Management -
Adult/Pediatric - Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
INTRODUCTION.................................................................................................................................................. 3
SCOPE ................................................................................................................................................................ 3
DEFINITIONS ...................................................................................................................................................... 3
RECOMMENDATIONS ......................................................................................................................................... 4
METHODOLOGY ................................................................................................................................................ 28
COLLATERAL TOOLS & RESOURCES .................................................................................................................... 31
APPENDIX A: PERIOPERATIVE MEDICATION MANAGEMENT ............................................................................. 32
APPENDIX B: TREATMENT ALGORITHM FOR THE TIMING OF ELECTIVE NONCARDIAC SURGERY IN PATIENTS WITH
CORONARY STENTS ........................................................................................................................................... 58
APPENDIX C: METHYLENE BLUE AND SEROTONIN SYNDROME ........................................................................... 59
APPENDIX D: AMINOLEVULINIC ACID AND PHOTOTOXICITY .............................................................................. 61
REFERENCES ...................................................................................................................................................... 65
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Contact for Content:
Scott Springman, MD – Anesthesiology
Phone Number: (608) 263-8100
Email Address: srspring@wisc.edu
Contact for Changes:
Philip J. Trapskin, PharmD, BCPS – Pharmacy, Drug Policy Program
Phone Number: (608) 263-1328
Email Address: ptrapskin@uwhealth.org
Guideline Authors:
Scott Springman, MD – Anesthesiology
Philip J. Trapskin, PharmD, BCPS – Pharmacy, Drug Policy Program
Anthony Hennes, PharmD – Pharmacy
Joshua Vanderloo, PharmD – Pharmacy, Drug Policy Program
Review Individuals/Bodies:
Daniel Mulkerin, MD – Oncology
Didier Mandelbrot, MD – Nephrology
Anne O’Connor, MD – Cardiology
Kurt Jacobson, MD – Cardiology
Annie Kelly, MD – Cardiology
Greg Heatley, MD – Ophthalmology
Edward Lalik, MD – Hospitalist
Joshua Medow, MD – Neurosurgery
Sumona Saha, MD – Gastroenterology and Hepatology
David Kushner, MD – Obstetrics/Gynecology
Dobie Giles, MD – Obstetrics/Gynecology
Megan Peterson, NP – Obstetrics/Gynecology
Michael Peterson, MD – Psychiatry
Timothy Mcculloch, MD – Otolaryngology – Head and Neck Surgery
Diane Heatley, MD – Otolaryngology – Head and Neck Surgery
Charles Leys, MD – Pediatric Surgery
Eliot Williams, MD – Hematology
Brett Michelotti, MD – Plastic Surgery
Barry Fox, MD – Infectious Disease
Daniel Bennett, MD – Dermatology
Jon Arnason, MD – Rheumatology
Michael Perouansky, MD – Anesthesiology
Chris Turner, MD – Anesthesiology
Zoltan Hevesi, MD – Anesthesiology
Committee Approvals/Dates:
Pharmacy & Therapeutics Committee (10/20/16, 3/19/20)
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Introduction
Clinicians providing care for surgical patients must decide whether to continue, hold, or modify prior to
surgery medication regimens throughout the perioperative period. The risks and benefits of continuing,
modifying, or holding a medication regimen in the perioperative period must be weighed and may require
the collaboration of the anesthesiologist and/or surgeon, and prescribing provider. Additionally,
preoperative instructions must be communicated to the patient to ensure medications are taken
appropriately the days prior to and day of surgery.
This guideline organizes medications by therapeutic use for ease of navigation. Key recommendations
are summarized in Appendix B. Individual medications can also be found using “Ctrl+F” function to
search for individual medications.
If you do not find the drug you are looking for in this document, you may consult the Preop PASS Clinic
(InBasket Pool: CSC SAFE TRIAGE NURSE [2277403] or the Preop Clinic main phone: 265-1800).
For research medication “study drugs”, the anesthesiologist and surgeon should coordinate with the study
coordinator, whose name can typically be found by checking the “research FYI flag” section in Health
Link.
Scope
Intended Users: Physicians, Advanced Practice Providers, Registered Nurses, Licensed Practical
Nurses, Medical Assistants, Pharmacists, Respiratory Therapists
Objectives: To standardize the perioperative management of medications and reduce perioperative
complications
Target Population: Patients undergoing an operation/procedure requiring anesthesia services
Clinical Questions Considered:
• For any medication a patient may be taking perioperatively, should the medication be continued,
held, or reviewed by the prescribing physician, anesthesiologist, and surgeon to coordinate a
plan?
Definitions
• Perioperative: The three phases of surgery, preoperative, intraoperative, and postoperative
• Hold: A temporary interruption of therapy
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Recommendations
1 Acid suppressants
1.1 H2-receptor antagonists: cimetidine, famotidine, nizatidine, ranitidine
1.2 Proton pump inhibitors: dexlansoprazole, esomeprazole, lansoprazole, omeprazole,
omeprazole/sodium bicarbonate, pantoprazole, rabeprazole
1.2.1 Parathyroid surgery
1.2.1.1 Recommend to hold proton pump inhibitors 7 days prior to and day of surgery
and post-operatively until directed to resume by surgeon. (UW Health strong
recommendation, low quality of evidence)
1.2.1.1.1 A reduction in gastric acidity may impair effective calcium uptake
through the intestine.1
1.2.1.1.2 Calcium lowering medications may alter intraoperative parathyroid
hormone kinetics which may lead to post-operative hypocalcemia.2
1.2.2 All other surgeries
1.2.2.1 It is reasonable to continue H2-receptor antagonist and proton pump inhibitor
regimens throughout the perioperative period.3 (UW Health weak
recommendation, low quality of evidence)
1.3 Antacids:
1.3.1 Non-soluble antacids: aluminum hydroxide, calcium carbonate, magnesium hydroxide,
magnesium oxide
1.3.1.1 Recommend holding non-soluble antacids the day of surgery to reduce aspiration
risk. (UW Health strong recommendation, low quality evidence)
1.3.2 Soluble antacids: sodium bicarbonate, sodium citrate
1.3.2.1 May continue soluble antacids perioperatively. (UW Health strong
recommendation, low quality evidence)
2 Allergen-specific Immunotherapy
2.1 Peanut allergen powder
2.1.1 Recommend to coordinate peanut allergen powder perioperative medication
management with surgeon and prescribing provider. (UW Health weak recommendation,
very low quality of evidence)
3 Alpha1 blockers: alfuzosin, doxazosin, phenoxybenzamine, phentolamine, prazosin, silodosin,
tamsulosin, terazosin
3.1 Cataract surgery
3.1.1 Recommend to coordinate perioperative alpha1-blocker medication management plan
with surgeon. (UW Health strong recommendation, low quality of evidence)
3.1.1.1 Intraoperative floppy iris syndrome has been associated with adrenergic alpha1-
blockers in the setting of cataract surgery.4,5
3.2 All other surgeries
3.2.1 Recommend to continue alpha1-blocker regimens throughout the perioperative period.3
(UW Health strong recommendation, low quality of evidence)
4 Alpha2-adrenergic agonists: clonidine, guanfacine, lofexidine, methyldopa, tizanidine
4.1 Recommend to continue alpha-2 agonist regimens throughout the perioperative period. (UW
Health strong recommendation, low quality of evidence)
4.1.1 Abrupt discontinuation of clonidine (both oral and transdermal) can result in rebound
tachycardia and hypertension.6-8
4.1.2 Although less likely due to a slower onset of actions, withdrawal symptoms have also
been reported with methyldopa and guanfacine.9
4.1.3 It is not recommended to initiate alpha-2 agonists perioperatively for the prevention of
cardiac events.10 (AHA Class III, Level of Evidence B)
5 Analgesics
5.1 Acetaminophen
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5.1.1 It is reasonable to continue acetaminophen regimens throughout the perioperative period.
(UW Health weak recommendation, low quality of evidence)
5.1.1.1 Multimodal pain management using acetaminophen is one of many multimodal
options for acute pain management in the perioperative setting.11
5.2 N-type calcium channel blockers: ziconotide
5.2.1 It is reasonable to continue N-type calcium channel blocker regimens throughout the
perioperative period. Any interruptions in therapy (holding or discontinuing) should be
coordinated with prescribing provider.(UW Health weak recommendation, low quality of
evidence)
5.3 Nonsteroidal anti-inflammatory drugs (NSAIDs)
5.3.1 Salicylates: aspirin, choline magnesium trisalicylate, diflunisal, magnesium salicylate,
salsalate
5.3.2 Acetic acids: diclofenac, etodolac, indomethacin, ketorolac, nabumetone, sulindac,
tolmetin
5.3.3 Propionic acids: fenoprofen, flurbiprofen, ibuprofen, ketoprofen, naproxen, oxaprozin
5.3.4 Fenamic acids: mefenamic acid, meclofenamate
5.3.5 Sulfonamides: celecoxib
5.3.6 Enolic acids: piroxicam, meloxicam
5.3.7 COX-2 selective: celecoxib, diclofenac, etodolac, meloxicam
5.3.8 For aspirin recommendations, refer to the Anti-platelet section of this guideline.
5.3.9 For non-aspirin NSAIDS, coordinate with surgeon and prescribing provider. (UW Health
strong recommendation, low quality of evidence)
5.3.9.1 The beneficial analgesic, anti-inflammatory, and antipyretic effects of NSAIDs
must be weighed against the thrombotic, arrthymogenic, bleeding, and
nephrotoxic risks.3,12,13
5.4 Opioid agonists: alfentanil, codeine, fentanyl, hydrocodone, hydromorphone, levorphanol,
meperidine, methadone, morphine, opium, oxycodone, oxymorphone, paregoric, remifentanil,
sufentanil, tapentadol, tramadol
5.4.1 Recommend to continue chronic opioid regimens throughout the perioperative period,
unless reduction or discontinuation is part of the perioperative analgesic plan. Abrupt
discontinuation of opioids may cause withdrawal symptoms and/or increased pain.3,11
(UW Health weak recommendation, low quality of evidence)
5.5 Opioid partial agonists
5.5.1 Buprenorphine (Suboxone®), buprenorphine injection (Sublocade®), butorphanol,
nalbuphine, pentazocine
5.5.1.1 Recommend to coordinate perioperative pain management plan for patients on
opioid partial agonists with anesthesiologist, surgeon, and prescribing physician.
(UW Health strong recommendation, low quality of evidence)
5.5.1.1.1 In surgeries with anticipated severe post-operative pain, the presence
of opioid partial agonists may limit the ability to achieve analgesia
goals. One author recommends tapering and discontinuing
buprenorphine three days prior to surgery or replacing buprenorphine
with methadone or another opioid prior to surgery.14 However, others
have recommended minor tapering or simply continuing these
medications in the perioperative period. Therefore, the planned
surgical procedure and patient-specific characteristics must be taken
into account with the development of perioperative pain management
plan. Consultation with the preoperative PASS clinic or Inpatient
Anesthesiology Acute Pain Service and the physician prescribing these
drugs is essential before and elective case.
6 Anorexiants
6.1 Serotonin 2C receptor agonist: lorcaserin
6.2 Sympathomimetic anorexiants: benzphetamine hydrochloride, diethylpropion hydrochloride,
phendimetrazine tartrate, phentermine hydrochloride
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6.3 Recommend to hold serotonin 2C receptor agonists and sympathomimetic anorexiant regimens
7 days prior to surgery and postoperatively until directed to resume by surgeon. (UW Health
weak recommendation, low quality of evidence)
6.3.1 A case report has documented the potential for sympathomimetic anorexiants to cause
unstable perioperative blood pressure.15
7 Anti-addiction agents
7.1 Antialcoholic agents: acamprosate calcium, disulfiram
7.1.1 Recommend to continue acamprosate regimens throughout the perioperative period.
(UW Health weak recommendation, low quality of evidence)
7.1.2 Recommend to hold disulfiram 7-14 days prior to surgery. (UW Health strong
recommendation, low quality of evidence)
7.1.2.1 Alcohols are present in some medications administered in the perioperative
setting, which when taken concomitantly with disulfiram increase serum
acetaldehyde levels leading to flushing, nausea, thirst, palpitations, chest pain,
vertigo and hypotension. The duration of action for disulfiram is 1 to 2 weeks
after the last dose.16
7.2 Opioid antagonist: naltrexone
7.2.1 Recommend to hold oral naltrexone for 1 week prior to surgery and intramuscular
naltrexone for 4 weeks prior to surgery. (UW Health strong recommendation, low quality
of evidence)
7.2.2 Recommend coordination of post-operative pain management plan with anesthesiologist,
surgeon, and primary care physician in order to minimize use of opioids, yet provide
sufficient postoperative analgesia.17 (UW Health strong recommendation, low quality of
evidence)
7.3 Nicotine replacement: nicotine gum, lozenges, patches, inhalers
7.3.1 Recommend abstinence from smoking in the perioperative period to reduce respiratory,
cardiac, and healing complications. (UW Health strong recommendation, strong quality
of evidence)18
7.3.2 Recommend to coordinate nicotine replacement perioperative medication management
plan with surgeon. If used the day of surgery, gum and lozenges should not be used
within 2 hours of procedure. (UW Health weak recommendation, weak quality of
evidence)19
8 Anti-Dementia (Alzheimer’s) agents
8.1 Cholinesterase inhibitors: donepezil, galantamine, rivastigmine
8.1.1 Recommend to continue cholinesterase inhibitors with the knowledge that adjustments to
neuromuscular blocking drugs may be necessary. (UW Health strong recommendation,
low quality of evidence)
8.1.1.1 Cholinesterase inhibitors may diminish the neuromuscular blocking effects of
nondepolarizing neuromuscular blockers.16,20
8.1.1.2 Cholinesterase inhibitors may prolong neuromuscular blocking effects (increase
serum concentrations) of succinylcholine.16
8.1.1.3 The duration to hold the medication is based upon the half-life of the medication
(donepezil=15 days, galantamine =7hrs, rivastigmine =3hrs)16
8.2 NMDA receptor antagonist: memantine
8.2.1 It is reasonable to continue NMDA receptor antagonist regimens throughout the
perioperative period. (UW Health weak recommendation, low quality of evidence)
9 Antiarrhythmics: amiodarone, disopyramide, dofetilide, dronedarone, flecainide, ibutilide, lidocaine
(systemic), mexiletine, procainamide, propafenone, quinidine
9.1 Electrophysiology surgeries/procedures
9.1.1 Recommend to coordinate antiarrhythmic perioperative medication management plan
with cardiologist and prescribing provider. (UW Health strong recommendation, low
quality of evidence)
9.2 Non-electrophysiology surgeries/procedures
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9.2.1 Recommend to continue antiarrhythmic regimens throughout the perioperative
period.3,13,21 (UW Health strong recommendation, low quality of evidence)
10 Anticholinergics: cyclizine, dimenhydrinate, meclizine, scopolamine, trimethobenzamide
10.1 It is reasonable to continue anti-cholinergics throughout the perioperative period, unless a
patient-specific perioperative management plan was provided by the surgeon. (UW Health weak
recommendation, low quality of evidence)
11 Anticoagulants
11.1 Vitamin K antagonist: warfarin
11.2 Direct oral anticoagulants: apixaban, betrixaban, dabigatran, edoxaban, rivaroxaban
11.3 Parenteral anticoagulants: argatroban, bivalirudin, enoxaparin, fondaparinux, unfractionated
heparin
11.4 Recommend to coordinate anticoagulant perioperative medication management plan including
any plan for neuraxial analgesia with surgeon, and prescribing provider. (UW Health strong
recommendation, low quality of evidence)
11.5 Additional information can be found in Periprocedural and Regional Anesthesia
Management with Antithrombotic Therapy – Adult – Inpatient and Ambulatory – Clinical
Practice Guideline
12 Anticonvulsants: acetazolamide, brivaracetam, cannabidiol (Epidiolex, prescription),
carbamazepine, cenobamate, divalproex, eslicarbazepine acetate, ethosuximide, ethotoin,
ezogabine, lacosamide, lamotrigine, levetiracetam, methsuximide, oxcarbazepine, perampanel,
phenytoin, pregabalin, primidone, rufinamide, stiripentol, tiagabine, topiramate, valproic acid,
vigabatrin, zonisamide
12.1 Neuromonitoring or Neuromapping
12.1.1 Recommend to coordinate anticonvulsant perioperative medication management plan
with surgeon, anesthesiologist, and prescribing provider. (UW Health strong
recommendation, low quality of evidence)
12.2 All other procedures
12.2.1 Recommend to continue anticonvulsant regimens throughout the perioperative
period.22,23 (UW Health strong recommendation, low quality of evidence.
12.2.1.1 Major motor seizures that occur during a surgical procedure can increase
morbidity and mortality. In patients with a history of well-controlled epilepsy, it
is vital that efforts are made to avoid disruption of antiepileptic medications
perioperatively.23
13 Anti-diabetic agents
13.1 See Diabetes Medication Adjustment: Ambulatory Procedures and Diabetes Medication
Adjustment: Inpatient Procedures for recommendations
13.2 Alpha-glucosidase inhibitors: acarbose, miglitol
13.3 Amylinomimetics: pramlintide
13.4 Biguanides: metformin
13.5 Dipeptidyl peptidase IV inhibitors: alogliptin, linagliptin, saxagliptin, sitagliptin
13.6 Glucagon-like peptide-1 receptor agonist: albiglutide, dulaglutide, exenatide, liraglutide,
lixisenatide, semaglutide
13.7 Insulins: insulin aspart, insulin degludec, insulin detemir, insulin glargine, insulin isophane,
insulin lispro, insulin regular
13.8 Meglitinide analogs: nateglinide, repaglinide
13.9 Sodium-glucose cotransporter-2 inhibitors: canagliflozin, dapagliflozin, empagliflozin,
ertugliflozin
13.10 Sulfonylureas: chlorpropamide, glimepiride, glipizide, glyburide, tolazamide, tolbutamide
13.11 Thiazolidinediones: pioglitazone, rosiglitazone
14 Anti-dopaminergics: chlorpromazine, metoclopramide, perphenazine, prochlorperazine,
promethazine
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14.1 It is reasonable to continue anti-dopaminergic regimens throughout perioperative period. (UW
Health weak recommendation, low quality of evidence)
15 Antiemetics
15.1 5HT3 antagonists: alosetron, dolasetron, granisetron, ondansetron, palonosetron
15.2 Phenothiazines: chlorpromazine, prochlorperazine, promethazine
15.3 Substance P/Neurokinin 1 receptor antagonist: aprepitant, fosaprepitant, fosnetupitant,
netupitant, rolapitant
15.4 It is reasonable to continue antiemetic regimens throughout the peri-operative period. (UW
Health weak recommendation, low quality of evidence)
16 Anti-glaucoma ophthalmics
16.1 Cholinesterase inhibitors: acetylcholine, carbachol, echothiophate iodide, pilocarpine
16.1.1 Recommend to continue cholinesterase inhibitors with the knowledge that adjustments
to neuromuscular blocking drugs may be necessary. (UW Health strong
recommendation, low quality of evidence)
16.2 Alpha adrenergic agonists: apraclonidine, brimonidine
16.3 Beta-adrenergic blocking agents (beta-blockers): betaxolol, carteolol, levobunolol, metipranolol,
timolol
16.4 Carbonic anhydrase inhibitors: brinzolamide, dorzolamide
16.5 Docosanoid, synthetic: unoprostone isopropyl
16.6 Prostaglandin analogues: bimatoprost, latanoprost, latanoprostene bunod, tafluprost, travoprost
16.7 Rho kinase inhibitors: netarsudil
16.8 Recommend to continue ophthalmic alpha adrenergic agonist, beta-adrenergic blocking agent
(beta-blockers), carbonic anhydrase inhibitor docosanoid, synthetic, and prostaglandin
analogue regimens throughout the perioperative period. (UW Health weak recommendation,
low quality of evidence)
17 Antihistamines
17.1 Peripherally selective: cetirizine, desloratadine, fexofenadine, loratadine, levocetirizine
17.2 Nonselective: brompheniramine, carbinoxamine, chlorcyclizine, chlorpheniramine, clemastine,
cyproheptadine, dexbrompheniramine, dexchlorpheniramine, diphenhydramine, doxylamine,
hydroxyzine, triprolidine
17.3 Recommend to continue antihistamine regimens throughout the perioperative period. (UW
Health weak recommendation, low quality evidence)
18 Anti-hyperlipemia agents (non-statins): alirocumab, bempedoic acid, cholestyramine,
colesevelam, colestipol, evolocumab, ezetimibe, fenofibrate, gemfibrozil, niacin, lomitapide,
mipomersen
18.1 Recommend to hold non-statin anti-hyperlipemia agent regimens 24 hours prior to surgery and
day of surgery to reduce risk of rhabdomyolysis and gastrointestinal obstruction.3,13 (UW Health
weak recommendation, low quality evidence)
19 Anti-hyperlipemia agents (HMG-CoA Reductase Inhibitors; statins): atorvastatin, fluvastatin,
lovastatin, pravastatin, rosuvastatin, simvastatin
19.1 Recommend to continue statin regimens throughout the perioperative period, particularly in
patients at high risk for cardiovascular disease.24-29 (UW Health strong recommendation, low
quality evidence)
19.2 Perioperative initiation of statin use is reasonable in patients undergoing vascular surgery.24,30
(AHA Class IIa Level B)
19.3 Perioperative initiation of statins may be considered in patients with a clinical risk factor who are
undergoing elevated-risk procedures.24 (AHA Class IIb Level C)
20 Anti-infective agents
20.1 Amebicides: iodoquinol
20.2 Aminoglycosides (oral): neomycin, paromomycin
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20.3 Aminoglycosides (parenteral): amikacin, gentamicin, plazomicin, streptomycin, tobramycin
20.4 Anthelmintics: albendazole, ivermectin, moxidectin, praziquantel, pyrantel, triclabendazole
20.5 Antibiotic combinations: erythromycin/sulfisoxazole, sulfamethoxazole/trimethoprim
20.6 Antifungal (Allylamine): terbinafine
20.7 Antifungal (Echinocandins): anidulafungin, caspofungin, flucytosine, griseofulvin, micafungin
20.8 Antifungal (Imidazole): ketoconazole
20.9 Antifungal (Polyene): amphotericin B, nystatin
20.10 Antifungal (Triazole): fluconazole, isavuconazole, itraconazole, posaconazole, voriconazole
20.11 Antimalarial (4-Aminoquinoline): chloroquine, hydroxychloroquine, tafenoquine
20.12 Antimalarial (8-Aminoquinoline): artemether/lumefantrine, atovaquone/proguanil, primaquine
20.13 Antimalarial (Cinchona Alkaloid): quinine sulfate
20.14 Antimalarial (Folic Acid Antagonist): pyrimethamine, mefloquine
20.15 Antiprotozoals: atovaquone, miltefosine, nitazoxanide pentamidine, tinidazole
20.16 Antiretroviral agents: abacavir, atazanavir, bictegravir, cobicistat, darunavir, delavirdine,
didanosine, dolutegravir, doravirine, efavirenz, elvitegravir, emtricitabine, enfuvirtide, etravirine,
fosamprenavir, ibalizumab, indinavir, lamivudine, lopinavir, maraviroc, nelfinavir, nevirapine,
raltegravir, rilpivirine, ritonavir, saquinavir, stavudine, tenofovir, tipranavir, zidovudine; or any
combination product of antiretrovirals
20.17 Antituberculosis Agents: aminosalicylic acid, bedaquiline, capreomycin, cycloserine,
ethambutol, ethionamide, isoniazid, pretomanid, pyrazinamide, rifabutin, rifampin, rifapentine,
streptomycin
20.18 Antiviral Agents: adefovir, amantadine, acyclovir, baloxavir, boceprevir, cidofovir, daclatasvir,
elbasvir/grazoprevir, entecavir, famciclovir, foscarnet, ganciclovir, glecaprevir/pibrentasvir,
ledipasvir/sofosbuvir, letermovir, ombitasvir/paritaprevir/ritonavir/dasabuvir, oseltamivir,
peramivir, ribavirin, rimantadine, simeprevir, sofosbuvir, tecovirimat, telaprevir, telbivudine,
valacyclovir, valganciclovir, velpatasvir, voxilaprevir, zanamivir
20.19 Bacitracin
20.20 Carbapenems: doripenem, ertapenem, imipenem/cilastatin, imipenem/cilastin/relebactam,
meropenem, meropenem/vaborbactam
20.21 Cephalosporins: cefaclor, cefadroxil, cefazolin, cefdinir, cefditoren, cefepime, cefiderocol,
cefixime, cefotaxime, cefotetan, cefoxitin, cefpodoxime, cefprozil, ceftaroline, ceftazidime,
ceftazidime/avibactam, ceftriaxone, cefuroxime, cephalexin
20.22 Chloramphenicol
20.23 Colistimethate
20.24 Fluoroquinolones: ciprofloxacin, delafloxacin, gemifloxacin, levofloxacin, moxifloxacin,
norfloxacin, ofloxacin, ozenoxacin
20.25 Folate Antagonists: trimethoprim
20.26 Glycylcyclines: tigecycline
20.27 Ketolides: telithromycin
20.28 Leprostatics: dapsone
20.29 Lincosamides: clindamycin, lincomycin
20.30 Lipoglycopeptides: dalbavancin, oritavancin, telavancin
20.31 Lipopeptides: Daptomycin
20.32 Macrolides: azithromycin, clarithromycin, erythromycin
20.33 Fidaxomicin
20.34 Methenamines: methenamine hippurate, methenamine mandelate
20.35 Metronidazole
20.36 Miscellaneous anti-infectives/antiseptics: benznidazole, fosfomycin, lefamulin, rifamycin,
secnidazole
20.37 Monobactams: aztreonam
20.38 Monoclonal antibodies: bezlotoxumab
20.39 Nitrofurans: nitrofurantoin
20.40 Oxazolidinones: linezolid, tedizolid
20.41 Penicillins: amoxicillin, amoxicillin/clavulanate, ampicillin, ampicillin/sulbactam, dicloxacillin,
nafcillin, oxacillin, penicillin G, penicillin V, piperacillin/tazobactam, ticarcillin/clavulanate
20.42 Polymyxin B Sulfate
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20.43 Rifaximin
20.44 Streptogramins: quinupristin/dalfopristin
20.45 Sulfadiazine
20.46 Tetracyclines: demeclocycline, doxycycline, eravacycline, minocycline, omadacycline,
sarecycline, tetracycline
20.47 Vancomycin
20.48 Active infections
20.48.1 Recommend to coordinate anti-infective perioperative medication management plan
for active infections with surgeon, and prescribing provider. (UW Health strong
recommendation, low quality of evidence)
20.49 Infection prophylaxis (medical)
20.49.1 Recommend to coordinate anti-infectives for prophylaxis indications with surgeon and
prescribing provider. (UW Health weak recommendation, low quality of evidence)
21 Anti-overactive bladder agents
21.1 Anticholinergic: oxybutynin
21.2 Muscarinic receptor antagonists: darifenacin, fesoterodine, solifenacin, tolterodine, trospium
21.3 M3 muscarinic agonist: mirabegron
21.4 Phosphodiesterase inhibitor: flavoxate
21.5 It is reasonable to continue anti-overactive bladder agent regimens throughout the
perioperative period. (UW Health weak recommendation, low quality of evidence)
22 Anti-neoplastics
22.1 Alkylating agents: altretamine, busulfan, carmustine, chlorambucil, dacarbazine, estramustine,
ifosfamide, lomustine, mechlorethamine, melphalan, streptozocin, thiotepa
22.2 Anthracenedione: mitoxantrone
22.3 Antibody-drug conjugates: ado-trastuzumab emtansine, brentuximab vedotin, enfortumab
vedotin, fam-trastuzumab deruxtecan, polatuzumab vedotin
22.4 Antimetabolites: allopurinol, capecitabine, cladribine, clofarabine, cytarabine, floxuridine,
fludarabine, fluorouracil, gemcitabine, mercaptopurine, methotrexate, pemetrexed, pentostatin,
pralatrexate, rasburicase, thioguanine
22.5 Antimitotic agents: cabazitaxel, docetaxel, eribulin, ixabepilone, paclitaxel, vinblastine,
vincristine, vinorelbine
22.6 Antineoplastic antibiotics: bleomycin, dactinomycin, daunorubicin, doxorubicin, epirubicin,
idarubicin, mitomycin, valrubicin
22.7 BCL-2 Inhibitor: venetoclax
22.8 Biologic response modifiers: aldesleukin, BCG live
22.9 Cytoprotective agents: amifostine, dexrazoxane, leucovorin, levoleucovorin, mesna
22.10 DNA demethylation agents: azacitidine, decitabine, nelarabine
22.11 DNA topoisomerase inhibitors: irinotecan, topotecan
22.12 Enzymes: asparaginase, calaspargase, pegaspargase
22.13 Epipodophyllotoxins: etoposide, teniposide
22.14 EZH2-Inhibitor: tazemetostat
22.15 Histone deacetylase inhibitors: belinostat, panobinostat, romidepsin, vorinostat
22.16 Hormones: abiraterone, anastrazole, apalutamide, bicalutamide, buserelin, darolutamide,
enzalutamide, exemestane, flutamide, fulvestrant, goserelin, histrelin, letrozole, leuprolide,
medroxyprogesterone, megestrol, nilutamide, tamoxifen, toremifene, triptorelin
22.17 Hedgehog Pathway Inhibitor: glasdegib, sonidegib, vismodegib
22.18 Imidazotetrazine derivatives: temozolomide
22.19 Kinase inhibitors: abemaciclib, acalabrutinib, afatinib, alectinib, alpelisib, axitinib, binimetinib,
bosutinib, brigatinib, cabozantinib, ceritinib, copanlisib, crizotinib, cobimetinib, dabrafenib,
dacomitinib, dasatinib, duvelisib, enasidenib, encorafenib, entrectinib, erdafitinib, erlotinib,
everolimus, gefitinib, gilteritinib, ibrutinib, idelalisib, imatinib, lapatinib, lenvatinib, lorlatinib,
larotrectinib, midostaurin, neratinib, nilotinib, osimertinib, palbociclib, pazopanib, pexidartinib,
ponatinib, regorafenib, ribociclib, ruxolitinib, sorafenib, sunitinib, temsirolimus, trametinib,
vandetanib, vemurafenib, zanubrutinib
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22.20 Methylhydrazine derivatives: procarbazine
22.21 Miscellaneous antineoplastics: arsenic trioxide, mitotane, porfimer, sipuleucel-T, sterile talc
powder, trabectedin, trifluridine/tipiracil
22.22 Monoclonal antibodies: alemtuzumab, atezolizumab, avapritinib, avelumab, bevacizumab (and
biosimilars), blinatumomab, brolucizumab, cemiplimab,cetuximab, daratumumab, dinutuximab,
elotuzumab, gemtuzumab, ibritumomab, inotuzumab, ipilimumab, mogamuliziumab,
moxetumomab, necitumumab, nivolumab, obinutuzumab, ofatumumab, olaratumab
panitumumab, pertuzumab, ramucirumab, rituximab (and biosimilars), tagraxofusp,
trastuzumab (and biosimilars)
22.23 PARP enzymes inhibitor: niraparib, olaparib, rucaparib, talazoparib
22.24 Platinum coordination complex: carboplatin, cisplatin, oxaliplatin
22.25 Proteasome inhibitors: bortezomib, carfilzomib, ixazomib
22.26 Protein synthesis inhibitor: omacetaxine
22.27 Radiopharmaceuticals: lutetium dotatate Lu-177, radium Ra-223, samarium Sm-153, sodium
iodide I-131, strontium-89
22.28 Retinoids: tretinoin, trifarotene
22.29 Rexinoids: bexarotene
22.30 Substituted ureas: hydroxyurea
22.31 Vascular endothelial growth factor inhibitor: ZIV-aflibercept
22.32 Recommend to coordinate perioperative medication management plan of all antineoplastics
with surgeon and prescribing provider. (UW Health strong recommendation, low quality of
evidence)
23 Anti-osteoporosis agents
23.1 Bisphosphonates: alendronate, etidronate, ibandronate, pamidronate, risedronate, tiludronate,
zolendronic acid
23.2 Calcitonin-salmon
23.3 Denosumab
23.4 Romosozumab
23.5 Dental surgery
23.5.1 Recommend to coordinate anti-osteoporosis perioperative medication management plan
with surgeon and prescribing provider. (UW Health strong recommendation, low quality
of evidence)
23.5.1.1 The risk of development of osteonecrosis of the jaw requires assessment of
bisphosphonate duration, concomitant use of corticosteroids or antiangiogenic
medications, clinical risk factors, and urgency of surgery.31
23.6 All other surgeries:
23.6.1 Recommend to hold bisphosphonate therapy the day of surgery and postoperatively
until directed to resume by surgeon. (UW Health strong recommendation, low quality of
evidence)
23.6.2 Recommend to coordinate calcitonin and denosumab perioperative plans with surgeon
and prescribing provider. (UW Health strong recommendation, low quality of evidence)
24 Anti-Parkinson’s agents: amantadine, apomorphine, belladonna alkaloids, benztropine,
bromocriptine, carbidopa, carbidopa/levodopa, carbidopa/levodopa/entacapone, entacapone,
istradefylline, pramipexole, rasagiline, ropinirole, rotigotine, selegiline, tolcapone
24.1 Recommend to continue anti-Parkinson’s agent regimens throughout the perioperative
period.3,32 (UW Health strong recommendation, low quality evidence)
24.1.1 Abrupt withdrawal of anti-Parkinson drugs may lead to exacerbation of Parkinson
symptoms and other withdrawal related syndromes, including, rarely, neuroleptic
malignant syndrome.33-36
25 Anti-platelet agents
25.1 Adenosine reuptake inhibitor: dipyridamole
25.2 Combination agents: dipyridamole and aspirin (Aggrenox®)
25.3 Phosphodiesterase-3 enzyme inhibitors: anagrelide, cilostazol
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25.4 Protease-activated receptor-1 (PAR-1) antagonist: vorapaxar
25.5 Salicylate: aspirin
25.6 P2Y12 platelet receptor inhibitors: cangrelor, clopidogrel, prasugrel, ticagrelor, ticlopidine
25.7 For patients on dual antiplatelet therapy (DAPT) with stents in place, ANY interruption in
antiplatelets should be coordinated with surgeon, anesthesiologist, the prescribing provider
(e.g. cardiologist, neurosurgeon, vascular surgeon). (UW Health strong recommendation, low
quality evidence)
25.8 If the prescribing provider is a non UW provider, every effort should be made to engage this
provider in this coordination of care. (UW Health strong recommendation, low quality evidence)
In select cases (e.g. unable to engage a non UW provider with coordination of DAPT
(especially if drug eluting stent placed within last 12 months) or irreconcilable
questions/concerns about their recommendations), it is reasonable to contact UW Cardiology.
(UW Health conditional recommendation, low quality evidence)
25.9 All patients with percutaneous coronary intervention (PCI) in the last 12 months should have
timing of surgery and antiplatelet medication administration coordinated with surgeon,
anesthesiologist and cardiologist. (UW Health strong recommendation, low quality evidence)
25.10 The selected regimen and duration for antiplatelet therapy after placement of cardiac stents
should be determined by the interventional cardiologist and after placement of carotid stents by
the neurosurgeon or vascular surgeon. (UW Health strong recommendation, low quality
25.11 Recommend that surgeon document in the medical record shared decision making discussions
of risks and benefits of anti-platelet interruption with patients using these agents for carotid and
cardiac stents. (UW Health strong recommendation, low quality of evidence)
25.12 Elective noncardiac surgery should be delayed at least 30 days after bare metal stent (BMS)
implantation and at least 6 months after drug-eluting stent (DES) implantation. (AHA Class I,
Level B-NR)37
25.13 In patients treated with dual antiplatelet therapy (DAPT) after coronary stent implantation who
must undergo surgical procedures that mandate the discontinuation of P2Y12 inhibitor therapy,
it is recommended that aspirin be continued if possible. The P2Y12 platelet receptor inhibitor
(and aspirin, if interrupted) should be restarted as soon as possible after surgery. (AHA Class I,
Level C-EO)37
25.14 When noncardiac surgery is required in patients currently taking a P2Y12 inhibitor, a
consensus decision among treating clinicians as to the relative risks of surgery and
discontinuation or continuation of antiplatelet therapy can be useful. (AHA Class IIa, Level C-
EO)37It is recommended that this decision and discussion with patient be documented in the
medical record.
25.15 Elective noncardiac surgery after DES implantation in patients for whom P2Y12 inhibitor
therapy will need to be discontinued may be considered after 3 months if the risk of further
delay of surgery is greater than the expected risks of stent thrombosis. (AHA Class IIb, Level C-
EO)37It is recommended that this decision and discussion with the patient be documented in the
medical record.
25.16 Elective noncardiac surgery should not be performed within 30 days after BMS implantation or
within 3 months after DES implantation in patients in whom DAPT will need to be discontinued
perioperatively. (AHA Class III, Level B-NR)37
25.17 Initiation or continuation of aspirin is not beneficial in patients undergoing elective noncardiac
noncarotid surgery who have not had previous coronary stenting (AHA Class III, Level B);
unless the risk of ischemic events outweighs the risk of surgical bleeding.10 (AHA Class III,
Level C)
26 Anti-psychotics
26.1 First generation – typical: chlorpromazine, fluphenazine, haloperidol, loxapine, perphenazine,
pimozide, prochlorperazine, thioridazine, thiothixene, trifluoperazine
26.2 Second generation – atypical: aripiprazole, asenapine, brexpiprazole, cariprazine, clozapine,
iloperidone, lumateperone, lurasidone, olanzapine, paliperidone, pimavanserin, quetiapine,
risperidone, ziprasidone
26.3 Recommend to continue anti-psychotic regimens throughout the perioperative period.3,13 (UW
Health strong recommendation, low quality evidence)
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27 Anti-rheumatics
27.1 General
27.1.1 The risks of infection and delayed wound healing with perioperative use of tofacitinib
must be weighed against risk of flare of underlying rheumatic disease leading to
treatment with steroids which may also increase infection risk and delay wound
healing.38,39
27.2 Janus associated kinase (JAK) inhibitors: baricitinib, fedratinib, ruxolitinib, tofacitinib,
upadactinib
27.2.1 Orthopedic surgery
27.2.1.1 Recommend to hold JAK inhibitor therapy 48 hours prior to surgery and
resume 7-14 days post-operatively if there are no signs or symptoms of
infection and incisions are healing well.38,39 (UW Health strong
recommendation, low quality of evidence)
27.2.2 All other surgery
27.2.2.1 Recommend to coordinate JAK inhibitor perioperative medication
management plan with surgeon and prescribing provider.38,39 (UW Health
strong recommendation, low quality of evidence)
27.3 Antimetabolites: methotrexate
27.3.1 Orthopedic surgery
27.3.1.1 Recommend to continue antimetabolite regimens throughout the
perioperative period.38,39 (UW Health strong recommendation, low quality of
evidence)
27.3.1.2 In a prospective randomized controlled trial of 388 patients with rheumatoid
arthritis (RA) undergoing orthopedic surgery, patients were randomized to
continue or withhold methotrexate.40 There were fewer complications in those
patients in whom methotrexate was continued. Similarly, in a prospective
randomized non-blinded study of 64 RA patients, the 32 who continued
methotrexate had no difference in wound health compared to patients in
whom methotrexate was withheld.41 However, neither study considered the
presence of diabetes, corticosteroid therapy, smoking, or disease activity in
their analysis, and the average methotrexate dose was less than 15 mg per
week.
27.3.2 All other surgery
27.3.2.1 Recommend to coordinate antimetabolite perioperative medication
management plan with surgeon and prescribing provider.38,39 (UW Health
strong recommendation, low quality of evidence)
27.4 Anti-TNF-alpha agents: adalimumab (and biosimilars), certolizumab, etanercept (and
biosimilars), golimumab, infliximab (and biosimilars)
27.4.1 Orthopedic surgery
27.4.1.1 Recommend to hold etanercept 2 weeks prior to surgery. 38,39 (UW Health
strong recommendation, low quality of evidence)
27.4.1.2 Recommend to coordinate anti-TNF-alpha agent perioperative medication
management plan with surgeon and prescribing provider.38,39 (UW Health
strong recommendation, low quality of evidence)
27.4.2 All other surgery
27.4.2.1 Recommend to coordinate anti-TNF-alpha agent perioperative medication
management plan with surgeon and prescribing provider.38,39 (UW Health
strong recommendation, low quality of evidence)
27.4.2.2 A systematic review and meta-analysis of postoperative complications in
patients with RA using a biological agent found a slightly increased relative
risk of skin and soft tissue infection but no increased risk of wound healing
after orthopedic surgery.42
27.5 Gold compounds: auranofin, gold sodium thiomalate
27.5.1 Orthopedic surgery
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27.5.1.1 Recommend to continue gold compound regimens throughout the
perioperative period.38,39 (UW Health weak recommendation, low quality of
evidence)
27.5.2 All other surgery
27.5.2.1 Recommend to coordinate gold compound perioperative medication
management plan with surgeon and prescribing provider.38,39 (UW Health
strong recommendation, low quality of evidence)
27.6 Interleukin-6 blockers: tocilizumab
27.6.1 Orthopedic surgery
27.6.1.1 Recommend to hold subcutaneous tocilizumab 3 weeks prior to surgery and
hold intravenous tocilizumab 4 weeks prior to surgery.38,39 (UW Health strong
recommendation, low quality of evidence)
27.6.2 All other surgery
27.6.2.1 Recommend to coordinate interleukin-6 blocker perioperative medication
management plan with surgeon and prescribing provider.38,39 (UW Health
strong recommendation, low quality of evidence)
27.6.2.2 For tocilizumab, there is no direct information on surgical site infection.
However, in a retrospective study of 161 operations in 122 patients with
rheumatoid arthritis, 20 cases are described in which wound healing was
delayed, as well as three infections, of which two were superficial.43 In
another case-control study, 22 tocilizumab-treated rheumatoid arthritis
patients were compared with 22 conventional disease modifying
antirheumatic drug (DMARD)-treated patients, a significant difference in
temperature rise and increase in C-reactive protein was demonstrated.44
Increased vigilance may be warranted in tocilizumab-treated patients, as the
usual manifestations of a post-operative complication such as fever may not
be present.
27.7 Interleukin-1 blockers: anakinra
27.7.1 Orthopedic surgery
27.7.1.1 Recommend to hold subcutaneous anakinra 7 days prior to surgery. 38,39,45
(UW Health strong recommendation, low quality of evidence)
27.7.2 All other surgery
27.7.2.1 Recommend to coordinate interleukin-1 blocker perioperative medication
management plan with surgeon and prescribing provider.38,39 (UW Health
strong recommendation, low quality of evidence)
27.8 Phosphodiesterase-4 enzyme inhibitor: apremilast
27.8.1 Recommend to coordinate phosphodiesterase-4 enzyme inhibitor perioperative
medication management plan with surgeon and prescribing provider. (UW Health
strong recommendation, low quality of evidence)
27.9 Pyrimidine synthesis inhibitors: leflunomide
27.9.1 Orthopedic surgery
27.9.1.1 Recommend to hold leflunomide 14 days prior to surgery. 38,39,45 (UW Health
strong recommendation, low quality of evidence)
27.9.2 All other surgery
27.9.2.1 Recommend to coordinate perioperative pyrimidine synthesis inhibitor
medication management plan with surgeon and prescribing provider.38,39
(UW Health strong recommendation, low quality of evidence)
27.10 Selective T-cell costimulation blocker: abatacept
27.10.1 Orthopedic surgery
27.10.1.1 Recommend to hold subcutaneous abatacept 2 weeks prior to surgery and
intravenous abatacept 4 weeks prior to surgery. 38,39,45 (UW Health strong
recommendation, low quality of evidence)
27.10.2 All other surgery
27.10.2.1 Recommend to coordinate selective T-cell costimulation blocker
perioperative medication management plan with surgeon and prescribing
provider.38,39 (UW Health strong recommendation, low quality of evidence)
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28 Beta-blockers
28.1 Alpha/beta-adrenergic blocking agents: carvedilol, labetalol
28.2 Beta-adrenergic blocking agents (beta-blockers): acebutolol, atenolol, betaxolol, bisoprolol,
esmolol, metoprolol, nadolol, nebivolol, penbutolol, pindolol, propranolol, sotalol, timolol
28.3 Recommend to continue beta-blocker regimens throughout the perioperative period unless
contraindicated by hemodynamic instability or profound bronchospasm.46,47 (AHA Grade I Level
B)
28.3.1 The use of beta-blockers for patients on established therapy perioperatively has been
shown to avoid withdrawal. Acute withdrawal of a beta blocker perioperatively can lead
to an increase in morbidity and mortality. In light of the potential benefits of
perioperative beta blockade, minimal adverse effects, and consequences of acute
withdrawal, it is recommended that beta blockers be continued in the perioperative
period and throughout the hospital stay, unless contraindicated by hemodynamic
instability or profound bronchospasm.48
29 Benzodiazepines: alprazolam, chlordiazepoxide, clobazam, clonazepam, clorazepate, diazepam,
lorazepam, oxazepam
29.1 Recommend to continue benzodiazepine regimens throughout the perioperative period.3,13,21
(UW Health strong recommendation, low quality evidence)
30 Calcium channel blockers
30.1 Dihydropyridines: amlodipine, clevidipine, felodipine, isradipine, nicardipine, nifedipine,
nimodipine, nisoldipine
30.2 Non-dihydropyridines: diltiazem, verapamil
30.3 Recommend to continue calcium channel blocker regimens throughout the perioperative
period.3 (UW Health strong recommendation, low quality of evidence)
31 Cardiovascular agents – Miscellaneous
31.1 Alpha1-agonist: midodrine
31.1.1 Recommend to continue alpha1-agonist regimens throughout the perioperative period.3
(UW Health strong recommendation, low quality evidence)
31.2 Cardiac glycosides: digoxin
31.2.1 Recommend to continue cardiac glycoside regimens throughout the perioperative
period.3,13 (UW Health strong recommendation, low quality evidence)
31.3 Central monoamine-depleting agents: deutetrabenazine, reserpine, tetrabenazine, valbenazine
31.3.1 Recommend to coordinate central monoamine-depleting agent perioperative
medication management plan with anesthesiologist, surgeon and prescribing provider.
(UW Health strong recommendation, low quality of evidence)
31.4 Cyclic nucleotide-gated (HCN) channels (f-channel): ivabradine
31.4.1 Recommend to continue cyclic nucleotide-gated (HCN) channels (f-channel ) regimens
throughout the perioperative period. (UW Health strong recommendation, low quality
evidence)
31.5 Dopamine agonist: fenoldopam
31.5.1 Recommend to coordinate dopamine agonist perioperative medication management
plan with anesthesiologist, surgeon and prescribing provider. (UW Health strong
recommendation, low quality of evidence)
31.6 Ganglionic Blocker: mecamylamine
31.6.1 Recommend to coordinate ganglionic blocker perioperative medication management
plan with anesthesiologist, surgeon, and prescribing provider. (UW Health strong
recommendation, low quality evidence)
31.7 Inotropics: inamrinone, milrinone
31.7.1 Recommend to coordinate inotropic perioperative medication management plan with
anesthesiologist, surgeon, and prescribing provider. (UW Health strong
recommendation, low quality evidence)
31.8 Inward sodium channel inhibitors: ranolazine
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31.8.1 Recommend to continue inward sodium channel inhibitor regimens throughout the
perioperative period. (UW Health strong recommendation, low quality evidence)
31.8.1.1 There were no trials identified looking at the risk and benefit of continuing
ranolazine during the perioperative period. One study was identified that
evaluated postoperative atrial fibrillation (POAF) after on-pump coronary
artery bypass graft (CABG) surgery. The results of the study did show a
statistically significant decrease in the number of patients with POAF that
were treated with ranolazine.49
31.9 Potassium removing resins: patiromer, sodium polystyrene sulfonate, sodium zirconium
cyclosilicate
31.9.1 Recommend to coordinate potassium removing resin perioperative medication
management plan with anesthesiologist, surgeon, and prescribing provider. (UW Health
strong recommendation, low quality evidence)
31.10 Transthyretin stabilizer: tafamidis
31.10.1 Recommend to coordinate tafamidis perioperative medication management plan with
anesthesiologist, surgeon, and prescribing provider. (UW Health strong
recommendation, very low quality evidence)
32 Central nervous system (CNS) miscellaneous
32.1 Antianxiety agents: buspirone, meprobamate
32.1.1 Recommend to continue antianxiety agent regimens throughout the perioperative
period. (UW Health strong recommendation, low quality evidence)
32.2 Antidepressants: bupropion, nefazodone, trazodone, vortioxetine
32.2.1 Recommend coordination of antidepressant perioperative medication management
plan with surgeon, anesthesiologist, and prescribing provider.3,13,21 (UW Health strong
recommendation, low quality evidence)
32.2.1.1 See Appendix D – Methylene Blue and Serotonin Syndrome
32.3 Anticholinesterase muscle stimulants: edrophonium, neostigmine, pyridostigmine
32.3.1 Recommend to coordinate anticholinesterase muscle stimulant perioperative
medication management plan with anesthesiologist, surgeon, and prescribing provider.
(UW Health strong recommendation, low quality evidence)
32.4 Antioxidants: edaravone
32.4.1 Recommend to coordinate anticholinesterase muscle stimulant perioperative
medication management plan with anesthesiologist, surgeon, and prescribing provider.
(UW Health strong recommendation, low quality evidence)
32.5 Antisense Oligonucleotide: eteplirsen, golodirsen, inotersen, nusinersin
32.5.1 Recommend to coordinate antisense oligonucleotide management plan with
anesthesiologist, surgeon, and prescribing provider. (UW Health strong
recommendation, low quality evidence)
32.6 Cholinergic muscle stimulant: guanidine
32.6.1 Recommend to coordinate cholinergic muscle stimulant perioperative medication
management plan with anesthesiologist, surgeon, and prescribing provider. (UW Health
strong recommendation, low quality evidence)
32.7 CNS stimulants: armodafinil, amphetamine, caffeine, dexmethylphenidate, dextroamphetamine,
lisdexamfetamine, methamphetamine, methylphenidate modafinil
32.7.1 Recommend to coordinate armodafinil and modafinil perioperative medication
management plan with anesthesiologist, surgeon, and prescribing provider.3 (UW
Health strong recommendation, low quality evidence)
32.7.2 It may be reasonable to continue chronic amphetamine, caffeine, dexmethylphenidate,
dextroamphetamine, lisdexamfetamine, methamphetamine, and methylphenidate
regimens throughout the perioperative period.3 (UW Health weak recommendation, low
quality evidence)
32.8 Dopamine and norepinephrine reuptake inhibitors: solriamfetol
32.8.1 Recommend to coordinate solriamfetol perioperative management plan with
anesthesiologist, surgeon, and prescribing provider. (UW Health strong
recommendation, very low quality evidence)
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32.9 Glutamate inhibitor: riluzole
32.9.1 Recommend to continue glutamate inhibitor regimens throughout the perioperative
period. (UW Health strong recommendation, low quality evidence)
32.10 Lithium
32.10.1 Recommend to continue lithium regimens throughout the perioperative period.3,13 (UW
Health strong recommendation, low quality evidence)
32.11 Miscellaneous psychotherapeutic agents: atomoxetine, pitolisant, sodium oxybate
32.11.1 Recommend to continue atomoxetine regimens throughout the perioperative period.
(UW Health strong recommendation, low quality evidence)
32.11.2 Recommend to coordinate pitolisant and sodium oxybate perioperative management
plan with anesthesiologist, surgeon, and prescribing provider. (UW Health strong
recommendation, low quality evidence)
32.12 Mixed 5HT1A agonist/5HT2A antagonists: flibanserin
32.12.1 Recommend to coordinate mixed 5HT1A agonist/5HT2A antagonist perioperative
management plan with anesthesiologist, surgeon, and prescribing provider. (UW Health
strong recommendation, low quality evidence)
32.13 N-Methyl-D-Aspartate (NMDA) antagonists: esketamine
32.13.1 Recommend to coordinate esketamine perioperative management plan with
anesthesiologist, surgeon, and prescribing provider. (UW Health strong
recommendation, very low quality evidence)
32.14 Partial neuronal α4 β2 nicotinic receptor agonist: varenicline
32.14.1 Recommend to hold therapy varenicline the day of surgery and post-operatively until
directed to resume by surgeon. (UW Health strong recommendation, low quality of
evidence)
32.15 Potassium channel blocker: amifampridine, dalfampridine
32.15.1 Recommend to continue potassium channel blocker regimens throughout the
perioperative period. (UW Health weak recommendation, low quality evidence)
32.16 Tripeptidyl peptidase-1 (TPP-1) analog: Cerliponase alfa
32.16.1 Recommend to coordinate cerliponase alfa perioperative management plan with
anesthesiologist, surgeon, and prescribing provider. (UW Health strong
recommendation, low quality evidence)
33 Corticosteroid: betamethasone, budesonide, cortisone, cosyntropin, deflazacort, dexamethasone,
fludrocortisone, hydrocortisone, methylprednisolone, prednisolone, prednisone, triamcinolone
33.1 Recommend to continue corticosteroid regimens throughout the perioperative period.3,13 (UW
Health strong recommendation, low quality evidence)
34 Diuretics
34.1 Carbonic anhydrase inhibitors: acetazolamide, methazolamide
34.2 Loop diuretics: bumetanide, ethacrynic acid, furosemide, torsemide
34.3 Osmotic: mannitol
34.4 Potassium sparing: amiloride, spironolactone, triamterene
34.5 Thiazides: chlorothiazide, chlorthalidone, hydrochlorothiazide, indapamide, methyclothiazide,
metolazone
34.6 Heart failure with volume overload indication
34.6.1 Recommend to coordinate diuretic perioperative management plan with
anesthesiologist, surgeon, and prescribing provider.3,13 (UW Health strong
recommendation, low quality of evidence)
34.7 Hypertension indication
34.7.1 Recommend to hold diuretic the day of surgery.3,13 (UW Health weak recommendation,
low quality of evidence)
34.7.1.1 Taking diuretics in the perioperative period has the potential to cause
hypotension and electrolyte abnormalities. These conditions can lead to the
need for more vasoactive medications and can potentiate the effects of
muscle relaxants used during anesthesia as well as provoke paralytic ileus.48
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35 Estrogens and Progestins
35.1 Estrogens: conjugated estrogens, ethinyl estradiol, estradiol valerate, esterified estrogens,
estradiol, estradiol cypionate, estropipate
35.2 Progestins: desogestrel, drospirenone, etonogestrel, ethynodiol diacetate,
hydroxyprogesterone caproate, levonorgestrel, medroxyprogesterone acetate, megestrol
acetate, norelgestromin, norgestimate, norgestrel, norethindrone acetate, progesterone,
segesterone, ulipristal
35.3 Selective estrogen receptor modulators: bazedoxifene, clomiphene citrate, ospemifene,
raloxifene
35.4 Recommend to coordinate estrogen and progestin perioperative management plan with
surgeon, and prescribing provider.3,13 (UW Health strong recommendation, low quality of
evidence)
36 Endocrine and metabolic agents - miscellaneous
36.1 4-Hydroxyphenylpyruvate dioxygenase inhibitors: nitisinone
36.2 5-Alpha reductase inhibitors: dutasteride, finasteride
36.3 Enzyme replacement: asfotase, agalsidase beta, alglucosidase alfa, elosulfase alfa, galsulfase,
idursulfase, imiglucerase, laronidase, sebelipase, taliglucerase alfa, velaglucerase alfa
36.4 Anabolic steroid: oxymetholone
36.5 Androgens: danazol, oxandrolone, fluoxymesterone, methyltestosterone, testosterone
36.6 Anti-androgen: cyproterone, dienogest
36.7 Anti-ammonia agent: carglumic acid, glycerol phenylbutyrate, sodium benzoate and sodium
phenylacetate, sodium phenylbutyrate
36.8 Anti-cystine agent: cysteamine
36.9 Anti-prolactin agents: bromocriptine, cabergoline
36.10 Antithyroid agents: methimazole, propylthiouracil, sodium iodide
36.11 Betaine anhydrous
36.12 Bile acids: cholic acid
36.13 Calcimimetics: cinacalcet, etelcalcetide
36.14 Chelating agents: deferasirox, deferiprone, deferoxamine
36.15 Cystic fibrosis transmembrane conductance regulator potentiator: elexacaftor, ivacaftor,
lumacaftor, tezacaftor
36.16 Detoxification agents: dimercaprol, edetate calcium disodium, pentetate calcium trisodium,
pentetate zinc trisodium, Prussian blue (ferric hexacyanoferrate succimer (DMSA)), trientine
hydrochloride
36.17 Glucosylceramide synthase inhibitor: eliglustat, miglustat
36.18 Gonadotropin releasing hormone agonist: nafarelin
36.19 Gonadotropin releasing hormone antagonist: cetrorelix, degarelix, elagolix,ganirelix
36.20 Growth hormone: somatropin
36.21 Growth hormone agonists: macimorelin
36.22 Insulin-like growth factor: mecasermin
36.23 Lipodystrophy agents: metreleptin, tesamorelin
36.24 Lipolytic: deoxycholic acid
36.25 Melanocortin receptor agonist: bremelanotide
36.26 Ovulation stimulator: choriogonadotropin alfa, chorionic gonadotropin, follitropin alfa, follitropin
beta, lutropin alpha, menotropins, urofollitropin
36.27 Parathyroid hormone analogues: abaloparatide, parathyroid, teriparatide
36.28 Pegvisomant
36.29 Pharmacologic chaperone: migalastat
36.30 Phenylketonuria agents: pagvaliase, sapropterin dichloride
36.31 Phosphate binders: lanthanum, sevelamer
36.32 Posterior pituitary hormones: desmopressin, vasopressin
36.33 Somatostatin analogs: lanreotide, octreotide, pasireotide
36.34 Thyroid drugs: potassium iodide, levothyroxine sodium, liothyronine sodium, liotrix, thyroid
desiccated
36.35 Tryptophan hydroxylase inhibitors: telotristat
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36.36 Uridine Triacetate
36.37 Uterine active agents: carboprost, dinoprostone, methylergonovine maleate, mifepristone,
oxytocin
36.38 Vasopressin receptor antagonists: conivaptan, tolvaptan
36.39 It is reasonable to continue these endocrine and metabolic agents - miscellaneous regimens
listed throughout the perioperative period, unless specific instructions provided by surgeon or
prescribing provider.13 (UW Health weak recommendation, low quality evidence)
37 Gastrointestinal agents
37.1 5-aminosalicylic acid derivatives: balsalazide, mesalamine, olsalazine, sulfasalazine
37.1.1 Recommend to continue 5-aminosalicylic acid derivative regimens throughout the
perioperative period.50 (UW Health strong recommendation, low quality evidence)
37.2 Antidiarrheals: bismuth subsalicylate, crofelemer, difenoxin/atropine, diphenoxylate/atropine,
loperamide, loperamide/simethicone
37.2.1 Recommend to hold bismuth subsalicylate the day of surgery due to the potential to
cause black stools. (UW Health strong recommendation, low quality evidence)
37.2.2 It is reasonable to continue other antidiarrheals throughout the perioperative period.
(UW Health weak recommendation, low quality evidence)
37.3 Laxatives
37.3.1 Bowel evacuants: polyethylene glycol, PEG-electrolyte combination, sodium
phosphate, sodium phosphate/magnesium oxide/citric acid
37.3.2 Bulk producing laxatives: calcium polycarbophil, methylcellulose, psyllium
37.3.3 Emollients: mineral oil
37.3.4 Surfactants: docusate calcium, docusate sodium
37.3.5 Hyperosmotic agents: glycerin, lactilol, lactulose, sorbitol
37.3.6 Stimulants: bisacodyl, cascara sagrada, sennosides
37.3.6.1 Recommend to coordinate laxative perioperative medication management
plan with surgeon and prescribing provider (UW Health strong
recommendation, low quality evidence)
37.4 Anti-TNF-alpha agents: adalimumab (and biosimilars), certolizumab, golimumab, infliximab
(and biosimilars)
37.4.1 Recommend to coordinate anti-TNF-alpha agents perioperative medication
management plan with surgeon and prescribing provider.50 (UW Health strong
recommendation, low quality evidence)
37.5 Anti-integrins: natalizumab, vedolizumab
37.5.1 Recommend to coordinate anti-integrin perioperative medication management plan
with surgeon and prescribing provider. (UW Health strong recommendation, low quality
evidence)
37.5.1.1 Clinical evidence suggests that perioperative vedolizumab use is associated
with no increase in postoperative complication risk and may possibly reduce
the risk of postoperative complications in patients with inflammatory bowel
disease.51
37.6 Other gastrointestinal agents
37.6.1 Antiflatulents: alpha-d-galactosidase, simethicone
37.6.2 Antispasmodics: dicyclomine
37.6.3 Belladonna alkaloids: atropine sulfate, hyoscyamine sulfate, scopolamine
37.6.4 Cholinergic agonists: cevimeline, pilocarpine
37.6.5 Chloride channel activator: lubiprostone
37.6.6 Digestive enzymes: pancreatic enzymes, pancrelipase
37.6.7 Gastrointestinal anticholinergic combinations: clidinium/chlordiazepoxide,
atropine/scopolamine/hyoscyamine/phenobarbital
37.6.8 Gastrointestinal quaternary anticholinergics – antispasmodics: glycopyrrolate,
mepenzolate, methscopolamine, propantheline
37.6.9 GI Stimulants: dexpanthenol, metoclopramide, prucalopride, tegaserod
37.6.10 GLP-2 analogs: teduglutide
37.6.11 Glutamine: L-glutamine
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37.6.12 Guanylate cyclase-C agonist: linaclotide, plecanatide
37.6.13 Miscellaneous: eluxadoline, sucralfate, chenodiol, ursodiol, alvimopan,
methylnaltrexone, naloxegol, tenapanor
37.6.14 Systemic deodorizers: bismuth subgallate, chlorophyll derivatives, chlorophyllin
37.6.15 Recommend to coordinate perioperative medication management plan of regimens
containing agents in 36.6 with surgeon and prescribing provider except sucralfate (UW
Health strong recommendation, low quality evidence)
37.6.15.1 Recommend to hold sucralfate the day of surgery (UW Health strong
recommendation, low quality evidence)
38 Genitourinary and renal agents – miscellaneous
38.1 Phosphodiesterase Type 5 (PDE-5) Inhibitors: avanafil, sildenafil, tadalafil, vardenafil (see
section 46)
38.2 Cystine depleting agents: cysteamine bitartrate, penicillamine, tiopronin
38.3 Interstitial cystitis agents: dimethyl sulfoxide, pentosan polysulfate sodium, phenazopyridine,
phenazopyridine/butabarbital/hyoscyamine
38.4 Urinary acidifiers: ascorbic acid
38.5 Urinary cholinergics: bethanechol
38.6 Urinary alkalinizers: potassium citrate, sodium bicarbonate, sodium bicarb/citric acid
38.7 Miscellaneous genitourinary agents: acetohydroxamic acid, cellulose sodium phosphate
38.8 It is reasonable to continue regimens containing agents in 37.2-37.7 throughout the
perioperative period. (UW Health weak recommendation, low quality evidence)
39 Gout agents
39.1 β-tubulin polymerization inhibitor: colchicine
39.1.1 Recommend to coordinate colchicine perioperative medication management plan with
surgeon and prescribing provider (UW Health strong recommendation, low quality
evidence)
39.2 Uric acid transporter-1(URAT-1) inhibitor: lesinurad
39.2.1 It is reasonable to continue uric acid transporter-1(URAT-1) inhibitor regimens
throughout the perioperative period. (UW Health weak recommendation, low quality
evidence)
39.3 Urate oxidase: pegloticase
39.3.1 It is reasonable to continue urate oxidase regimens throughout the perioperative
period. (UW Health weak recommendation, low quality evidence)
39.4 Xanthine oxidase inhibitors: allopurinol, febuxostat
39.4.1 It is reasonable to continue xanthine oxidase inhibitors regimens throughout the
perioperative period. (UW Health weak recommendation, low quality evidence)
39.5 Uricosuric agents: probenecid
39.5.1 Recommend to hold probenecid therapy the day of surgery and postoperatively until
directed to resume by surgeon. (UW Health strong recommendation, low quality of
evidence)
40 Hematological agents
Additional information can be found in Periprocedural and Regional Anesthesia Management
with Antithrombotic Therapy – Adult – Inpatient and Ambulatory – Clinical Practice Guideline
40.1 Activin Receptor Ligand Trap: luspatercept
40.1.1 Recommend to coordinate luspatercept perioperative medication management plan
with surgeon and prescribing provider (UW Health strong recommendation, low quality
evidence)
40.2 Antihemophilic agents: anti-inhibitor coagulant complex, antihemophilic Factor VIII, coagulation
Factor XIIIa, Factor IX, Factor VIIa, Factor XIII, antihemophilic factor/von Willebrand factor
complex
40.2.1 Recommend to coordinate antihemophilic agent perioperative medication management
plan with anesthesiologist, surgeon, and prescribing provider (typically a Hematologist).
(UW Health strong recommendation, low quality of evidence)
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40.3 Anti-von Willebrand Factor: caplacizumab
40.3.1 Recommend to coordinate caplacizumab perioperative medication management plan
with anesthesiologist, surgeon, and prescribing provider. (UW strong recommendation,
low quality of evidence)
40.4 Antisickling agents: hydroxyurea, voxelotor
40.4.1 Recommend to continue antisickling agent regimens throughout the perioperative
period. (UW Health strong recommendation, low quality of evidence)
40.5 Bradykinin inhibitors: icatibant
40.5.1 It is reasonable to continue bradykinin inhibitor regimens throughout the perioperative
period. (UW Health weak recommendation, low quality evidence)
40.6 Coagulants: protamine
40.6.1 Recommend to coordinate protamine perioperative medication management plan with
anesthesiologist, surgeon, and prescribing provider. (UW strong recommendation, low
quality of evidence)
40.7 Erythropoiesis-stimulating agents (ESA): darbepoetin (and biosimilars), epoetin alfa (and
biosimilars), epoetin beta (and biosimilars), methoxy polyethylene glycol-epoetin beta
40.7.1 It is reasonable to continue erythropoiesis-stimulating agent regimens throughout the
perioperative period. (UW Health weak recommendation, low quality evidence)
40.8 Hematopoietic stem cell mobilizer: plerixafor
40.8.1 Recommend to coordinate plerixafor perioperative medication management plan with
surgeon and prescribing provider (UW Health strong recommendation, low quality
evidence)
40.9 Granulocyte-colony stimulating factors: filgrastim(and biosimilars), pegfilgrastim (and
biosimilars)
40.9.1 Recommend to coordinate granulocyte-colony stimulating factor perioperative
medication management plan with surgeon and prescribing provider (UW Health strong
recommendation, low quality evidence)
40.10 Granulocyte macrophage colony-stimulating factor: sargramostim
40.10.1 Recommend to coordinate granulocyte macrophage colony-stimulating factor
perioperative medication management plan with surgeon and prescribing provider (UW
Health strong recommendation, low quality evidence)
40.11 Thrombopoietic agents: avatrombopag, eltrombopag, lusutrombopag, oprelvekin, romiplostim
40.11.1 Recommend to coordinate thrombopoietic agent perioperative medication management
plan with surgeon and prescribing provider (UW Health strong recommendation, low
quality evidence)
40.12 Porphyria agents: hemin, givosiran
40.12.1 Recommend to coordinate porphyria agents perioperative medication management
plan with surgeon and prescribing provider (UW Health strong recommendation, low
quality evidence)
40.13 Hemorrheologic agents: pentoxifylline
40.13.1 Recommend to coordinate pentoxifylline perioperative medication management plan
with surgeon and prescribing provider (UW Health strong recommendation, low quality
evidence)
40.14 Hemostatics: absorbable gelatin, aminocaproic acid, ferric subsulfate, fibrinogen concentrate,
microfibrillar collagen hemostat, oxidized cellulose, prothrombin complex concentrate, thrombin,
tranexamic acid
40.14.1 Recommend to coordinate hemostatic perioperative medication management plan with
anesthesiologist, surgeon, and prescribing provider (UW Health strong
recommendation, low quality evidence)
40.15 Kallikrein Inhibitor: ecallantide, lanadelumab
40.15.1 It is reasonable to continue kallikrein inhibitor regimens throughout the perioperative
period. (UW Health weak recommendation, low quality evidence)
40.16 Plasma expanders: albumin human, dextran 40, hetastarch, plasma protein fraction, tetrastarch
40.16.1 It is reasonable to continue plasma expander regimens throughout the perioperative
period. (UW Health weak recommendation, low quality evidence)
40.17 Protein C1 esterase inhibitor: C1 esterase inhibitor (Cinryze)
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40.17.1 Recommend to continue C1 esterase inhibitor regimens throughout the perioperative
period. (UW Health strong recommendation, low quality evidence)
40.18 Thrombolytic agents: alteplase, defibrotide, protein C concentrate, reteplase, tenecteplase,
urokinase
40.18.1 Recommend to coordinate thrombolytic agents perioperative medication management
plan with anesthesiologist, surgeon, and prescribing provider (UW Health strong
recommendation, low quality evidence)
40.19 Monoclonal antibodies: crizanlizumab
40.19.1 Recommend to coordinate monoclonal antibodies perioperative medication
management plan with anesthesiologist, surgeon, and prescribing provider (UW Health
strong recommendation, low quality evidence)
41 Herbals and Supplements
41.1 Amino Acids: levocarnitine, L-lysine, methionine, threonine
41.2 Cannabidiol (CBD oil, OTC or supplement; not including Epidiolex prescription for seizure
management)
41.3 Electrolytes: potassium, sodium chloride
41.4 Fish Oils: omega-3 fatty acids
41.5 Lipotropics: choline, inositol
41.6 Minerals: calcium, magnesium, phosphorus
41.7 Miscellaneous: coenzyme q10, lactase, sacrosidase
41.8 Systemic Alkalinizers: citric acid, citrate, tromethamine
41.9 Trace Elements: chromium, copper, ferric maltol, fluoride, iron, manganese, selenium, zinc
41.10 Vitamins: beta-carotene, phytonadione, vitamin A, calcitriol, cholecalciferol, doxercalciferol,
ergocalciferol, paricalcitol, vitamin E, aminobenzoate potassium, bioflavonoids, biotin,
hydroxycobalamin, cobalamin, folic acid, niacin, niacinamide, pantothenic acid, pyridoxine,
riboflavin, thiamin, vitamin C, ascorbic acid, calcium ascorbate, sodium ascorbate
41.11 Patients with inborn errors of metabolism
41.11.1 Recommend to coordinate use of supplements and perioperative medication
management plan with anesthesiologist, surgeon, and prescribing provider (UW Health
strong recommendation, low quality evidence)
41.12 All other patients
41.12.1 Recommend to hold herbals and supplements 7 days prior to surgery.3,13,21 (UW Health
strong recommendation, low quality evidence)
42 Immunologic agents
42.1 Immunomodulators: abatacept, adalimumab (and biosimilars), anakinra, apremilast,
brodalumab, canakinumab, certolizumab, daclizumab, dimethyl fumarate, diroximel fumarate,
etanercept (and biosimilars), fingolimod, golimumab, guselkumab, infliximab (and biosimilars),
interferons, ixekizumab, lenalidomide, mitoxantrone, natalizumab, pembrolizumab,
pomalidomide, rilonacept, risankizumab, secukinumab, selinexor, siponimod, teriflunomide,
thalidomide, tildrakizumab, tocilizumab, ustekinumab, vedolizumab
42.2 Immunostimulants: elapegademase, pegademase bovine
42.3 Immunosuppressives: alefacept, azathioprine, basiliximab, belatacept, cyclosporine,
dupilumab, durvalumab, glatiramer, mycophenolate, ocrelizumab, sirolimus, tacrolimus
42.4 Keratinocyte Growth Factors: palifermin
42.5 Miscellaneous Monoclonal Antibodies: belimumab, burosumab, denosumab, eculizumab, ,
palivizumab, ravulizumab, raxibacumab, sarilumab, siltuximab, teprotumumab
42.6 Recommend to coordinate immunologic agent perioperative medication management plan with
surgeon and prescribing provider. (UW Health strong recommendation, low quality evidence)
42.6.1 Ustekinumab continued perioperatively did not increase surgical site infections in
Crohn’s disease patients undergoing abdominal surgery.52
43 Intranasal anti-allergy: azelastine, olopatadine
43.1 It is reasonable to continue intranasal anti-allergy regimens throughout the perioperative period.
(UW Health weak recommendation, low quality evidence)
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44 Migraine agents: isometheptene, almotriptan, eletriptan, eptinezumab, erenumab, fremanezumab,
frovatriptan, galcanezumab, lasmiditan, naratriptan, rimegepant, rizatriptan, sumatriptan, zolmitriptan,
ubrogepant
44.1 Recommend to hold migraine agents the day of surgery, although may be approved with
coordination of anesthesiologist. (UW Health strong recommendation, low quality evidence)
See Appendix C – Methylene Blue and Serotonin Syndrome
44.1.1 Drug-drug interactions between serotonin agonists “triptans” and common perioperative
medications (e.g. ondansetron, methylene blue) may result in serotonin syndrome.16
45 Monoamine Oxidase Inhibitors (MAOIs): isocarboxazid, phenelzine, selegiline, tranylcypromine
45.1 Recommend to coordinate monoamine oxidase inhibitor perioperative medication management
plan with anesthesiologist, surgeon, and prescribing provider (UW Health strong
recommendation, low quality evidence) See Appendix C – Methylene Blue and Serotonin
Syndrome
46 Ophthalmic/Otic agents (miscellaneous); see above for anti-glaucoma agents
46.1 Cycloplegic mydriatics: atropine sulfate, cyclopentolate HCl, homatropine hydrobromide,
scopolamine hydrobromide, tropicamide, cyclopentolate/phenylephrine hydroxyamphetamine,
hydrobromide/tropicamide
46.2 Antibiotics: azithromycin, bacitracin, besifloxacin, ciprofloxacin HCl, erythromycin, gatifloxacin,
gentamicin, levofloxacin, moxifloxacin, ofloxacin, sulfacetamide Na, tobramycin
46.3 Antihistamines: alcaftadine, azelastine HCl, emedastine difumarate, epinastine HCl, ketotifen,
olopatadine HCl
46.4 Corticosteroids: dexamethasone, difluprednate, fluocinolone acetonide, fluorometholone
acetate, loteprednol etabonate, prednisolone, rimexolone, triamcinolone acetonide
46.5 Decongestants: naphazoline HCl, oxymetazoline HCl, phenylephrine HCl, tetrahydrozoline HCl
46.6 Immunologic: cyclosporine
46.7 Mast Cell Stabilizer: bepotastine besilate, cromolyn Na, lodoxamide tromethamine, nedocromil
Na
46.8 Nonsteroidal Anti-Inflammatories: bromfenac, diclofenac Na, flurbiprofen Na, ketorolac
tromethamine, nepafenac
46.9 Otic Preparations (Miscellaneous): antipyrine/benzocaine, ciprofloxacin, ofloxacin, fluocinolone
acetonide, ciprofloxacin HCl/hydrocortisone, ciprofloxacin/dexamethasone, neomycin/polymyxin
b/hydrocortisone
46.10 Recombinant Human Nerve Growth Factor: cenegermin
46.11 Selective Vascular Endothelial Growth Factor Antagonists: aflibercept, pegaptanib Na,
ranibizumab
46.12 It is reasonable to continue regimens using agents in 45.1-45.11 throughout the perioperative
period. (UW Health weak recommendation, low quality evidence)
47 Phosphodiesterase Type 5 (PDE-5) Inhibitors: avanafil, sildenafil, tadalafil, vardenafil
47.1 Erectile dysfunction
47.1.1 Recommend to hold phosphodiesterase type 5 (PDE-5) inhibitor regimens when used
for erectile dysfunction five days prior to and the day of surgery. (UW Health strong
recommendation, low quality of evidence)
47.2 Pulmonary artery hypertension (PAH)
47.2.1 Recommend to continue phosphodiesterase type 5 (PDE-5) inhibitor regimens
when used for PAH throughout the perioperative period as discontinuation may be
fatal. 53-56 (UW Health strong recommendation, low quality of evidence)
47.3 Benign prostatic hyperplasia (BPH)
47.3.1 Recommend to coordinate phosphodiesterase type 5 (PDE-5) inhibitor perioperative
medication management plan when used for BPH with anesthesiologist, surgeon, and
prescribing provider. 53-56 (UW Health strong recommendation, low quality of evidence)
48 Pheochromocytoma agents
48.1 Tyrosine Hydroxylase Inhibitor: metyrosine
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48.2 Alpha 1-Blocker: phenoxybenzamine hydrochloride, phentolamine mesylate
48.3 Recommend to coordinate pheochromocytoma agent perioperative medication management
plan with anesthesiologist, surgeon, and prescribing provider. Typically these medications
should be continued. (UW Health strong recommendation, low quality evidence)
49 Renin Angiotensin System Antagonists
49.1 Angiotensin Converting Enzyme Inhibitor (ACE): benazepril, captopril, cilazapril enalapril,
enalaprilat, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, trandolapril
49.2 Angiotensin II receptor blockers (ARB): candesartan, losartan, olmesartan, valsartan
49.3 Direct renin inhibitors: aliskiren
49.4 Recommend holding ACE, ARB, and direct renin inhibitor regimens 24 hours prior to surgery
and the day of surgery.57 (UW Health strong recommendation, moderate quality evidence)
49.4.1 Perioperative omission of ACE inhibitors is associated with reduced intraoperative
hypotension; intraoperative hypotension is associated with an increased risk of end
organ damage and death.58
49.4.2 Sample patient instructions
One day prior to surgery Day of surgery
Morning doses Take prior to 0700 Do not take
Noon, evening, or
bedtime doses Do not take Do not take
49.5 Recommend to coordinate ACE, ARB, and direct renin inhibitor perioperative medication
management plan with anesthesiologist and prescribing physician in patients with significant
heart failure (American College of Cardiology Foundation/American Heart Association
(ACCF/AHA) heart failure staging system Stage D, or New York Heart Association (NYHA)
Functional Classification III or IV) or history of very high blood pressure (systolic ≥180 mmHg or
diastolic ≥120 mmHg) (UW Health strong recommendation, low quality evidence)
49.5.1 Studies have shown that continuing ACE inhibitors through the perioperative phase
increases the likelihood of intraoperative hypotension.59,60 These medications should be
restarted after surgery as soon as clinically appropriate.61
49.6 Neprilysin inhibitor: sacubitril
49.6.1 Recommend to coordinate neprilysin inhibitor regimens with anesthesiologist and
prescribing physician. (UW Health strong recommendation, low quality evidence)
49.7 Aldosterone Receptor Antagonists: eplerenone, spironolactone
49.7.1 It is reasonable to continue aldosterone receptor antagonist regimens throughout the
perioperative period. (UW Health weak recommendation, low quality evidence)
50 Respiratory agents
50.1 Inhaled (oral) sympathomimetics: albuterol, arformoterol, ephedrine, epinephrine, formoterol,
indacaterol, isoproterenol, levalbuterol, metaproterenol, olodaterol, pirbuterol, salmeterol,
terbutaline, vilanterol
50.1.1 Recommend to continue inhaled (oral) sympathomimetics regimens throughout the
perioperative period and to administer on the morning of surgery. (UW Health strong
recommendation, low quality of evidence).62
50.2 Inhaled (oral) anticholinergics: aclidinium, ipratropium, revefenacin, tiotropium, umeclidinium
50.2.1 Recommend to continue inhaled (oral) anticholinergics regimens throughout the
perioperative period and to administer on the morning of surgery.63 (UW Health strong
recommendation, low quality of evidence)
50.3 Xanthine derivatives: aminophylline, dyphylline, theophylline
50.3.1 Recommend to coordinate xanthine derivative perioperative medication management
plan with anesthesiologist, surgeon, and prescribing provider.64 Generally, hold the day
of surgery. (UW Health strong recommendation, low quality of evidence)
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50.3.1.1 No specific evidence is available to show that theophylline decreases
pulmonary complications after surgery, however it does have the potential to
cause serious arrhythmias and neurotoxicity
50.4 Inhaled corticosteroids: beclomethasone, budesonide, ciclesonide, flunisolide, fluticasone,
mometasone
50.4.1 Recommend to continue inhaled corticosteroid regimens throughout the perioperative
period.65 (UW Health strong recommendation, moderate quality of evidence)
50.5 Interleukin-5 receptor antagonists: mepolizumab, reslizumab
50.5.1 Recommend to continue interleukin-5 receptor antagonist regimens throughout the
perioperative period. (UW Health strong recommendation; low quality evidence)
50.6 Leukotriene inhibitors/ modifiers: montelukast, zafirlukast, zileuton
50.6.1 Recommend to continue leukotriene inhibitor/ modifier regimens throughout the
perioperative period and administer on the morning of surgery.13 (UW Health strong
recommendation, low quality evidence)
50.7 Monoclonal antibody (IgE): omalizumab
50.7.1 Recommend to continue monoclonal antibody (IgE) regimens throughout the
perioperative period. (UW Health strong recommendation; low quality evidence)
50.8 Antifibrotic agent: pirfenidone
50.8.1 Recommend to coordinate pirfenidone perioperative medication management plan with
surgeon and prescribing provider. (UW Health strong recommendation, low quality
evidence)
50.9 Arylalkylamine decongestants: phenylephrine, pseudoephedrine
50.9.1 Recommend to hold arylalkylamine decongestants the day of surgery. (UW Health
strong recommendation, low quality evidence)
50.10 Expectorants: guaifenesin, potassium iodide
50.10.1 It is reasonable to continue expectorant regimens throughout the perioperative period.
(UW Health weak recommendation; low quality evidence)
50.11 Lung surfactant: beractant, calfactant, lucinactant, poractant
50.11.1 It is reasonable to continue lung surfactant regimens throughout the perioperative
period. (UW Health weak recommendation; low quality evidence)
50.12 Mucolytic: acetylcysteine, dornase alfa
50.12.1 Recommend to continue mucolytic regimens throughout the perioperative period. (UW
Health strong recommendation, low quality of evidence)
50.13 Non-narcotic anti-tussive: benzonatate, dextromethorphan
50.13.1 It is reasonable to continue non-narcotic anti-tussive regimens throughout the
perioperative period. (UW Health weak recommendation; low quality evidence)
50.14 Phosphodiesterase 4 inhibitor: roflumilast
50.14.1 Recommend to continue phosphodiesterase 4 inhibitor regimens throughout the
perioperative period. (UW Health strong recommendation, low quality evidence)
50.15 Respiratory enzymes: alpha 1- proteinase inhibitor
50.15.1 Recommend to continue respiratory enzyme regimens throughout the perioperative
period. (UW Health strong recommendation, low quality of evidence)
50.16 Tyrosine kinase inhibitor: fostamatinib, nintedanib
50.16.1 Recommend to continue tyrosine kinase inhibitor regimens throughout the
perioperative period. (UW Health strong recommendation, low quality of evidence)
51 Sedatives and Hypnotics
51.1 Barbiturates: amobarbital, butabarbital, pentobarbital, phenobarbital, secobarbital
51.2 Nonbarbiturates: chloral hydrate, dexmedetomidine, eszopiclone, lemborexant, ramelteon,
suvorexant, tasimelteon, zaleplon, zolpidem
51.3 Recommend to coordinate sedative and hypnotic perioperative medication management plan
with anesthesiologist, surgeon, and prescribing provider. (UW Health strong recommendation,
low quality evidence)
52 Selective Serotonin Reuptake Inhibitors (SSRIs): citalopram, escitalopram, fluoxetine,
fluvoxamine, paroxetine, sertraline, vilazodone
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52.1 Recommend to coordinate SSRI perioperative medication management plan with surgeon,
anesthesiologist, and prescribing provider.3,13,21 (UW Health strong recommendation, low
quality evidence) See Appendix D – Methylene Blue and Serotonin Syndrome
52.1.1 Drug interactions between SSRIs and antiplatelet therapy for secondary prevention
(aspirin or thienopyridine therapy) may increase the risk of bleeding.66,67,68
53 Selective Norepinephrine Reuptake Inhibitors (SNRIs): desvenlafaxine, duloxetine,
levomilnacipran, milnacipran, venlafaxine
53.1 Recommend to coordinate SNRI perioperative medication management plan with surgeon,
anesthesiologist, and prescribing provider. 3,13,21 (UW Health strong recommendation, low
quality evidence) See Appendix D – Methylene Blue and Serotonin Syndrome
54 Skeletal Muscle Relaxants
54.1 Direct Acting: dantrolene
54.1.1 Recommend to continue dantrolene regimens throughout the perioperative period. (UW
Health strong recommendation, low quality evidence)
54.2 Centrally Acting: baclofen, carisoprodol, chlorzoxazone, cyclobenzaprine, diazepam,
metaxalone, methocarbamol, orphenadrine, tizanidine
54.2.1 Recommend to continue baclofen regimens throughout the perioperative period.69,70
(UW Health strong recommendation, low quality evidence)
54.2.1.1 Baclofen acts as an agonist at GABA receptors in the spinal cord. It reduces
the pain associated with muscle spasms and may delay development of
contractures. This facilitates normal daily activity. Abrupt withdrawal from oral
or intrathecal baclofen may result in seizures, hallucinations, disorientation,
dyskinesias, and itching. Symptoms may last up to 72 hours.69
54.2.2 It is reasonable to continue carisoprodol, chlorzoxazone, cyclobenzaprine, diazepam,
metaxalone, methocarbamol, orphenadrine, and tizanidine regimens throughout the
perioperative period. (UW Health weak recommendation, low quality evidence)
55 Tetracyclic antidepressants: maprotiline, mirtazapine
55.1 It is reasonable to continue tetracyclic antidepressant regimens throughout the perioperative
period. (UW Health weak recommendation, low quality of evidence)
56 Toxins
56.1 Botulinum Type A toxin: abobotulinum, incobotulinum, onabotulinum, prabotulinumtoxinA
56.2 Type B toxin: rimabotulinum
56.3 It is reasonable to hold toxins 48 hours prior to surgery and not resume until approved by
surgeon. (UW Health weak recommendation, low quality of evidence)
57 Tricyclic antidepressants: amitriptyline, amoxapine, clomipramine, desipramine, doxepin,
imipramine, nortriptyline, protriptyline, trimipramine
57.1 It is reasonable to continue tricyclic antidepressant regimens throughout the perioperative
period.3,13,21 (UW Health weak recommendation, low quality of evidence)
57.1.1 Due to effects on the cardiac conduction system, tricyclic antidepressants may increase
the risk of cardiac arrhythmia.71
57.1.2 Drug-drug interactions between tricyclic antidepressants and common perioperative
medications (sympathomimetics [epinephrine, norepinephrine], serotonergics
[meperidine, tramadol], and anticholinergics (atropine, scopolamine) may result in
hypertension, serotonin syndrome or confusion.71
58 Vasodilators
58.1 Endothelin Receptor Antagonist: ambrisentan, bosentan, macitentan
58.1.1 Recommend to continue endothelin receptor antagonist regimens throughout the
perioperative period. (UW Health strong recommendation, low quality evidence)
58.2 Human B-Type Natriuretic Peptide: nesiritide
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58.2.1 Recommend to continue nesiritide regimens throughout the perioperative period. (UW
Health strong recommendation, low quality evidence)
58.3 Nitrates: amyl nitrate, isosorbide dinitrate, isosorbide mononitrate, nitroglycerin
58.3.1 Recommend to continue nitrate regimens throughout the perioperative period.3,13 (UW
Health strong recommendation, low quality evidence)
58.4 Peripheral Vasodilators: hydralazine, isoxsuprine, minoxidil, papaverine
58.4.1 Recommend to coordinate peripheral vasodilator perioperative medication
management plan with surgeon, anesthesiologist and prescribing provider. (UW Health
strong recommendation, low quality evidence)
58.5 Prostanoids: epoprostenol, iloprost, selexipag, treprostinil
58.5.1 Recommend to coordinate prostanoid perioperative medication management plan with
surgeon, anesthesiologist and prescribing provider. (UW Health strong
recommendation, low quality evidence)
58.6 Soluble Guanylate Cyclase Stimulator : riociguat
58.6.1 Recommend to coordinate riociguat perioperative medication management plan with
surgeon, anesthesiologist and prescribing provider. (UW Health strong
recommendation, low quality evidence)
59 Vasopressors: dobutamine, dopamine, droxidopa, ephedrine, epinephrine, isoproterenol,
norepinephrine, phenylephrine
59.1 Recommend to coordinate vasopressor perioperative medication management plan with
surgeon, anesthesiologist and prescribing provider. (UW Health strong recommendation, low
quality evidence)
Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and treatment of
patients. This guideline outlines the preferred approach for most patients. It is not intended to replace a
clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will not fit
the clinical condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
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Methodology
Development Process
Each guideline is reviewed and updated a minimum of every 3 years. All guidelines are developed using
the guiding principles, standard processes, and styling outlined in the UW Health Clinical Practice
Guideline Resource Guide. This includes expectations for workgroup composition and recruitment
strategies, disclosure and management of conflict of interest for participating workgroup members,
literature review techniques, evidence grading resources, required approval bodies, and suggestions for
communication and implementation.
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline authors and workgroup
members to collect evidence for review. Search terms included: perioperative medication management,
intraoperative complications, postoperative complications, therapeutic drug classes (e.g. adrenergic alpha
2 receptor antagonist), and individual drug names. Medical Subject Heading (MeSH) terms were also
used when available. Expert opinion and clinical experience were also considered during discussions of
the evidence.
Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external organizations and/or
created recommendations internally via a consensus process using discussion of the literature and expert
experience/opinion. If issues or controversies arose where consensus could not be reached, the topic
was escalated appropriately per the guiding principles outlined in the UW Health Clinical Practice
Guideline Resource Guide.
Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade assigned within
the original source document and were adopted for use at UW Health.
Internally developed recommendations, or those adopted from external sources without an assigned
evidence grade, were evaluated by the guideline workgroup using an algorithm adapted from the Grading
of Recommendations Assessment, Development and Evaluation (GRADE) methodology (see Figure 1).
.
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Figure 1. GRADE Methodology adapted by UW Health
GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.
GRADE Ratings for Recommendations For or Against Practice
Strong (S) Generally should be performed (i.e., the net benefit of the treatment is clear, patient values and circumstances are unlikely to affect the decision.)
Conditional (C)
May be reasonable to perform (i.e., may be conditional upon patient values and
preferences, the resources available, or the setting in which the intervention will
be implemented.)
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Figure 2. ACC/AHA Recommendation System: Applying Class of Recommendation and Level of
Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care72
Recognition of Potential Heath Care Disparities:
Health disparities exist in surgical patients, particularly amongst those who have inadequate health
literacy. Health literacy issues affect upwards of 90 million Americans and have been linked to poor
perioperative outcomes.73,74 Careful consideration of health literacy during the perioperative period is
paramount in order to ensure the best perioperative outcome for surgical patients. Health literacy issues
are pervasive amongst all races and peoples
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Collateral Tools & Resources
The following collateral tools and resources support staff execution and performance of the evidence-
based guideline recommendations in everyday clinical practice.
Metrics
• Perioperative medication-related complications (e.g. hypotension, bleeding, infection)
• Delay or cancellation of surgeries because of a failure to modify/hold a medication preoperatively
Guidelines
• Standards of Medical Care in Diabetes – Pediatric/Adult – Inpatient/Ambulatory
o Diabetes Medication Adjustment (Inpatient Procedures)
o Diabetes Medication Adjustment (Ambulatory Procedures)
• Periprocedural and Regional Anesthesia Management with Antithrombotic Therapy – Adult –
Inpatient/Ambulatory
• Assessment of Tobacco Use or Secondhand Exposure – Adult/Pediatric – Inpatient/Ambulatory
• Management of Patients with Non-ST Elevation Acute Coronary Syndromes – Adult - Inpatient
• Mechanical Circulatory Device (MCD) – Adult – Inpatient/Ambulatory
External Databases
• Lexicomp Drug Information Database
• Natural Medicines Database
• Natural Products Database
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Appendix A: Perioperative Medication Management
From: Perioperative Medication Management – Adult/Pediatric – Inpatient/Ambulatory
Clinical Practice Guideline
Last Reviewed 6/2019; Last Updated 8/2022
Contact information: Philip J. Trapskin, PharmD, Phone Number: (608) 263-1328,
PTrapskin@uwhealth.org
Class Medication Recommendation
Acid Suppressants
Antacids Non-soluble
Aluminum hydroxide
Calcium carbonate
Magnesium hydroxide
Magnesium oxide
Soluble
Sodium bicarbonate
Sodium citrate
Non-soluble: Recommend to hold
therapy the day of surgery
Soluble: Recommend to continue
regimen throughout the perioperative
period
H2-Receptor
Antagonists
Cimetidine
Famotidine
Nizatidine
Ranitidine
It is reasonable to continue regimen
throughout the perioperative period
Proton pump
inhibitors
Dexlansoprazole
Esomeprazole
Lansoprazole
Omeprazole
Omeprazole/sodium bicarbonate
Pantoprazole
Rabeprazole
Parathyroid surgery: Recommend
to hold 7 days prior to and day of
surgery and post-operatively until
directed to resume by surgeon.
All other surgeries: Recommend to
continue regimen throughout the
perioperative period
Allergen-specific Immunotherapy
Peanut allergen powder Recommend to coordinate
perioperative medication
management plan with surgeon and
prescribing physician
Alpha1 blockers
Alpha1 blockers Alfuzosin
Doxazosin
Phenoxybenzamine
Phentolamine
Prazosin
Silodosin
Tamsulosin
Terazosin
Cataract surgery: Recommend to
coordinate perioperative medication
management plan with surgeon
All other surgeries: Recommend to
continue regimen throughout the
perioperative period
Alpha2-adrenergic agonists
Alpha2- agonists Clonidine
Guanfacine
Lofexidine
Methyldopa
Tizanidine
Recommend to continue regimen
throughout the perioperative period
Analgesics
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Class Medication Recommendation
Acetaminophen It is reasonable to continue regimen
throughout the perioperative period
N-type calcium
channel blocker
Ziconotide It is reasonable to continue regimen
throughout the perioperative period.
Any interruptions in therapy (holding
or discontinuing) should be
coordinated with prescribing provider.
Nonsteroidal anti-
inflammatory drugs
(NSAIDs)
Aspirin
Celecoxib
Choline magnesium
trisalicylate Diclofenac
Diflunisal
Etodolac
Fenoprofen
Flurbiprofen
Ibuprofen
Indomethacin
Ketoprofen
Ketorolac
Magnesium salicylate
Meclofenamate
Mefenamic acid
Meloxicam
Nabumetone
Naproxen
Oxaprozin
Piroxicam
Salsalate
Sulindac
Tolmetin
For aspirin recommendations,
refer to the Anti-platelet section.
For non-aspirin NSAIDS, coordinate
with surgeon and prescribing
provider.
Opioid agonists Alfentanil
Codeine
Fentanyl
Hydrocodone
Hydromorphone
Levorphanol
Meperidine
Methadone
Morphine sulfate
Opium
Oxycodone
Oxymorphone
Paregoric
Remifentanil
Sufentanil
Tapentadol
Tramadol
Recommend to continue chronic
opioid regimen throughout the
perioperative period, unless
reduction or discontinuation is part of
the perioperative analgesic plan.
Abrupt discontinuation of opioids may
cause withdrawal symptoms and/or
increased pain
Opioid partial
agonists
Buprenorphine
Buprenorphine injection
Buprenorphine/naloxone (Suboxone®)
Butorphanol
Morphine sulfate/naltrexone
Nalbuphine
Pentazocine
Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon, and
prescribing physician
Anorexiants
Serotonin 2C
receptor agonists
Lorcaserin Recommend to hold therapy 7 days
prior to surgery and postoperatively
until directed to resume by surgeon
Sympathomimetic
anorexiants
Benzphetamine
Diethylpropion
Phendimetrazine
Phentermine
Anti-addiction Agents (see also “Opioid partial agonists” above)
Antialcoholic
agents
Acamprosate calcium
Disulfiram
Acamprosate: Recommend to
continue regimen throughout the
perioperative period
Disulfiram: Recommend to hold 7
to14 days prior to surgery
Opioid Antagonist Naltrexone Recommend to hold oral naltrexone
for 1 week prior to surgery and
intramuscular naltrexone for 4 weeks
prior to surgery
Recommend coordination of post-
operative pain management plan with
anesthesiologist, surgeon, and
primary care physician in order to
minimize use of opioids
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Class Medication Recommendation
Nicotine
replacement
Nicotine gum, lozenges, patches, inhalers Recommend abstinence from
smoking in the perioperative period
Recommend to coordinate nicotine
replacement perioperative
medication management plan with
surgeon. If used the day of surgery,
gum and lozenges should not be
used within 2 hours of procedure
Anti-Dementia (Alzheimer’s)Agents
Cholinesterase
inhibitors
Donepezil
Galantamine
Rivastigmine
Recommend to continue
cholinesterase inhibitors with the
knowledge that adjustments to
neuromuscular blocking drugs may
be necessary
NMDA receptor
antagonist
Memantine It is reasonable to continue regimen
throughout the perioperative period
Anti-arrhythmics
Anti-arrhythmics Amiodarone
Disopyramide
Dofetilide
Dronedarone
Flecainide
Ibutilide
Lidocaine (systemic)
Mexiletine
Procainamide
Propafenone
Quinidine
Electrophysiology
surgeries/procedures
Recommend to coordinate
perioperative medication
management plan with cardiologist
and prescribing provider
Non-electrophysiology
surgeries/procedures
Recommend to continue regimen
throughout the perioperative period
Anti-cholinergics
Anti-cholinergics Cyclizine
Dimenhydrinate
Diphenhydramine
Meclizine
Scopolamine
Trimethobenzamide
It is reasonable to continue anti-
cholinergics throughout the
perioperative period, unless a
patient-specific perioperative
management plan was provided by
the surgeon.
Anti-coagulants
Anticoagulants Antithrombin
Apixaban
Betrixaban
Argatroban
Bivalirudin
Dabigatran
Dalteparin
Desirudin
Edoxaban
Enoxaparin
Fondaparinux
Heparin
Rivaroxaban
Warfarin
Recommend to coordinate
perioperative medication
management including any plan for
neuraxial analgesia with surgeon,
anesthesiologist and prescribing
provider
Refer to Management of
Antithrombotic Therapy in the Setting
of Periprocedural, Regional
Anesthesia and/or Pain Procedures
Clinical Practice Guideline
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Anti-convulsants
Anticonvulsants Acetazolamide
Brivaracetam
Cannabidiol
(Epidiolex)
Carbamazepine
Cenobamate
Divalproex
Eslicarbazepine
Felbamate
Lacosamide
Lamotrigine
Levetiracetam
Oxcarbazepine
Perampanel
Primidone
Rufinamide
Stiripentol
Tiagabine
Topiramate
Valproic acid
Vigabatrin
Planned Neuromonitoring or
Neuromapping
Recommend to coordinate
anticonvulsant perioperative
medication management plan with
surgeon, anesthesiologist, and
prescribing provider
All other Procedures
Recommend to continue
anticonvulsant regimens throughout
the perioperative period. Anticonvulsants
(GABA analogues)
Gabapentin Pregabalin
Hydantoins Ethotoin
Fosphenytoin
Phenytoin
Potassium Channel
Openers
Ezogabine
Succinimides Ethosuximide Methsuximide
Sulfonamides Zonisamide
Anti-diabetic agents
Alpha-glucosidase
inhibitor
Acarbose
Miglitol
Refer to:
• Diabetes Medication
Adjustment: Ambulatory
Procedures
• Diabetes Medication
Adjustment: Inpatient
Procedures
Amylinomimetic Pramlintide
Biguanide Metformin
Dipeptidyl
Peptidase IV
Inhibitor
Alogliptin
Linagliptin
Saxagliptin
Sitagliptin
Glucagon-Like
Peptide-1 Receptor
Agonist
Albiglutide
Dulaglutide
Exenatide
Liraglutide
Lixisenatide
Semaglutide
Insulin Insulin Aspart
Insulin Degludec
Insulin Detemir
Insulin Glargine
Insulin Isophane
Insulin Lispro
Insulin Regular
Meglitinide Analog Nateglinide
Repaglinide
Sodium-Glucose
Cotransporter-2
Inhibitor
Canagliflozin
Dapagliflozin
Empagliflozin
Ertugliflozin
Sulfonylurea Chlorpropamide
Glimepiride
Glipizide
Glyburide
Tolazamide
Tolbutamide
Thiazolidinedione Pioglitazone Rosiglitazone
Anti-dopaminergics
Antidopaminergics Chlorpromazine
Amisulpride
Metoclopramide
Perphenazine
It is reasonable to continue regimen
in the perioperative period
Anti-emetics
5HT3 antagonists Alosetron
Dolasetron
Granisetron
Ondansetron
Palonosetron
It is reasonable to continue regimen
in the perioperative period
Phenothiazine Prochlorperazine Promethazine
Substance
P/Neurokinin 1
receptor antagonist
Aprepitant
Fosaprepitant
Fosnetupitant
Netupitant
Rolapitant
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Anti-glaucoma ophthalmics
Miotics,
Cholinesterase
Inhibitors
Acetylcholine
Carbachol
Echothiophate Iodide
Pilocarpine
Recommend to continue
cholinesterase inhibitors with the
knowledge that adjustments to
neuromuscular blocking drugs may
be necessary.
Alpha Adrenergic
Agonists
Apraclonidine Brimonidine Recommend to continue ophthalmic
alpha adrenergic agonist, beta-
adrenergic blocking agent (beta-
blockers), carbonic anhydrase
inhibitor docosanoid, synthetic, and
prostaglandin analogue regimens
throughout the perioperative period
Beta-Adrenergic
Blocking Agents
(Beta-Blockers)
Betaxolol
Carteolol
Levobunolol
Metipranolol
Timolol
Carbonic
Anhydrase
Inhibitors
Brinzolamide
Dorzolamide
Prostaglandin
Analogues
Bimatoprost
Latanoprost
Latanoprostene bunod
Tafluprost
Travoprost
Rho kinase inhibitor Netarsudil
Unoprostone
Isopropyl
Unoprostone Isopropyl
Anti-histamines
Peripherally
selective
Cetirizine
Desloratadine
Fexofenadine
Loratadine
Levocetirizine
Recommend to continue regimen
throughout the perioperative period
Nonselective Brompheniramine
Carbinoxamine
Chlorcyclizine
Chlorpheniramine
Clemastine
Cyproheptadine
Dexbrompheniramine
Dexchlorpheniramine
Diphenhydramine
Doxylamine
Hydroxyzine
Triprolidine
Anti-hyperlipidemia agents (non-statins)
Alirocumab
Bempedoic acid
Cholestyramine
Colesevelam
Colestipol
Evolocumab
Ezetimibe
Fenofibrate
Gemfibrozil
Niacin
Lomitapide
Mipomersen
Recommend to hold therapy 24
hours prior to surgery and day of
surgery to reduce risk of
rhabdomyolysis and gastrointestinal
obstruction
Statins (HMG-CoA Reductase Inhibitors)
Statins Atorvastatin
Fluvastatin
Lovastatin
Pravastatin
Rosuvastatin
Simvastatin
Recommend to continue regimen
throughout the perioperative period,
particularly in patients at high risk for
cardiovascular disease
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Anti-infectives
Amebicides Iodoquinol (Yodoxin) Active infection: Recommend to
coordinate perioperative medication
management plan with surgeon,
anesthesiologist, and prescribing
provider
Infection Prophylaxis: Recommend
to coordinate anti-infectives for
prophylaxis indications with surgeon
and prescribing provider
Aminoglycosides
(oral)
Neomycin Paromomycin
Aminoglycosides
(parenteral)
Amikacin
Gentamicin
Plazomicin
Streptomycin
Tobramycin
Anthelmintics Albendazole (Albenza)
Ivermectin
(Stromectol)
Moxidectin
Praziquantel
(Biltricide)
Pyrantel (Pin-X)
Triclabendazole
Antibiotic
Combinations
Erythromycin/Sulfisoxazole
Sulfamethoxazole/Trimethoprim
Antifungal
(Allylamine)
Terbinafine
Anidulafungin
Caspofungin
Flucytosine
Griseofulvin
Micafungin
Ketoconazole
Amphotericin B
Nystatin
Fluconazole
Isavuconazonium
Itraconazole
Posaconazole
Voriconazole
Antimalarial Chloroquine
Hydroxychloroquine
Artemether/Lumefantri
ne
Atovaquone/Proguanil
Primaquine
Quinine sulfate
Pyrimethamine
Mefloquine
Tafenoquine
Antiprotozoals Atovaquone
Miltefosine
Nitazoxanide
Pentamidine
Tinidazole
Antiretroviral
agents
Abacavir
Atazanavir
Bictegravir
Cobicistat
Darunavir
Delavirdine
Didanosine
Dolutegravir
Doravirine
Efavirenz
Elvitegravir
Emtricitabine
Enfuvirtide
Etravirine
Fosamprenavir
Ibalizumab
Indinavir
Lamivudine
Lopinavir
Maraviroc
Nefinavir
Nevirapine
Raltegravir
Rilpivirine
Ritonavir
Saquinavir
Stavudine
Tenofovir
Tipranavir
Zidovudine
Any antiretroviral
combination product
Antituberculosis
Agents
Aminosalicylic acid
Benaquiline
Capreomycin
Cycloserine
Ethambutol
Ethionamide
Isoniazid
Pretomanid
Pyrazinamide
Rifabutin
Rifampin
Rifapentine
Streptomycin
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38
Antiviral Agents Adefovir
Amantadine
Acyclovir
Baloxavir
Boceprevir
Cidofovir
Daclatasvir
Elbasvir/grazoprevir
Entecavir
Famciclovir
Foscarnet
Ganciclovir
Glecaprevir/pibrentasv
ir
Ledipasvir/Sofosbuvir
Letermovir
Ombitasvir/Paritaprevi
r/Ritonavir/Dasabuvir
Oseltamivir
Peramivir
Ribavirin
Rimantadine
Simeprevir
Sofosbuvir
Tecovirimat
Telaprevir
Telbivudine
Valacyclovir
Valganciclovir
Velpatasvir
Voxilaprevir
Zanamivir
Active infection: Recommend to
coordinate perioperative medication
management plan with surgeon,
anesthesiologist, and prescribing
provider
Infection Prophylaxis: Recommend
to coordinate anti-infectives for
prophylaxis indications with surgeon
and prescribing provider
Bacitracin Bacitracin
Carbapenems Doripenem
Ertapenem
Imipenem/Cilastatin
Meropenem
Meropenem/vaborbact
am
Cephalosporins Cefaclor
Cefadroxil
Cefazolin
Cefdinir
Cefditoren
Cefepime
Cefiderocol
Cefixime
Cefotaxime
Cefotetan
Cefoxitin
Cefpodoxime
Cefprozil
Ceftaroline
Ceftazidime
Ceftazidime/Avibacta
m
Ceftriaxone
Cefuroxime
Cephalexin
Chloramphenicol
Colistimethate
Fluoroquinolones Ciprofloxacin
Delafloxacin
Gemifloxacin
Levofloxacin
Moxifloxacin
Norfloxacin
Ofloxacin (drops)
Ozenoxacin
Folate Antagonists Trimethoprim
Glycylcylines Tigecycline
Ketolides Telithromycin
Leprostatics Dapsone
Lincosamides Clindamycin Lincomycin
Lipoglycopeptides Dalbavancin
Oritavancin
Telavancin
Lipopeptides Daptomycin
Macrolides Azithromycin
Clarithromycin
Erythromycin
Fidaxomicin
Methenamines Methenamine Hippurate
Methenamine Mandelate
Miscellaneous Benznidazole
Fosfomycin
Lefamulin
Metronidazole
Rifamycin
Secnidazole
Monobactams Aztreonam
Monoclonal
antibodies
Bezlotoxumab
Nitrofurans Nitrofurantoin
Oxazolidinones Linezolid Tedizolid
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Penicillins Amoxicillin
Amoxicillin/Clavulanat
e
Ampicillin
Ampicillin/sulbactam
Dicloxacillin
Nafcillin
Oxacillin
Penicillin G
Penicillin V
Piperacillin/Tazobacta
m
Ticarcillin/Clavulanate
Active infection: Recommend to
coordinate perioperative medication
management plan with surgeon,
anesthesiologist, and prescribing
provider
Infection Prophylaxis: Recommend
to coordinate anti-infectives for
prophylaxis indications with surgeon
and prescribing provider
Polymyxin B Sulfate
Rifaximin
Streptogramins Quinupristin/Dalfopristin
Sulfadiazine Sulfadiazine
Tetracyclines Demeclocycline
Doxycycline
Eravacycline
Minocycline
Omadacycline
Sarecycline
Tetracycline
Vancomycin Vancomycin
Anti-over active bladder agents
Anticholinergic Oxybutynin It is reasonable to continue regimen
throughout the perioperative period
Muscarinic receptor
antagonist
Darifenacin
Fesoterodine
Solifenacin
Tolterodine
Trospium
M3 muscarinic
agonist
Mirabegron
Phosphodiesterase
inhibitor
Flavoxate
Anti-neoplastics
Alkylating Agents Altretamine
Busulfan
Carmustine
Chlorambucil
Dacarbazine
Estramustine
Ifosfamide
Lomustine
Mechlorethamine
Melphalan
Streptozocin
Thiotepa
Recommend to coordinate
antineoplastic perioperative
medication management plan with
surgeon and prescribing provider
Anthracenedione Mitoxantrone
Antibody-Drug
Conjugates
ADO-Trastuzumab
Brentuximab Vedotin
Emtansine
Enfortumab vedotin
Fam-trastuzumab
deruxtecan
Polatuzumab vedotin
Antimetabolites Allopurinol
Capecitabine
Cladribine
Clofarabine
Cytarabine
Floxuridine
Fludarabine
Fluorouracil
Gemcitabine
Mercaptopurine
Methotrexate
Pemetrexed
Pentostatin
Pralatrexate
Rasburicase
Thioguanine
Antimitotic agents Cabazitaxel
Docetaxel
Eribulin
Ixabepilone
Paclitaxel
Vinblastine
Vincristine
Vinorelbine
Antineoplastic
Antibiotics
Bleomycin
Dactinomycin
Daunorubicin
Doxorubicin
Epirubicin
Idarubicin
Mitomycin
Valrubicin
BCL-2 Inhibitor Venetoclax
Biologic Response
Modifiers
Aldesleukin BCG live
Cytoprotective
Agents
Amifostine
Dexrazoxane
Leucovorin
Levoleucovorin
Mesna
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40
DNA
Demethylation
Agents
Azacitidine
Decitabine
Nelarabine
Recommend to coordinate
antineoplastic perioperative
medication management plan with
surgeon and prescribing provider
DNA
Topoisomerase
Inhibitors
Irinotecan
Topotecan
Enzymes Asparaginase
Calaspargase
Pegaspargase
Epipodophyllotoxin Etoposide Teniposide
EZH2-Inhibitor Tazemetostat
Histone
Deacetylase
Inhibitors
Belinostat
Panobinostat
Romidepsin
Vorinostat
Hormones Abiraterone
Anastrazole
Apalutamide
Bicalutamide
Buserelin
Darolutamide
Enzalutamide
Exemestane
Flutamide
Fulvestrant
Goserelin
Histelin
Letrozole
Leuprolide
Medroxyprogesterone
Megestrol
Nilutamide
Tamoxifen
Toremifene
Triptorelin
Hedgehog Pathway
Inhibitor
Glasdegib
Sonidegib
Vismodegib
Imidazotetrazine
derivatives
Temozolomide
Kinase inhibitors Abemaciclib
Acalabrutinib
Afatinib
Alectinib
Alpelisib
Axitinib
Binimetinib
Bosutinib
Brigatinib
Cabozantinib
Ceritinib
Cobimetinib
Copanlisib
Crizotinib
Dabrafenib
Dacomitinib
Dasatinib
Duvelisib
Encorafenib
Enasidenib
Entrectinib
Erdafitinib
Erlotinib
Everolimus
Gefitinib
Gilteritinib
Ibrutinib
Idelalisib
Imatinib
Ivosidenib
Lapatinib
Lenvatinib
Lorlatinib
Larotrectinib
Midostaurin
Neratinib
Nilotinib
Osimertinib
Palbociclib
Pazopanib
Pexidartinib
Ponatinib
Regorafenib
Ribociclib
Ruxolitinib
Sorafenib
Sunitinib
Temsirolimus
Trametinib
Vandetanib
Vemurafenib
Zanubrutinib
Methylhydrazine
derivatives
Procarbazine
Miscellaneous
Antineoplastics
Arsenic Trioxide
Mitotane
Porfimer
Sipuleucel-T
Sterile Talc Powder
Trabectedin
Trifluridine/tipiracil
Monoclonal
antibodies
Alemtuzumab
Atezolizumab
Avapritinib
Avelumab
Bevacizumab (and
biosimilars)
Blinatumomab
Ipilimumab
Mogamuliziumab
Moxetumomab
Necitumumab
Nivolumab
Obinutuzumab
Ofatumumab
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Brolucizumab
Cemiplimab
Cetuximab
Daratumumab
Dinutuximab
Elotuzumab
Gemtuzumab
Ibritumomab
Inotuzumab
Olaratumab
Panitumumab
Pertuzumab
Ramucirumab
Rituximab (and
biosimilars)
Tagraxofusp
Trastuzumab (and
biosimilars)
Recommend to coordinate
antineoplastic perioperative
medication management plan with
surgeon and prescribing provider
PARP Enzymes
Inhibitor
Niraparib
Olaparib
Rucaparib
Talazoparib
Platinum
Coordination
Complex
Carboplatin
Cisplatin
Oxaliplatin
Proteasome
Inhibitors
Bortezomib
Carfilzomib
Ixazomib
Protein Synthesis
Inhibitor
Omacetaxine
Radiopharmaceutic
als
Lutetium Lu-177
Radium Ra-223
Samarium Sm-153
Sodium Iodide I-131
Strontium-89 Chloride
Retinoids Tretinoin
Trifarotene
Rexinoids Bexarotene
Substituted Ureas Hydroxyurea
Vascular
Endothelial Growth
Factor
ZIV-Aflibercept
Anti-osteoporosis Agents
Bisphosphonates Alendronate
Etidronate
Ibandronate
Pamidronate
Risedronate
Tiludronate
Zolendronic Acid
Dental surgeries: Recommend to
coordinate anti-osteoporosis
perioperative medication
management plan with surgeon and
prescribing provider
All other surgeries:
Recommend to hold bisphosphonate
therapy the day of surgery and
postoperatively until directed to
resume by surgeon and to coordinate
perioperative calcitonin and
denosumab medication management
plan with surgeon and prescribing
provider
Calcitonin-salmon Calcitonin-salmon
Denosumab Denosumab
Romosozumab Romosozumab
Anti-Parkinson’s Agents
Antiparkinson
agents
Amantadine
Apomorphine
Belladonna alkaloids
Benztropine
Bromocriptine
Carbidopa
Carbidopa/Levodopa
Carbidopa/Levodopa/E
ntacapone
Istradefylline
Entacapone
Pramipexole
Rasagiline
Ropinirole
Rotigotine
Selegiline
Tolcapone
Recommend to continue regimen
throughout the perioperative period
Anti-platelets
Antiplatelet agents Anagrelide
Dipyridamole
Dipyridamole/Aspirin
Cangrelor
Cilostazol
Clopidogrel
Prasugrel
Ticagrelor
Ticlopidine
Vorapaxar
Recommend to coordinate
perioperative medication
management plan with surgeon,
anesthesiologist, and prescribing
provider (e.g. interventional
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42
cardiologist, neurosurgeon, vascular
surgeon)
Anti-psychotics
1st generation –
Typical
Chlorpromazine
Fluphenazine
Haloperidol
Loxapine
Perphenazine
Pimozide
Prochlorperazine
Thioridazine
Thiothixene
Trifluoperazine
Recommend to continue regimen
throughout the perioperative period
2nd generation –
Atypical
Aripiprazole
Asenapine
Brexpiprazole
Cariprazine
Clozapine
Iloperidone
Lumateperone
Lurasidone
Olanzapine
Paliperidone
Pimavanserin
Quetiapine
Risperidone
Ziprasidone
Antirheumatic Agents
Janus associated
kinase (JAK)
inhibitors
Baricitinib
Fedratinib
Ruxolitinib
Tofacitinib
Upadacitinib
Orthopedic surgery: Recommend to
hold therapy 48 hours prior to
surgery and resume 7-14 days post-
operatively if there are no signs or
symptoms of infection and incisions
are healing well
All other surgeries: Recommend to
coordinate perioperative medication
management plan with surgeon and
prescribing provider
Antimetabolites Methotrexate Orthopedic surgery: Recommend to
continue regimen throughout the
perioperative period
All other surgeries: Recommend
to coordinate perioperative
medication management plan with
surgeon and prescribing provider
Anti-TNF-alpha
agents
Adalimumab (and biosimilars)
Certolizumab
Etanercept (and biosimilars)
Golimumab
Infliximab (and biosimilars)
Orthopedic surgery: Recommend to
hold etanercept 2 weeks prior to
surgery
Orthopedic surgery: Recommend
to coordinate all other anti-TNF-alpha
agent perioperative medication
management plan with surgeon and
prescribing provider
All other surgeries: Recommend
to coordinate perioperative
medication management plan with
surgeon and prescribing provider
Gold compounds Auranofin
Gold sodium thiomalate
Orthopedic surgery: Recommend
to continue regimen throughout the
perioperative period
All other surgeries: Recommend
to coordinate perioperative
medication management plan with
surgeon and prescribing provider
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Interleukin-6
blockers
Tocilizumab Orthopedic surgery: Recommend
to
• hold subcutaneous tocilizumab 3
weeks prior to surgery
• hold intravenous tocilizumab 4
weeks prior to surgery
All other surgeries: Recommend to
coordinate perioperative medication
management plan with surgeon and
prescribing provider
Interleukin-1
blockers
Anakinra Orthopedic surgery: Recommend to
hold subcutaneous anakinra 7 days
prior to surgery
All other surgeries: Recommend
to coordinate perioperative
medication management plan with
surgeon and prescribing provider
Phosphodiesterase
-4 enzyme inhibitor
Apremilast Orthopedic surgery: Recommend
to coordinate perioperative
medication management plan with
surgeon and prescribing provider
All other surgeries: Recommend
to coordinate perioperative
medication management plan with
surgeon and prescribing provider
Pyrimidine
synthesis inhibitors
Leflunomide Orthopedic surgery: Recommend
to hold 14 days prior to surgery
All other surgeries: Recommend
to coordinate perioperative
medication management plan with
surgeon and prescribing provider
Selective T-cell
costimulation
blocker
Abatacept Orthopedic surgery: Recommend
to hold subcutaneous abatacept 2
weeks prior to surgery and
intravenous abatacept 4 weeks prior
to surgery
All other surgeries: Recommend
to coordinate perioperative
medication management plan with
surgeon and prescribing provider
Beta-blockers
Beta-Adrenergic
Blocking Agents
(Beta-Blockers)
Acebutolol
Atenolol
Betaxolol
Bisoprolol
Esmolol
Metoprolol
Nadolol
Nebivolol
Penbutolol
Pindolol
Propranolol
Sotalol
Timolol
Recommend to continue beta-blocker
regimens throughout the
perioperative period unless
contraindicated by hemodynamic
instability or profound bronchospasm
Alpha/Beta-
Adrenergic
Blocking Agents
Carvedilol
Labetalol
Benzodiazepines
Benzodiazepines Alprazolam
Chlordiazepoxide
Clobazam
Clonazepam
Clorazepate
Diazepam
Lorazepam
Oxazepam
Recommend to continue regimen
throughout the perioperative period
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Calcium Channel Blockers
Calcium channel
blockers
Amlodipine
Clevidipine
Diltiazem
Felodipine
Isradipine
Nicardipine
Nifedipine
Nimodipine
Nisoldipine
Verapamil
Recommend to continue regimen
throughout the perioperative period
Cardiovascular Agents – Miscellaneous
Alpha1-Agonist Midodrine Recommend to continue regimen
throughout the perioperative period
Cardiac Glycoside Digoxin Recommend to continue regimen
throughout the perioperative period
Central
Monoamine-
Depleting Agent
Deutetrabenazine
Reserpine
Tetrabenazine
Valbenazine
Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon and
prescribing provider
Cyclic nucleotide-
gated (HCN)
channels (f-
channels)
Ivabradine Recommend to continue regimen
throughout the perioperative period
Dopamine Agonist Fenoldopam Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon and
prescribing provider
Ganglionic Blocker Mecamylamine Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon and
prescribing provider
Inotropics Inamrinone
Milrinone
Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon and
prescribing provider
Inward sodium
channel inhibitor
Ranolazine Recommend to continue regimen
throughout the perioperative period
Potassium
removing resins
Patiromer
Sodium polystyrene sulfonate
Sodium zirconium cyclosilicate
Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon and
prescribing provider
Transthyretin
stabilizer
Tafamidis Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon and
prescribing provider
Central Nervous System – Miscellaneous
Antianxiety agent Buspirone
Meprobamate
Recommend to continue regimen
throughout the perioperative period
Antidepressants Bupropion
Nefazodone hydrochloride
Trazodone
Vortioxetine
Recommend coordination of
perioperative medication
management plan with surgeon,
anesthesiologist, and prescribing
provider
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Anticholinesterase
muscle stimulants
Edrophonium
Neostigmine
Pyridostigmine
Recommend coordination of
perioperative medication
management plan with surgeon,
anesthesiologist, and prescribing
provider
Antioxidants Edaravone Recommend coordination of
perioperative medication
management plan with surgeon,
anesthesiologist, and prescribing
provider
Antisense
Oligonucleotide
Eteplirsen
Golodirsen
Inotersen
Nusinersin
Recommend to coordinate antisense
oligonucleotide management plan
with anesthesiologist, surgeon, and
prescribing provider
Cholinergic muscle
stimulant
Guanidine Recommend coordination of
perioperative medication
management plan with surgeon,
anesthesiologist, and prescribing
provider
CNS stimulants Amphetamine
Armodafinil
Caffeine
Dexmethylphenidate
Dextroamphetamine
Doxapram
Lisdexamfetamine
Methamphetamine
Methylphenidate
Modafinil
Armodafinil, Modafinil:
Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon, and
prescribing provider
All other CNS stimulants:
Recommend to continue regimen
throughout the perioperative period
Dopamine and
Norepinephrine
Reuptake Inhibitor
Solriamfetol Recommend to coordinate
perioperative management plan with
anesthesiologist, surgeon, and
prescribing provider
Glutamate Inhibitor Riluzole Recommend to continue regimen
throughout the perioperative period
Lithium Lithium Recommend to continue regimen
throughout the perioperative period
Miscellaneous
psychotherapeutic
agents
Atomoxetine
Sodium oxybate
Atomoxetine: Recommend to
continue regimen throughout the
perioperative period
Pitolisant, Sodium oxybate:
Recommend to coordinate
perioperative management plan with
anesthesiologist, surgeon, and
prescribing provider
Mixed 5HT1A
agonist/5HT2A
antagonist
Flibanserin Recommend to coordinate
perioperative management plan with
anesthesiologist, surgeon, and
prescribing provider
NMDA Antagonist Esketamine Recommend to coordinate
perioperative management plan with
anesthesiologist, surgeon, and
prescribing provider
Partial neuronal α4
β2 nicotinic
receptor agonist
Varenicline Recommend to hold therapy the day
of surgery and post-operatively until
directed to resume by surgeon
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Potassium Channel
Blocker
Amifampridine
Dalfampridine
Recommend to continue regimen
throughout the perioperative period
Tripeptidyl
peptidase-1 (TPP-
1) analog
Cerliponase alfa Recommend to coordinate
perioperative management plan with
anesthesiologist, surgeon, and
prescribing provider
Corticosteroid
Corticosteroid Betamethasone
Budesonide
Cortisone
Cosyntropin
Deflazacort
Dexamethasone
Hydrocortisone
Fludrocortisone
Methylprednisolone
Prednisolone
Prednisone
Triamcinolone
Recommend to continue regimen
throughout the perioperative period
Diuretics
Carbonic
anhydrase
inhibitors
Acetazolamide
Methazolamide
Heart failure of volume overload
indication:
Recommend to coordinate diuretic
perioperative management plan with
anesthesiologist, surgeon, and
prescribing provider
Hypertension indication:
Recommend to hold diuretic the day
of surgery
Diuretic
Combinations
Amiloride/Hydrochlorothiazide
Spironolactone/ Hydrochlorothiazide
Triamterene/ Hydrochlorothiazide
Loop Diuretics Bumetanide
Ethacrynic Acid
Furosemide
Torsemide
Osmotic Mannitol
Potassium Sparing Amiloride
Spironolactone
Triamterene
Thiazides Chlorothiazide
Chlorthalidone
Hydrochlorothiazide
Indapamide
Methyclothiazide
Metolazone
Estrogens and Progestins – Miscellaneous
Estrogen Conjugated Estrogens
Ethinyl Estradiol
Estradiol valerate
Esterified Estrogens
Estradiol
Estradiol Cypionate
Estropipate
Recommend to coordinate
perioperative management plan with
surgeon, and prescribing provider
Progestins Desogestrel
Drospirenone
Etonogestrel
Ethynodiol Diacetate
Hydroxyprogesterone
caproate
Levonorgestrel
Medroxyprogesterone
acetate
Megestrol Acetate
Norelgestromin
Norgestimate
Norgestrel
Norethindrone Acetate
Progesterone
Segesterone
Ulipristal
Selective Estrogen
Receptor Modulator
Bazedoxifene
Clomiphene Citrate
Ospemifene
Raloxifene
Endocrine and Metabolic Agents – Miscellaneous
4-
Hydroxyphenylpyru
vate dioxygenase
inhibitor
Nitisinone It is reasonable continue regimen
throughout the perioperative period.
5-Alpha Reductase
Inhibitor
Dutasteride
Finasteride
Anabolic Steroid Oxymetholone
Androgens Danazol
Oxandrolone
Fluoxymesterone
Methyltestosterone
Testosterone
Anti-androgen Cyproterone Dienogest
Antithyroid Agents Methimazole
Propylthiouracil
Sodium Iodide
Betaine Anhydrous Betaine Anhydrous
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Bile Acids Cholic Acid
Bromocriptine
Mesylate
Bromocriptine Mesylate
Cabergoline Cabergoline
Calcimimetics Cinacalcet Etelcalcetide
Carglumic acid Carglumic acid
Chelating Agent Deferasirox
Deferiprone
Deferoxamine
Cysteamine Cysteamine
Cystic fibrosis
transmembrane
conductance
regulator
potentiator
Elexacaftor
Ivacaftor
Lumacaftor
Tezacaftor
Detoxification
agents
Dimercaprol
Edetate Calcium
Disodium
Pentetate Calcium
Trisodium
Pentetate Zinc
Trisodium
Prussian Blue (Ferric
Hexacyanoferrate)
Succimer (DMSA)
Trientine
Hydrochloride
Enzyme
replacement
Asfotase
Agalsidase Beta
Alglucosidase alfa
Elosulfase alfa
Galsulfase
Idursulfase
Imiglucerase
Laronidase
Sebelipase
Taliglucerase Alfa
Velaglucerase alfa
Farnesoid X
receptor agonist
Obeticholic acid
Glucosylceramide
Synthase Inhibitor
Eliglustat
Miglustat
Glycerol
Phenylbutyrate
Glycerol Phenylbutyrate
Gonadotropin
Releasing Hormone
Agonist
Nafarelin
Gonadotropin
Releasing Hormone
Antagonist
Cetrorelix
Degarelix
Elagolix
Ganirelix
Growth Hormone Somatropin
Growth Hormone
Agonists
Macimorelin
Insulin-like growth
factor
Mecasermin
Lipodystrophy
agents
Metreleptin
Tesamorelin
Lipolytic Deoxycholic acid
Ovulation
Stimulator
Choriogonadotropin
Alfa
Chorionic
Gonadotropin
Follitropin alfa
Follitropin beta
Lutropin Alpha
Menotropins
Urofollitropin
Melanocortin
receptor agonist
Bremelanotide
Parathyroid
hormone analogues
Abaloparatide
Parathyroid
Teriparatide
Pegvisomant Pegvisomant
Pharmacologic
Chaperone
Migalastat
Phenylketonuria
agents
Sapropterin Dichloride
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Phosphate Binders Lanthanum Sevelamer
Posterior Pituitary
Hormones
Desmopressin
Vasopressin
Selective Estrogen
Receptor Modulator
Bazedoxifene
Clomiphene Citrate
Ospemifene
Raloxifene
Sodium Benzoate
and Sodium
Phenylacetate
Sodium Benzoate and Sodium Phenylacetate
Sodium
Phenylbutyrate
Sodium Phenylbutyrate
Somatostatin
Analogs
Lanreotide
Octreotide
Pasireotide
Thyroid Drugs Potassium Iodide
Levothyroxine Sodium
Liothyronine Sodium
Liotrix
Thyroid Desiccated
Tryptophan
hydroxylase
inhibitors
Telotristat
Uridine Triacetate
Uterine Active
Agents
Carboprost
Dinoprostone
Methylergonovine
Maleate
Mifepristone
Oxytocin
Vasopressin
Receptor
Antagonists
Conivaptan Hydrochloride
Tolvaptan
Gastrointestinal Agents – Laxatives
Bowel evacuants Polyethylene glycol (PEG)
PEG-electrolyte combination
Sodium phosphate
Sodium phosphate/magnesium oxide/citric acid
Recommend to coordinate
perioperative medication
management plan with surgeon and
prescribing provider
Bulk-producing
laxatives
Calcium polycarbophil
Methylcellulose
Psyllium
Emollients Mineral oil
Surfactants Docusate calcium Docusate sodium
Hyperosmotic
agents
Glycerin
Lactilol
Lactulose
Sorbitol
Stimulants Bisacodyl
Cascara sagrada
Sennosides
Gastrointestinal Agents – Miscellaneous
5-Aminosalicylic
Acid Derivative
Balsalazide
Mesalamine
Olsalazine
Sulfasalazine
Recommend to continue regimen
throughout the perioperative period
Antidiarrheals Bismuth subsalicylate
Crofelemer
Difenoxin/atropine
Diphenoxylate/atropine
Loperamide
Loperamide/simethicone
Bismuth subsalicylate:
Recommend to hold bismuth
subsalicylate the day of surgery due
to the potential to cause black stools
All other medications: It is
reasonable to continue other
antidiarrheals throughout the
perioperative period
Antiflatulents Alpha-d-galactosidase Simethicone Sucralfate: Recommend to hold
sucralfate the day of surgery
Antispasmodics Dicyclomine
Belladonna
alkaloids
Atropine sulfate
Hyoscyamine sulfate
Scopolamine
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Cholinergic Agonist Cevimeline Pilocarpine All other medications:
Recommend to continue regimen
throughout the perioperative period
Chloride Channel
Activator
Lubiprostone
Digestive Enzymes Pancreatic Enzymes Pancrelipase
GI Anticholinergic
Combinations
Atropine/scopolamine/hyoscyamine/phenobarbit
al
Clidinium/chlordiazepoxide
GI Quaternary
Anticholinergics
Glycopyrrolate
Mepenzolate
Methscopolamine
Propantheline
GI stimulants Dexpanthenol
Metoclopramide
Prucalopride
Tegaserod
GLP-2 analogs Teduglutide
Glutamine L-glutamine
Guanylate cyclase-
C agonist
Linaclotide
Plecanatidecalci
Miscellaneous Eluxadoline
Sucralfate
Chenodiol
Ursodiol
Alvimopan
Methylnaltrexone
Naloxegol
Tenapanor
Systemic
Deodorizers
Bismuth subgallate
Chlorophyll derivatives
Chlorophyllin
Genitourinary and Renal Agents – Miscellaneous
Cystine depleting
agents
Cysteamine bitartrate
Penicillamine
Tiopronin It is reasonable to continue regimen
throughout the perioperative period
Interstitial cystitis
agents
Dimethyl sulfoxide
Pentosan polysulfate
sodium
Phenazopyridine
Phenazopyridine/buta
barbital/hyoscyamine
Urinary acidifiers Ascorbic acid
Urinary cholinergics Bethanechol
Urinary alkalinizers Potassium citrate
Sodium bicarbonate
Sodium bicarbonate/citric acid (Shohl’s solution)
Miscellaneous Acetohydroxamic acid
Cellulose sodium phosphate
Gout Agents
β-tubulin
polymerization
inhibitor
Colchicine Recommend to coordinate
perioperative medication
management plan with surgeon and
prescribing provider
Uric acid
transporter-1
(URAT-1) inhibitor
Lesinurad It is reasonable to continue regimen
throughout the perioperative period
Xanthine Oxidase
Inhibitor
Allopurinol
Febuxostat
It is reasonable to continue regimen
throughout the perioperative period
Recombinant urate-
oxidase
Pegloticase It is reasonable to continue regimen
throughout the perioperative period
Uricosurics Probenecid Recommend to hold therapy the day
of surgery and postoperatively until
directed to resume by surgeon
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Hematological Agents – Miscellaneous
For additional information, see Management of Antithrombotic Therapy in the Setting of Periprocedural, Regional
Anesthesia and/or Pain Procedures Clinical Practice Guideline
Antihemophilic
agents
Anti-inhibitor coagulant complex
Antihemophilic Factor VIII
Coagulation Factor XIIIa
Factor IX
Factor VIIa
Factor XIII
Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon, and
prescribing provider
Antihemophilic
Factor
Combinations
Antihemophilic factor/von Willebrand Factor
Complex
Anti-von Willebrand
Factor
Caplacizumab Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon, and
prescribing provider
Antisickling agents Hydroxyurea
Voxelotor
Recommend to continue regimen in
the perioperative period
Bradykinin
inhibitors
Icatibant It is reasonable to continue regimen
in the perioperative period
Coagulants Protamine Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon, and
prescribing provider
Erythropoiesis-
stimulating agents
Darbepoetin and biosimilars
Epoetin Alfa and biosimilars
Epoetin Beta and biosimilars
Methoxy Polyethylene Glycol-Beta
It is reasonable to continue regimen
in the perioperative period
Hematopoietic stem
cell mobilizer
Plerixafor Recommend to coordinate
perioperative medication
management plan with surgeon and
prescribing provider
Granulocyte-colony
stimulating factors
Filgrastim (and biosimilars)
Pegfilgrastim (and biosimilars)
Recommend to coordinate
perioperative medication
management plan with surgeon and
prescribing provider
Granulocyte
macrophage
colony-stimulating
factor
Sargramostim Recommend to coordinate
perioperative medication
management plan with surgeon and
prescribing provider
Thrombopoietic
agents
Avatrombopag
Eltrombopag
Lusutrombopag
Oprelvekin
Romiplostim
Recommend to coordinate
perioperative medication
management plan with surgeon and
prescribing provider
Porphyria Agents Hemin
Givosiran
Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon, and
prescribing provider
Hemorrheologic
agents
Pentoxifylline Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon, and
prescribing provider
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Hemostatics Absorbable Gelatin
Aminocaproic Acid
Ferric subsulfate
Fibrinogen
Concentrate
Microfibrillar Collagen
Hemostat
Oxidized Cellulose
Prothrombin Complex
Concentrate
Thrombin
Tranexamic Acid
Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon, and
prescribing provider
Kallikrein Inhibitor Ecallantide
Lanadelumab
It is reasonable to continue regimen
in the perioperative period
Plasma expanders Albumin Human
Dextran 40
Hetastarch
Plasma Protein
Fraction
Tetrastarch
It is reasonable to continue regimen
in the perioperative period
Protein C1
inhibitors
C1 Inhibitor (Cinryze) Recommend to continue regimen in
the perioperative period
Thrombolytic
agents
Alteplase
Defibrotide
Protein C Concentrate
Reteplase
Tenecteplase
Urokinase
Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon, and
prescribing provider
Monoclonal
Antibodies
Crizanlizumab Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon, and
prescribing provider
Herbals and Supplements
Amino Acids Levocarnitine
L-Lysine
Methionine
Threonine
Inborn errors of metabolism
Recommend to coordinate use of
supplements and perioperative
medication management plan with
anesthesiologist, surgeon, and
prescribing provider
All other patients
Recommend to hold herbals and
supplements 7 days prior to surgery.
Cannabidiol CBD oil, OTC or supplement; not including
Epidiolex prescription for seizure management)
Electrolytes Potassium Sodium Chloride
Fish Oils Omega-3 Fatty Acids
Lipotropics Choline Inositol
Minerals Calcium
Magnesium
Phosphorus
Systemic
Alkalinizers
Citric Acid
Citrate
Tromethamine
Trace Elements Chromium
Copper
Fluoride
Ferric Maltol
Iron
Manganese
Selenium
Zinc
Vitamins Beta-Carotene
Phytonadione (Vitamin
K)
Vitamin A
Calcitriol
Cholecalciferol
Doxercalciferol
Ergocalciferol
Paricalcitol
Vitamin E
Aminobenzoate
potassium
Bioflavonoids
Biotin
Hydroxycobalamin
Cobalamin (B12)
Folic Acid
Niacin (B3)
Niacinamide
Pantothenic Acid (B5)
Pyridoxine (B6)
Riboflavin (B2)
Thiamine (B1)
Ascorbic acid (Vitamin
C)
Calcium Ascorbate
Sodium Ascorbate
Miscellaneous Coenzyme Q10
Edavarone
Lactase
Sacrosidase
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Immunologic Agents
Immunomodulators Abatacept
Adalimumab (and
biosimilars)
Anakinra
Apremilast
Brodalumab
Canakinumab
Certolizumab
Daclizumab
Dimethyl Fumarate
Diroximel Fumarate
Etanercept (and
biosimilars)
Fingolimod
Golimumab
Guselkumab
Infliximab (and
biosimilars)
Interferons
Ixekizumab
Lenalidomide
Mitoxantrone
Natalizumab
Pembrolizumab
Pomalidomide
Rilonacept
Secukinumab
Selinexor
Siponimod
Risankizumab
Teriflunomide
Thalidomide
Tildrakizumab
Tocilizumab
Ustekinumab
Vedolizumab
Recommend to coordinate
perioperative medication
management plan with surgeon and
prescribing provider
Immunostimulants Elapegdemase Pegademase Bovine
Immunosuppressiv
es
Alefacept
Azathioprine
Basiliximab
Belatacept
Cyclosporine
Dupilumab
Durvalumab
Glatiramer
Mycophenolate
Ocrelizumab
Sirolimus
Tacrolimus
Keratinocyte
Growth Factors
Palifermin
Miscellaneous
Monoclonal
Antibodies
Belimumab
Burosumab
Denosumab
Eculizumab
Palivizumab
Ravulizumab
Raxibacumab
Sarilumab
Siltuximab
Teprotumumab
Intranasal anti-allergy
Antihistamines Azelastine Olopatadine It is reasonable to continue regimen
in the perioperative period
Mast cell stabilizers Cromolyn
Steroids Beclomethasone
Budesonide
Ciclesonide
Flunisolide
Fluticasone
Mometasone
Triamcinolone
Migraine Agents
Sympathomimetic Isometheptene Recommend to hold therapy the day
of surgery, although may be
approved with coordination of
anesthesiologist
Serotonin 5HT1B,1D
Agonist (triptans)
Almotriptan
Eletriptan Frovatriptan
Naratriptan
Rizatriptan,
Sumatriptan,
Zolmitriptan
Serotonin 5HT1F
Agonist
Lasmiditan
Ergot Derivatives Dihydroergotamine mesylate
Ergotamine tartrate
Calcitonin Gene-
related Peptide
Receptor
Antagonist
Eptinezumab
Erenumbe
Fremanezumab
Galcanezumab
Rimegepant
Ubrogepant
Monoamine Oxidase Inhibitors
Monoamine
Oxidase Inhibitors
(MAOI)
Isocarboxazid
Phenelzine
Tranylcypromine
Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon, and
prescribing provider
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Ophthalmic Agents – Miscellaneous
Cycloplegic
Mydriatics
Atropine Sulfate
Cyclopentolate HCl
Homatropine HBr
Scopolamine HBr
Tropicamide
Cyclopentolate/Phenyl
ephrine
Hydroxyamphetamine
Hydrobromide/Tropica
mide
Recommend to continue regimen
throughout the perioperative period
Antibiotics Azithromycin
Bacitracin
Besifloxacin
Ciprofloxacin HCl
Erythromycin
Gatifloxacin
Gentamicin
Levofloxacin
Moxifloxacin
Ofloxacin
Sulfacetamide
Tobramycin
Antihistamines Alcaftadine
Azelastine HCl
Emedastine
difumarate
Epinastine HCl
Ketotifen
Olopatadine HCl
Corticosteroids Dexamethasone
Difluprednate
Fluocinolone
acetonide
Fluorometholone
acetate
Loteprednol etabonate
Prednisolone
Rimexolone
Triamcinolone
acetonide
Decongestants Naphazoline HCl
Oxymetazoline HCl
Phenylephrine HCl
Tetrahydrozoline HCl
Decongestant/
Antihistamine
Naphazoline/Pheniramine
Immunologic Cyclosporine
Mast Cell Stabilizer Bepotastine besilate
Cromolyn Na
Lodoxamide
tromethamine
Nedocromil Na
Nonsteroidal Anti-
Inflammatory
Bromfenac
Diclofenac
Flurbiprofen
Ketorolac
Nepafenac
Otic Preparations
Misc.
Antipyrine/Benzocaine
Ciprofloxacin
Ofloxacin
Fluocinolone acetonide
Ciprofloxacin HCl/Hydrocortisone
Ciprofloxacin/Dexamethasone
Neomycin/Polymyxin B/Hydrocortisone
Recombinant
Human Nerve
Growth Factor
Cenegermin
Selective VEGF
Antagonist
Aflibercept
Pegaptanib Na
Ranibizumab
Steroid/ Antibiotic Bacitracin/Neomycin/Polymyxin
B/Hydrocortisone
Dexamethasone/Tobramycin
Loteprednol/Tobramycin
Neomycin/Polymyxin B/Dexamethasone
Neomycin/Polymyxin B/Hydrocortisone
Sulfacetamide/Prednisolone
Phosphodiesterase-5 enzyme inhibitors
Phosphodiesterase
-5 enzyme
inhibitors
Avanafil
Sildenafil
Tadalafil
Vardenafil
Taking for Pulmonary Arterial
Hypertension (PAH) indication:
Recommend to continue regimen
throughout the perioperative period
Taking for BPH
Recommend to coordinate
perioperative management plan with
anesthesiologist, surgeon, and
prescribing provider
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Taking for other indications:
Recommend to hold therapy five
days prior to and the day of surgery
in all patients
Pheochromocytoma Agents
Tyrosine
Hydroxylase
Inhibitor
Metyrosine Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon, and
prescribing provider
Alpha1-Blocker Phenoxybenzamine HCL
Phentolamine Mesylate
Renin Angiotensin System Antagonists
Angiotensin
Converting Enzyme
(ACE) Inhibitors
Benazepril
Captopril
Cilazapril
Enalapril Enalaprilat
Fosinopril
Lisinopril
Moexipril
Perindopril
Quinapril
Ramipril
Trandolapril
Significant Heart Failure (American
College of Cardiology
Foundation/American Heart
Association (ACCF/AHA) heart
failure staging system Stage D, or
New York Heart Association (NYHA)
Functional Classification III or IV) or
History of High Blood Pressure
(systolic ≥180 mmHg or diastolic
≥120 mmHg):
Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, prescribing
provider
For all other indications:
Hold for 24 hours prior to surgery
and the day of surgery
Angiotensin II
receptor blockers
Candesartan
Losartan
Olmesartan
Valsartan
Direct renin
inhibitors
Aliskiren
Neprilysin inhibitor Sacubitril Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, prescribing
provider
Selective
Aldosterone
Receptor
Antagonists
Eplerenone It is reasonable to continue regimen
throughout the perioperative period
Respiratory Agents
Antifibrotic agents Pirfenidone Recommend to coordinate
perioperative medication
management plan with surgeon and
prescribing provider
Arylalkylamine
decongestants
Phenylephrine
Pseudoephedrine
Recommend to hold therapy the day
of surgery
Inhaled
anticholinergics
Aclidinium
Ipratropium
Revefenacin
Tiotropium
Umeclidinium
Recommend to continue regimen
throughout the perioperative period
and to administer on the morning of
surgery
Expectorants Guaifenesin
Potassium iodide
It is reasonable to continue regimen
throughout the perioperative period
Inhaled
corticosteroids
Beclomethasone
Budesonide
Ciclesonide
Flunisolide
Fluticasone
Mometasone
Recommend to continue regimen
throughout the perioperative period
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Inhaled
sympathomimetics
Albuterol
Arformoterol
Ephedrine
Epinephrine
Formoterol
Indacaterol
Isoproterenol
Levalbuterol
Metaproterenol
Olodaterol
Pirbuterol
Salmeterol
Terbutaline
Vilanterol
Recommend to continue regimen
throughout the perioperative period
and to administer on the morning of
surgery
Interleukin-5
receptor
antagonists
Mepolizumab
Reslizumab
Recommend to continue regimen
throughout the perioperative period
Leukotriene
modifiers
Montelukast
Zafirlukast
Zileuton Recommend to continue regimen
throughout the perioperative period
and administer on the morning of
surgery
Lung surfactants Beractant
Calfactant
Lucinactant
Poractant
It is reasonable to continue regimen
throughout the perioperative period
Monoclonal
antibodies (IgE
inhibitor)
Omalizumab Recommend to continue regimen
throughout the perioperative period
Mucolytics Acetylcysteine Dornase alfa Recommend to continue regimen
throughout the perioperative period
Non-narcotic
antitussives
Benzonatate
Dextromethorphan
It is reasonable to continue regimen
throughout the perioperative period
PDE-4 inhibitor Roflumilast Recommend to continue regimen
throughout the perioperative period
Respiratory
enzymes
Aplha1-proteinase inhibitor Recommend to continue regimen
throughout the perioperative period
Tyrosine kinase
inhibitor
Fostamatinib
Nintedanib
Recommend to continue regimen
throughout the perioperative period
Xanthine
derivatives
Aminophylline
Dyphylline
Theophylline Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon, and
prescribing provider
Sedatives and Hypnotics
Sedatives and
hypnotics
Amobarbital
Butabarbital
Pentobarbital
Phenobarbital
Secobarbital
Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, and prescribing
provider
Nonbarbiturate
sedatives and
hypnotics
Chloral hydrate
Dexmedetomidine
Eszopiclone
Lemborexant
Ramelteon
Suvorexant
Tasimelteon
Zaleplon
Zolpidem
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Selective Serotonin Reuptake Inhibitors (SSRIs) & Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)
SSRI Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
Vilazodone
Recommend to coordinate
perioperative medication
management plan with surgeon,
anesthesiologist, and prescribing
provider
SNRI Desvenlafaxine
Duloxetine
Levomilnacipran
Milnacipran
Venlafaxine
Skeletal Muscle Relaxants
Direct acting Dantrolene Recommend to continue regimen
throughout the perioperative period
Centrally acting Baclofen
Carisoprodol
Chlorzoxazone
Cyclobenzaprine
Diazepam
Metaxalone
Methocarbamol
Orphenadrine
Tizanidine
It is reasonable to continue regimen
throughout the perioperative period
Tetra-cyclic antidepressants
Tetra-cyclic
antidepressants
Maprotiline
Mirtazapine
It is reasonable to continue regimen
throughout the perioperative period
Toxins
Botulinum toxins:
Type A
AbobotulinumtoxinA
IncobotulinumtoxinA
OnabotulinumtoxinA
PrabotulinumtoxinA
It is reasonable to hold 48 hours
prior to surgery and not resume until
approved by surgeon
Type B toxin Rimabotulinum toxin B
Tri-cyclic antidepressants
Tricyclic
antidepressants
Amitriptyline
Amoxapine
Clomipramine
Desipramine
Doxepin
Imipramine
Nortriptyline
Protriptyline
Trimipramine
It is reasonable to continue regimen
throughout the perioperative period
Vasodilators
Endothelin
Receptor
Antagonist
Ambrisentan
Bosentan
Macitentan
Recommend to continue regimen
throughout the perioperative period
Human B-Type
Natriuretic Peptide
Nesiritide Recommend to continue regimen
throughout the perioperative period
Nitrates Amyl Nitrate
Isosorbide Dinitrate
Isosorbide Mononitrate
Nitroglycerin
Recommend to continue regimen
throughout the perioperative period
Peripheral
Vasodilators
Hydralazine
Isoxsuprine
Minoxidil
Papaverine
Recommend to coordinate
perioperative medication
management plan with surgeon,
anesthesiologist and prescribing
provider
Prostanoids Epoprostenol
Iloprost
Selexipag
Treprostinil
Recommend to coordinate
perioperative medication
management plan with surgeon,
anesthesiologist and prescribing
provider
Soluble Guanylate
Cyclase Stimulator
Riociguat Recommend to coordinate
perioperative medication
management plan with surgeon,
anesthesiologist and prescribing
provider
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Vasopressors Angiotensin II
Dobutamine
Dopamine
Droxidopa
Ephedrine
Epinephrine
Isoproterenol
Norepinephrine
Phenylephrine
Recommend to coordinate
perioperative medication
management plan with surgeon,
anesthesiologist and prescribing
provider
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Appendix B: Treatment Algorithm for the Timing of Elective Noncardiac
Surgery in Patients With Coronary Stents
From: Perioperative Medication Management – Adult/Pediatric – Inpatient/Ambulatory
Clinical Practice Guideline
Last Reviewed 2/2020; Last Updated 4/2016
Contact information: Philip J. Trapskin, PharmD, Phone Number: (608) 263-1328,
PTrapskin@uwhealth.org
Reference: Bittl JA, Baber U, Bradley SM, Wijeysundera DN. Duration of Dual Antiplatelet Therapy: A Systematic Review
for the 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary
Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical
Practice Guidelines. J Am Coll Cardiol. Mar 22 2016.
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59
Appendix C: Methylene Blue and Serotonin Syndrome
From: Perioperative Medication Management – Adult/Pediatric – Inpatient/Ambulatory
Clinical Practice Guideline
Last Reviewed 2/2020; Last Updated 6/2019
Contact information: Philip J. Trapskin, PharmD, Phone Number: (608) 263-1328, PTrapskin@uwhealth.org
Summary:
Although the exact mechanism of this drug interaction is unknown, methylene blue inhibits the action of
monoamine oxidase A - an enzyme responsible for breaking down serotonin in the brain. It is believed that when
methylene blue is given to patients taking serotonergic psychiatric medications, high levels of serotonin can build up
in the brain, causing toxicity. See Table 1. Psychiatric medications with serotonergic activity.
• In emergency situations requiring life-threatening or urgent treatment with methylene blue (as described
above), the availability of alternative interventions should be considered and the benefit of methylene blue
treatment should be weighed against the risk of serotonin toxicity. If methylene blue must be administered to a
patient receiving a serotonergic drug, the serotonergic drug must be immediately stopped, and the patient should
be closely monitored for emergent symptoms of CNS toxicity for two weeks (five weeks if fluoxetine [Prozac] was
taken), or until 24 hours after the last dose of methylene blue, whichever comes first.
• In non-emergency situations when non-urgent treatment with methylene blue is contemplated and planned,
the serotonergic psychiatric medication should be stopped to allow its activity in the brain to dissipate. Most
serotonergic psychiatric drugs should be stopped at least 2 weeks in advance of methylene blue treatment.
Fluoxetine (Prozac), which has a longer half-life compared to similar drugs, should be stopped at least 5 weeks
in advance
• Possible signs/symptoms of Serotonin Syndrome: mental status changes, muscle twitching, excessive sweating,
shivering or shaking, diarrhea, ataxia, fever
• Treatment with the serotonergic psychiatric medication may be resumed 24 hours after the last dose of
methylene blue
• Serotonergic psychiatric medications should not be started in a patient receiving methylene blue. Wait until 24
hours after the last dose of methylene blue before starting the antidepressant.
References:
1. FDA Drug Safety Communication. http://www.fda.gov/Drugs/DrugSafety/ucm263190.htm#Hcp. Updated
10/20/2011.
2. Bach KK, Lindsay FW, Berg LS, Howard RS. Prolonged postoperative disorientation after methylene blue
infusion during parathyroidectomy. Anesth Analg. 2004;99:1573-4.
3. Kartha SS, Chacko CE, Bumpous JM, Fleming M, Lentsch EJ, Flynn MB. Toxic metabolic encephalopathy
after parathyroidectomy with methylene blue localization. Otolaryngol Head Neck Surg. 2006;135:765-8.
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Table 1. Psychiatric medications with serotonergic activity
Generic name Found in Brand name(s)
Selective Serotonin Reuptake Inhibitors (SSRIs)
paroxetine Paxil, Paxil CR, Pexeva
fluvoxamine Luvox, Luvox CR
fluoxetine Prozac, Sarafem, Symbyax
sertraline Zoloft
citalopram Celexa
escitalopram Lexapro
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
venlafaxine Effexor, Effexor XR
desvenlafaxine Pristiq
duloxetine Cymbalta
Tricyclic Antidepressants (TCAs)
amitriptyline Amitid, Amitril, Elavil, Endep, Etrafon, Limbitrol, Triavil
desipramine Norpramin, Pertofrane
clomipramine Anafranil
imipramine Tofranil, Tofranil PM, Janimine, Pramine, Presamine
nortriptyline Pamelor, Aventyl hydrochloride
protriptyline Vivactil
doxepin Sinequan, Zonalon, Silenor
trimipramine Surmontil
Monoamine Oxidase Inhibitors (MAOIs)
isocarboxazid Marplan
phenelzine Nardil
selegiline Emsam, Eldepryl, Zelapar
tranylcypromine Parnate
Other Psychiatric Medications
amoxapine Asendin
maprotiline Ludiomil
nefazodone Serzone
trazodone Desyrel, Oleptro, Trialodine
bupropion Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban, Aplenzin
buspirone Buspar
vilazodone Viibryd
mirtazapine Remeron, Remeron Soltab
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Appendix D: Aminolevulinic acid and Phototoxicity
From: Perioperative Medication Management – Adult/Pediatric – Inpatient/Ambulatory Clinical Practice
Guideline
Last Reviewed 2/2020; Last Updated 6/2019
Contact information: Philip Trapskin, PharmD, Phone Number: 608-263-1328; PTrapskin@uwhealth.org
Summary
Use of aminolevulinic acid is associated with photosensitivity. Patients exposed to photosensitizing
agents may experience phototoxic skin reactions (e.g. severe sunburn). Due to the increased risk of
phototoxic reactions, administration of other phototoxic medications should be avoided whenever possible
for 24 hours before and after systemic aminolevulinic acid administration.
Medications associated with inducing phototoxicity are listed in the table below. Coordinate a
management plan for these medications with the surgeon and prescribing physician.
Generic name Therapeutic class
Acitretinoin Retinoid
Adapalene Retinoid
Afatinib Antineoplastic; tyrosine kinase inhibitor
Alitretinoin Retinoid
Alprazolam Anxiolytic
Aminolevulinic acid topical Photosensitizing agent
Amiodarone Anti-arrhythmic
Amlodipine Calcium channel blocker
Aripiprazole Antipsychotic
Atorvastatin HMG Co-A reductase inhibitor
Atovaquone/proguanil Anti-malarial
Bexarotene Retinoid
Bicalutamide Antineoplastic; antiandrogen
Cabazitaxel Antineoplastic; antimitotic agent
Calcitriol Vitamin D analog
Candesartan Angiotensin II receptor blocker
Capecitabine Antineoplastic; anti-metabolite
Carbamazepine Anticonvulsant
Cefotaxime Beta-lactam antimicrobial
Ceftazidime Beta-lactam antimicrobial
Celecoxib Non-steroidal anti-inflammatory
Chlordiazepoxide Anxiolytic
Chloroquine Anti-malarial
Chlorothiazide Diuretic
Chlorpromazine Antipsychotic
Chlorthalidone Diuretic
Ciprofloxacin Fluoroquinolone
Citalopram Antidepressant
Clomipramine Antidepressant
Clopidogrel Antiplatelet
Clozapine Antipsychotic
Cobimetinib Antineoplastic; MEK inhibitor
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Generic name Therapeutic class
Crizotinib Antineoplastic; tyrosine kinase inhibitor
Dacarbazine Antineoplastic; anti-metabolite
Dapsone Antimicrobial
Demeclocycline Tetracycline
Diclofenac Non-steroidal anti-inflammatory
Diflunisal Non-steroidal anti-inflammatory
Diltiazem Calcium channel blocker
Diphenhydramine Antihistamine
Docetaxel Antineoplastic; antimitotic agent
Doxorubicin Antineoplastic; antimitotic agent
Doxycycline Tetracycline
Dronedarone Anti-arrhythmic
Eculizumab Monoclonal antibody
Efavirenz Antiretroviral
Enalapril Angiotensin II converting enzyme inhibitor
Epirubicin Antineoplastic; antimitotic agent
Eravacycline Tetracycline
Erlotinib Antineoplastic; tyrosine kinase inhibitor
Escitalopram Antidepressant
Esomeprazole Proton pump inhibitor
Ethinyl estradiol Contraceptive hormone
Etodolac Non-steroidal anti-inflammatory
Fenofibrate Fibrate
Fenoprofen Non-steroidal anti-inflammatory
Fluorouracil Antineoplastic; anti-metabolite
Fluoxetine Antidepressant
Flupentixol Antipsychotic
Fluphenazine Antipsychotic
Flurbiprofen Non-steroidal anti-inflammatory
Flutamide Antineoplastic; antiandrogen
Fluvoxamine Antidepressant
Furosemide Diuretic
Glimepiride Anti-diabetic
Glipizide Anti-diabetic
Glyburide Anti-diabetic
Griseofulvin Antifungal
Haloperidol Antipsychotic
Hydrochlorothiazide Diuretic
Hydroxychloroquine Anti-malarial
Hydroxyurea Antineoplastic
Ibuprofen Non-steroidal anti-inflammatory
Imatinib Antineoplastic; tyrosine kinase inhibitor
Imipramine Antidepressant
Indapamide Diuretic
Indomethacin Non-steroidal anti-inflammatory
Irbesartan Angiotensin II receptor blocker
Isoniazid Anti-tuberculosis
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Generic name Therapeutic class
Isotretinoin Retinoid
Itraconazole Antifungal
Ketoconazole Antifungal
Ketoprofen Non-steroidal anti-inflammatory
Ketorolac Non-steroidal anti-inflammatory
Leflunomide Anti-inflammatory
Levofloxacin Fluoroquinolone
Losartan Angiotensin II receptor blocker
Meclofenamate Non-steroidal anti-inflammatory
Meclofenamide sodium Non-steroidal anti-inflammatory
Mefenamic acid Non-steroidal anti-inflammatory
Meloxicam Non-steroidal anti-inflammatory
Mesalamine Anti-inflammatory
MESNA Chemoprotective agent
Metformin Anti-diabetic
Methyldopa Antihypertensive; centrally acting agent
Metolazone Diuretic
Minocycline Tetracycline
Moxifloxacin Fluoroquinolone
Nabumetone Non-steroidal anti-inflammatory
Naproxen Non-steroidal anti-inflammatory
Nifedipine Calcium channel blocker
Ofloxacin Fluoroquinolone
Olanzapine Antipsychotic
Olmesartan Angiotensin II receptor blocker
Omadacycline Tetracycline
Oxaprozin Non-steroidal anti-inflammatory
Paclitaxel Antineoplastic; antimitotic agent
Panitumumab Antineoplastic; monoclonal antibody
Pantoprazole Proton pump inhibitor
Paroxetine Antidepressant
Perphenazine Antipsychotic
Phenelzine Antidepressant
Pirfenidone Anti-inflammatory
Piroxicam Non-steroidal anti-inflammatory
Porfimer Antineoplastic
Pravastatin HMG Co-A reductase inhibitor
Prochlorperazine Antipsychotic
Promethazine Antihistamine
Pyrazinamide Anti-tuberculosis
Quinapril Angiotensin II converting enzyme inhibitor
Quinidine Anti-malarial
Quinine Anti-malarial
Ramipril Angiotensin II converting enzyme inhibitor
Ranitidine Antihistamine
Risperidone Antipsychotic
Sarecycline Tetracycline
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Generic name Therapeutic class
Sertraline Antidepressant
Simvastatin HMG Co-A reductase inhibitor
Sitagliptin Anti-diabetic
St. John’s Wort Herbal
Sulfadiazine Antimicrobial; sulfa derivative
Sulindac Non-steroidal anti-inflammatory
Tegafur Antineoplastic; anti-metabolite
Telmisartan Angiotensin II receptor blocker
Tenofovir Antiretroviral
Terbinafine Antifungal
Tetracycline Tetracycline
Thioridazine Antipsychotic
Tocilizumab Monoclonal antibody
Tolbutamide Anti-diabetic
Tolmetin Non-steroidal anti-inflammatory
Tretinoin Retinoid
Triamterene Diuretic
Trifluoperazine Antipsychotic
Trimethoprim Antimicrobial
Trimethoprim/sulfamethoxazole Antimicrobial; sulfa derivative
Valsartan Angiotensin II receptor blocker
Vandetanib Antineoplastic; tyrosine kinase inhibitor
Vemurafenib Antineoplastic; BRAF kinase inhibitor
Venlafaxine Antidepressant
Verteporfin Ophthalmic agent
Vinblastine Antimitotic agent
Voriconazole Antifungal
References:
1. Blakely KM, Drucker AM, Rosen CF. Drug-induced phototoxicity- an update: culprit drugs, prevention, and management.
Drug Saf. 2019;42:827-847.
2. Lexicomp Online, Hudson, Ohio: Wolters Kluwer Clinical Drug Information, Inc.; accessed March 4, 2020.
3. Monteiro M, Rato M, Martins, C. Drug induced photosensitivity: photoallergic and phototoxic reactions. Clin Dermatol.
2016;34:571-581.
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Introduction
Scope
Definitions
Recommendations
Methodology
Collateral Tools & Resources
Appendix A: Perioperative Medication Management
Appendix B: Treatment Algorithm for the Timing of Elective Noncardiac Surgery in Patients With Coronary Stents
Appendix C: Methylene Blue and Serotonin Syndrome
Appendix D: Aminolevulinic acid and Phototoxicity
References