Perioperative Medication Plan

Drug + indication → last dose → procedure-day plan → restart condition and owner.

Find the high-consequence decision

before assigning a hold

Key
decisions

PCI / thromboembolismInterruption authority, current-regimen surgical feasibility and harm of delay.

AnticoagulantActual last dose, clearance, bleed risk and catheter restrictions.

HF / BPCurrent congestion/perfusion. Reason to continue or withhold.

Key
decisions

Metabolic therapySGLT2 exposure, fasting insulin, glucose checks and aspiration assessment.

TransplantGraft trajectory, interacting drugs, immunosuppression route and pharmacy review.

RestartHemostasis, intake, perfusion and laboratory gates.

Reconcile before executing

actual exposure, actual procedure

1 · Verify usePrescriptions and actual use, weekly injections, patches, infusions, supplements and recent antibiotics. Include combination tablets.

2 · Confirm constraintsOperation, urgency and anesthesia technique.

3 · Reassess changesShock, bleeding, AKI, prolonged fasting or a short-notice organ offer.

Sources distinguish guidelines, trials, product restrictions and individualized planning. Templates are synthesis. Related: perioperative risk • transplant • CABG/PCI evidence • cardiac-surgery holds.

Indication + perfusion + congestion determine the dose decision.

Before surgery / before restart

avoid blanket holds

Drug	Before surgery	Reassess
Beta blocker	Continue if tolerated. Newly indicated: optimally >7 days before. No routine operative-day initiation.	Rate, conduction, perfusion, BP
ACEi/ARB	Controlled HTN + elevated-risk surgery: consider omission 24 hours before. HFrEF: continuation reasonable if tolerated.	BP, K, kidney trend, restart owner
Sacubitril/valsartan	HF/anesthesia decision: BP, perfusion, kidneys	Dose/tolerance. ACEi↔ARNI ≥36-hour separation. No duplicate ARB.
Loop/thiazide	Congestion may need treatment. Morning hold may suit euvolemia/depletion. Account for fasting/fluid shifts.	Volume, I/O, creatinine, electrolytes, oral/IV route
MRA / potassium	K, kidneys and concurrent K-raising drugs	Continue/restart only when K/kidneys permit
Clonidine / rate drugs	Prevent withdrawal. Check beta blocker + diltiazem/verapamil/digoxin bradycardia.	NPO route and hemodynamic tolerance

STOP-or-NOT

ACEi/ARB trial, not an ARNI rule

Population

2,222

Major noncardiac surgery

28-day death / major complications

22% / 22%

Continue / stop 48 hours before

Vasopressor-treated intraoperative hypotension

54% / 41%

Continue / interrupt

Limits Few HF patients, no ARNI strategy. No universal HFrEF/ARNI hold.
Individualize Diuretic/MRA dosing depends on volume, K, kidneys and instability. No fixed washout.
Switching safeguard 36-hour ACEi/ARNI separation prevents angioedema during switching. It is not a preoperative ARNI washout.

Authorize interruption before calculating washout.

PCI timing and protection

date • indication • anatomy

Context	Plan
Elective DES + interruption	Prefer ≥12 months after ACS, ≥6 months after chronic-disease PCI
Time-sensitive DES	Consider ≥3 months when delay is more harmful
Time-sensitive surgery: BMS within 30 days / DES <3 months	Continue DAPT unless bleeding outweighs thrombosis protection
Aspirin after PCI	Continue low dose if feasible

Verify Date, ACS/chronic disease, anatomy/complexity, regimen and consequences of delay or declining an organ.

Authorized platelet interruption

2024 AHA/ACC recovery anchors

Aspirin

~4 days

Clopidogrel

5-7 days

Prasugrel

7-10 days

Ticagrelor

3-5 days

Neuraxial: 5 days

Restart and exceptions

reassess daily during interruption

Restart order First agent, hemostatic gate, intended time, loading-dose decision, catheter restrictions and interventional owner.
Bleeding/reoperation Calendar target alone is insufficient.

Bridging Heparin cannot replace DAPT. IV antiplatelet bridging is specialist-selected, not routine.
No PCI Distinguish primary/secondary prevention and bleed consequence. No routine aspirin initiation solely for surgery.

High-risk transplant offer → joint surgery/anesthesia/interventional decision. Abbreviated DAPT does not validate stopping all antiplatelets for transplant. Evidence and limits.

Count full omitted days plus no operative-day dose. These are elective surgical, not neuraxial, intervals.

Usual DOAC interruption

appropriate drug / renal candidates

Agent and clearance	Low/moderate bleeding risk	High bleeding risk
Apixaban/rivaroxaban	Omit 1 full day before	Omit 2 full days before
Edoxaban	Often 1 day before under CHEST	Often 2 days before under CHEST
Dabigatran, CrCl ≥50 mL/min	Omit 1 full day before	Omit 2 full days before
Dabigatran, CrCl 30-49 mL/min	Omit 2 full days before	Omit 4 full days before

Scope Minimal-risk procedures may permit continuation or less interruption.

Last dose → operation → restart

worked example

1 · Friday 20:00Final twice-daily apixaban dose for high-risk Monday 08:00 surgery. Suitable kidneys, no neuraxial procedure.

2 · Saturday–MondayOmit Saturday/Sunday and Monday morning → 60 hours, not exactly 48. Confirm actual date/time.

3 · Restart~24 hours low/moderate risk or 48-72 hours high risk. Hemostasis, oral route, clearance and catheter/anesthesia gates.

No routine bridge No routine therapeutic heparin bridging. Interim VTE prophylaxis is separate.

PAUSE boundaries

prospective AF cohort

Population 3,007 AF patients, no therapeutic bridging.
30-day major bleeding Apixaban 1.35% • dabigatran 0.90% • rivaroxaban 1.85%.

Not enrolled CrCl <25 mL/min for apixaban, <30 mL/min for dabigatran/rivaroxaban. No edoxaban.
Reassess Dialysis, unstable AKI, liver transplant, interactions or altered exposure. Verify clearance and dose before post-transplant restart. These AF data do not establish safety for recent VTE or mechanical valves.

Routine AF bridging adds bleeding without usual thromboembolic benefit.

Warfarin clock

interruption and bridging are separate

1 · HoldUsually 5 days before a procedure needing interruption. Verify INR and define correction if above target.

2 · RestartOften 12-24 hours after surgery when hemostasis and oral route permit. Effect is delayed.

3 · Bridge?Decide from indication, event date and exceptional risk.

CHEST Against routine AF bridging. Conditional suggestion against bridging for elective mechanical-valve/VTE interruption.
2024 AHA/ACC Individual consideration in selected very-high-risk patients.

Specialist review Mechanical mitral/older valves, recent embolism, VTE or LV thrombus.
Document rationale Guidelines differ in exceptional groups. State why the chosen branch applies.

BRIDGE

1,884 AF patients

Arterial thromboembolism

0.4% / 0.3%

No bridge / bridge

Major bleeding

1.3% / 3.2%

No bridge / bridge

Limits Mechanical valves and recent stroke/systemic embolism excluded. Very-high-risk patients underrepresented.

If bridging is selected

write the full schedule

Phase	Required order
Before	Indication • drug/dose • renal adjustment • start/final dose
Procedure	Coagulation checks • separate neuraxial/catheter plan
After	Hemostasis • therapeutic versus prophylactic timing • warfarin overlap/INR

Distinctions VTE prophylaxis is not therapeutic bridging. Severe renal impairment can change LMWH agent/timing.
Some procedures need no interruption Pacemaker/ICD implantation or generator change may favor continued warfarin over interruption plus heparin bridging. Device-team INR plan required.
Discharge hold Reason, reassessing clinician and next contact/INR date. Prevent accidental permanent discontinuation.

Key
decisions

Surgical clockHemostasis + procedure-specific postoperative restart interval.

Anesthesia clockASRA needle placement/catheter removal → next-dose interval. Both clocks must be satisfied.

ASRA fifth-edition DOAC anchors

neuraxial + deep plexus/peripheral blocks

DOAC category	Minimum pre-block interval	Needle/removal to first postoperative dose
High-dose apixaban or rivaroxaban	≥72 hours	≥24 hours
Low-dose apixaban	≥36 hours	≥6 hours
Low-dose rivaroxaban	≥24 hours, or ≥30 hours if CrCl <30 mL/min	≥6 hours
High-dose dabigatran, CrCl ≥50	≥72 hours	≥24 hours
High-dose dabigatran, CrCl 30-49	≥120 hours	≥24 hours

Category and exceptions

anesthesia adjudication

Dose category Dose + indication, not tablet strength alone.
Dabigatran CrCl <30 Avoid blocks unless ASRA’s drug-level criterion is met.
Reassess Shorter hold or a dose given with catheter in place needs a new anesthesia plan before removal. Traumatic puncture: manufacturers delay the next apixaban dose ≥48 hours, rivaroxaban ≥24 hours. A longer surgical interval still governs.

Aspirin alone No ASRA interval. Coagulopathy, thrombocytopenia and combined drugs still matter.
Ticagrelor 5 days before needle placement. Verify P2Y12 catheter/loading rules.
Other agents Edoxaban, low-dose dabigatran, UFH, LMWH and fondaparinux require their complete ASRA pathway.

No reversal solely for routine neuraxial anesthesia. ASRA advises against it. Display both clocks in the order.

Normal glucose does not exclude SGLT2-associated ketoacidosis. Applies to HF, CKD and diabetes.

Planned surgery / prolonged fasting

write the final dose

Canagliflozin / dapagliflozin / empagliflozin

≥3 days

Hold before surgery

Ertugliflozin

≥4 days

Hold before surgery

Original schematic. Friday 08:00 → Monday 08:00 is 72 hours. This meets a 3-day interval, not the 4-day ertugliflozin interval. Confirm actual times.

Urgent surgery / organ offer

incomplete hold

1 · Handoff exposureAgent, actual last dose, recent insulin, nutrition, illness and volume state.

2 · Check metabolismNausea, vomiting, abdominal pain, tachypnea or unexplained acidosis → ketones + acid-base assessment despite normal glucose.

3 · Treat and decideSuspected ketoacidosis: stop drug, treat through inpatient pathway. Team weighs metabolic illness against surgical urgency.

Restart gate

recovery, not the calendar

Labels Clinical stability + resumed intake. Confirm nutrition/hydration and resolution of ketoacidosis concerns.
Residual risk Glucosuria and ketoacidosis can persist after stopping. A completed hold does not exclude postoperative ketoacidosis. Recheck volume, kidneys and indication.
Discharge Explicit restart instruction, or named reviewer and required recovery condition.

Key
decisions

Type 1 diabetesMaintain basal insulin during fasting.

ADA 2026Perioperative glucose target 100-180 mg/dL. Hold metformin and other oral glucose-lowering agents on the procedure day.

Fasting insulin plan

individualize actual doses

Component	Action
Basal	Common starting adjustment: 75-80% long-acting analog or half NPH. Specify units and timing. Individualize for regimen and hypoglycemia risk, especially type 1 diabetes.
Prandial	Hold meal doses while NPO. Correctional or IV insulin as appropriate.
Pump	Continue only if safe. Establish alternative insulin before stopping.
Monitoring	At least every 2-4 hours while NPO, more often if needed. CGM alone is insufficient intraoperatively.

Specify dose, frequency and team. ADA 2026 updates the practical plan alongside older cardiac guidance.

Metformin + iodinated contrast

label pathway, separate from operative-day hold

Interrupt at/before contrast eGFR 30-60 mL/min/1.73 m², history of liver disease/alcoholism/HF, or intra-arterial contrast.
Restart Recheck eGFR at 48 hours. Resume only if stable. Contraindicated at eGFR <30.

Longer hold Instability, hypoxia, AKI or hepatic dysfunction. Recheck intake, renal function and contraindications after major surgery.
Transplant recovery Steroids, graft function and nutrition rapidly change insulin needs. Recalculate through recovery and before discharge.

Select one aspiration pathway. Liquid diet and clear liquids are different instructions.

Keep guidance distinct

continuation + fasting

Key
decisions

Multisociety 2024Continue if gastric-emptying/aspiration risk is not elevated.

Higher riskConsider ≥24-hour liquid diet, gastric ultrasound or adjusted airway plan.

Key
decisions

SPAQI 2025Continue without significant GI symptoms. Fast from solids for 24 hours, allowing only clear liquids.

Clear-liquid intervals≥10% carbohydrate: 8 hours. Low/no carbohydrate: 4 hours. Source-specific, not universal.

Assess the actual risk

drug + symptoms + anesthesia

Record Agent/dose, last administration, escalation, nausea/vomiting, oral tolerance and other delayed-emptying conditions.
Higher-risk features Escalation, higher dose, weekly dosing, GI symptoms or gastric-emptying disorder.
If withholding Optimal duration unknown. Multisociety suggests older daily-day-of/weekly-7-day approach. Holding does not establish an empty stomach.
Uncertain contents / urgency Gastric ultrasound if available, aspiration-focused anesthesia or feasible deferral.

Restart

diet + tolerance

SPAQI gate Usual diet resumed, GI tolerance confirmed.
Reassess dose Prolonged interruption or high maintenance dose → prescriber review. Ileus/acute illness requires a new decision.
SPAQI scope Significant symptoms include severe nausea, vomiting or inability to tolerate intake. Fullness/early satiety alone is not this definition. Gastroparesis or high-dose opioids need a separate assessment.
Patient instruction Specify exact food/fluid restrictions under the selected pathway.

Graft transitions change clearance, perfusion and interactions. Recheck before each important restart.

Four transplant contexts

first transplant or existing recipient

Setting	Medication consequence
Dialysis / unstable AKI	Usual DOAC intervals may not apply. Recheck renally cleared rhythm, anticoagulant and diabetes drugs.
Kidney graft recovery	Clearance may change rapidly in either direction. Recheck dose/eligibility.
Decompensated cirrhosis	Low perfusion, renal vulnerability, metabolism and product restrictions override generic continuation.
Liver graft recovery	Perfusion, kidneys/liver, coagulation, oral tolerance and new interactions.

Regimen transition First transplant: holds + new immunosuppression. Existing recipient: explicit established-drug and route plan.

Portal-hypertension beta blockade

Baveno VII, cirrhosis with ascites

Persistent SBP

<90 mm Hg

Reduce/stop NSBB or carvedilol

Persistent MAP

<65 mm Hg

Reduce/stop NSBB or carvedilol

HRS-AKI

Reduce / stop

Reintroduce/retitrate after recovery

Scope These are portal-hypertension rules, not universal cardiac beta-blocker thresholds.
ACEi/ARB Decompensated cirrhosis: hypotension/renal-failure risk. Coordinate HF indication with hepatology and transplant anesthesia.

Statin exceptions

label + liver + interactions

Continue selectively When agent, liver status and interactions permit. AHA supports monitored use for clinical CAD in appropriate cirrhosis patients.
Rosuvastatin Contraindicated in acute liver failure/decompensated cirrhosis. Cyclosporine: maximum 5 mg daily from increased exposure/myopathy risk.
Before restart Review actual product, dose and toxicity risk.

New prophylaxis can make the old antiarrhythmic regimen unsafe.

Do not miss the interaction

actionable conflicts

Exposure	Required action
Dofetilide + TMP/SMX	Contraindicated, including trimethoprim alone. Verapamil and hydrochlorothiazide also contraindicated.
Dofetilide interruption / AKI	Recheck CrCl, QT and interactions. Initiation/reinitiation: ≥3 days monitored care. Do not resume old dose blindly.
Sotalol interruption / renal change	CrCl determines interval. Review QT, K/Mg, bradycardia. Initiation/reinitiation: ≥3 days or steady state, continuous ECG/resuscitation capability.
Amiodarone / diltiazem / verapamil + tacrolimus	Tacrolimus may rise. Review dose/troughs when the inhibitor starts, stops or changes.
Colchicine + P-gp/strong CYP3A4 inhibitor	Contraindicated with renal/hepatic impairment. Cyclosporine/antimicrobials can cause serious toxicity. Review statin-associated myotoxicity.

Before the first postoperative dose

EP + transplant

Current physiology Rhythm/rate, conduction, relevant QT, renal trend and K/Mg.
Current exposure New drugs, duration of interruption, indicated drug levels.

Tacrolimus itself QT/electrolyte concerns. Follow label monitoring for interacting cardiac drugs. Both starting and stopping inhibitors change exposure.
Restart authority Label-directed monitoring. EP/transplant teams determine missed-dose threshold and alternative rhythm/prophylaxis strategy. No universal restart rule.

NPO requires a route plan, not silent interruption of transplant therapy.

Before fasting

transplant-team instructions

1 · VerifyFormulation, schedule, recent troughs, actual last dose and route.

2 · Plan conversionTacrolimus products are not automatically interchangeable. IV conversion is not universally mg-for-mg.

3 · Assign pharmacyConversion, interactions and monitoring. Intentional change needs indication, rejection/infection assessment, prescriber and follow-up.

Interactions and wound healing

whole-regimen review

Issue	Action
Tacrolimus + strong CYP3A inhibitors	Azoles, clarithromycin, ritonavir → increased exposure. Review dose and frequent troughs.
Tacrolimus + inducers	Rifampin/rifabutin → lower exposure. Levels/dose review when starting or stopping.
Tacrolimus + ACEi/ARB/MRA/K	Monitor potassium/kidneys. Reassess combined K-raising regimen.
Sirolimus / mTOR regimen	Wound-healing concern. Sirolimus label: delayed healing, lymphocele and dehiscence. Transplant-specific hold/substitution/restart plan.

Glucocorticoids

preserve + cover + reconcile

Baseline Preserve regimen or route equivalent. Assess adrenal risk from exposure and prior testing.
2024 ESE/Endocrine Society Current/recent users with unexcluded glucocorticoid-induced adrenal insufficiency need stress coverage.
Parenteral coverage General/regional anesthesia, major stress or prolonged inability to take oral medication.
Avoid duplication Reconcile transplant induction. Specify regimen and taper/return to baseline. Suspected adrenal crisis with instability needs prompt acute treatment.

Key
decisions

Continuous prostacyclinILTS: continue all pretransplant IV/subcutaneous infusions throughout liver transplantation.

Oral/inhaled PAH therapyContinue postoperatively as feasible. PH team directs any substitution/adjustment. NPO triggers route planning.

Protect every transfer

verified handoff + backup

Transition	Check
Home → OR	Drug • concentration • rate • access • supply • operator
Pump/line change	Continuous delivery • verified handoff • backup pump/supply • emergency contact
NPO / ileus	Deliverable oral/inhaled doses • PH-directed alternative
Recovery	RV/perfusion • entire regimen • PH reassessment

Indication and interaction

before giving nitrates

Sildenafil for PAH Essential disease therapy, not incidental erectile-dysfunction treatment.
Contraindicated Organic nitrates and riociguat. Check exposure before nitrates for chest discomfort.

Other cautions Hypotension and interacting therapy. Never improvise infusion interruption or conversion.
Escalate Intolerance, rising support or delivery interruption → immediate PH/transplant/anesthesia review. Agree on RV support, monitoring and recovery location.

Urgent reversal starts with actual exposure and the time available.

Before choosing reversal

agent • time • clearance

1 · VerifyAgent/dose, actual last dose, kidneys/liver, bleeding, urgency and useful delay.

2 · Assess assaysNormal global coagulation tests do not exclude DOAC effect. Prompt drug-specific tests may inform reversal.

3 · ActDo not delay necessary urgent hemostatic treatment. No single assay threshold certifies every transplant/operation.

Reversal map

indication + thrombosis risk

Exposure	Approach
Warfarin	4-factor PCC labeled for urgent VKA reversal in major bleeding/urgent surgery. Concurrent vitamin K. INR/weight pathway.
Dabigatran	Idarucizumab for emergency surgery/urgent procedure or life-threatening/uncontrolled bleeding: 5 g IV as two 2.5-g vials.
Factor Xa DOAC	Specialists may consider 4-factor PCC off label. Weigh exposure, bleeding, urgency, evidence limits and thrombosis.

Current U.S. availability

update older tables

Andexxa U.S. commercial sales ended 22 December 2025. FDA reported serious risks outweighed benefit. Company submitted voluntary withdrawal request.
Verify formulary Confirm current availability and the specialist reversal pathway. The 2020 ACC pathway predates this FDA communication.
Organ offer Anesthesia, surgery, hematology/anticoagulation and pharmacy: decision, product, reassessment and postoperative antithrombotics. Reversal does not erase thrombosis risk.
Other clocks DAPT, SGLT2, fasting insulin, aspiration risk and uninterrupted PAH therapy require separate decisions.

Turn each hold into a dated instruction and a conditional restart.

Procedure and current state

verified facts

Procedure [ ] Date/time • urgency • anesthesia • catheter plan
Hemodynamics [ ] BP/HR • perfusion • congestion

Clearance [ ] Creatinine/CrCl and trend • liver status
Electrolytes [ ] K • Mg

Medication action

repeat for each relevant drug

Field	Complete the instruction
Drug [ ]	Name • dose • indication
Action [ ]	Continue / omit specified doses / specialist decision
Final dose [ ]	Planned calendar date/time • admission confirmation and source
Reason [ ]	Bleeding • thrombosis • perfusion • metabolic • interaction
Procedure day [ ]	Lab • route • glucose/insulin • infusion
Restart [ ]	Drug/dose • earliest time • hemostasis/catheter interval • BP/perfusion • renal/K • intake/metabolic recovery
During the gap [ ]	Prophylaxis / alternative treatment
Ownership [ ]	Decision-maker/contact • if still held at discharge: reason, reviewer/date

High-consequence handoff

one plan for patient and teams

PCI / urgent offer [ ] DAPT/interventional reviewer • OAC/SGLT2/GLP-1 exposure
Transplant [ ] Interactions/troughs • pharmacy • immunosuppression/steroid route and coverage

Metabolic / PAH [ ] Fasting insulin/glucose checks • PAH delivery/backup/PH contact
Confirm [ ] Instructions reviewed with patient and operating teams. Delete unused branches.

Reassess after bleeding, reoperation, shock, AKI, new interactions, nutrition or anesthesia changes. Handoff the revision. Close with documented restart or a reason to keep holding.