2021 Updated Medication List Update:

Revised 10/26/21
WakeMed Perioperative Services:
Outpatient Preoperative Medication Guidelines – 2021
ANTIHYPERTENSIVES/ANTIARRHYTHMICS
Drug Class Drugs in Class When to Hold Reason
Angiotensin Benazepril / amlodipine (Lotrel) HOLD Day of Surgery * Potential
Converting Enzyme Benazepril (Lotensin) Hypotension
(ACE) Inhibitors *EXCEPTION- intra-op risk
Benazepril / HCTZ (Lotensin HCT)
Captopril (Capoten®) DO NOT HOLD FOR
Captopril / HCTZ (Capozide) CATARACT SURGERY
Enalapril (Vasotec®)
Enalapril / HCTZ (Vaseretic)
Fosinopril (Monopril)
Fosinopril / HCTZ (Monopril HCT)
Lisinopril (Prinivil®, Zestril®)
Lisinopril / HCTZ (Prinzide or
Zestoretic)
Moexipril (Univasc)
Moexipril / HCTZ (Uniretic)
Perindopril (Aceon)
Quinapril (Accupril)
Quinapril / HCTZ (Accuretic)
Ramipril (Altace)
Trandolapril (Mavik)
Trandolapril/verapamil (Tarka)
Angiotensin Azilsartan (Edarbi) HOLD Day of Surgery Potential
Receptor Blockers Candesartan (Atacand) Hypotension
(ARB) Candesartan/HCTZ (Atacand HCT) intra-op risk
Azilsartan medoxomil and
chlorthalidone (Edarbyclor)
Eprosartan (Teveten)
Eprosartan/HCTZ (Teveten HCT)
Irbesartan (Avapro)
Irbesartan / HCTZ (Avalide)
Losartan (Cozaar)
Losartan / HCTZ (Hyzaar)
Olmesartan (Benicar)
Olmesartan / HCTZ (Benicar HCT)
Telmisartan (Micardis)
Telmisartan/HCTZ (Micardis HCT)
Valsartan (Diovan)
Valsartan / HCTZ (Diovan HCT)
Sacubitril / Valsartan (Entresto)
Beta Blockers Acebutolol (Sectral) Do NOT hold prior to Withdrawal/rebou
Revised 10/26/21
 Atenolol (Tenormin) surgery nd effects if held
Betaxolol (Kerlone)
Bisoprolol (Zebeta)
Carvedilol (Coreg)
Metoprolol (Lopressor, Toprol XL)
Nadolol (Corgard)
Nebivolol (Bystolic)
Penbutolol (Levatol)
Pindolol (Visken)
Propranolol (Inderal)
Sotalol (Betapace)
Calcium Channel Amlodipine (Norvasc®) Do NOT hold prior to
Blockers Clevipidine (Cleviprex®) surgery
Diltiazem (Cardizem®)
Felodipine (Plendil®)
Isradipine (Dynacirc®)
Nicardipine (Cardene®)
Nifedipine (Procardia®, Adalat®)
Nimodipine (Nimotop®)
Verapamil (Calan®, Covera-HS®,
Verelan®)
Digoxin Digoxin (Lanoxin®) Do NOT hold prior to
surgery

Tikosyn Dofetilide (Tikosyn) Do NOT hold prior to

surgery

Non-selective MAO Hydralazine (Apresoline) Do NOT hold prior to

Hydralazine surgery

Anti-anginal Isosorbide (IMDUR) Do NOT hold prior to

surgery

Alpha 1 Blocker Prazosin (Minipress) Do NOT hold prior to

Tamsulosin (Flomax) surgery

Dronedarone Dronedarone (Multaq)- Do NOT hold prior to

surgery

Revised 10/26/21
Flecanide Flecainide (Tambocor) Do NOT hold prior to
surgery

Diuretics Acetazolamide (Diamox) HOLD day of surgery Increases the risk

Amiloride of hypokalemia /
Amiloride/Hydrochlorothiazide hypovolemia
(Moduretic)
Bendroflumethiazide
Bumetanide (Bumex)
Chlorothiazide (Diuril)
Chlorthalidone (Thalitone/Hygroten )
Eplerenone (Inspra®)
Ethacrynic acid (Edecrin)
Furosemide (Lasix®)
Hydrochlorothiazide (Microzide,
Esidrix®)
Indapamide (Lozol)
Metolazone (Zaroxolyn)
Methazolamide
Methyclothiazide
Metolazone (Zaroxoxlyn)
Spironolactone (Aldactone)
Spironolactone/Hydrochlorothiazide
(Aldactazide)
Torsemide (Demadex)
Triamterene (Dyrenium)
Triamterene / HCTZ (Dyazide,
Maxzide)
Statins Atorvastatin (Lipitor) Do NOT hold prior to
Fluvastatin (Lescol) surgery
Lovastatin (Mevacor)
Pitavastatin (Livalo)
Pravastatin (Pravachol)
Rosuvastatin (Crestor)
Simvastatin (Zocor)
RESPIRATORY MEDICATIONS
Drug Class Drugs in Class When to hold Reason
Bronchodilators Albuterol (ProAir, Proventil, Use on day of surgery
Ventolin)
Albuterol/Ipratropium (Duoneb,
Combivent)
Formoterol/Budesonide (Symbicort)
Formoterol/Mometasone (Dulera)
Ipratropium (Atrovent)
Levalbuterol (Xopenex)

Revised 10/26/21
 Salmeterol (Serevent )
Salmeterol/Fluticasone (Advair)
Inhaled Steroids Beclomethasone (QVAR) Use on day of surgery
Flunisolide (AeroBid)
Fluticasone (Flovent )
Mometasone (Asmanex)
Triamcinolone (Asmacort)
ANTICOAGULANTS
Drug Class Drugs in Class When to hold Reason
Direct Thrombin Dabigatran (Pradaxa®) Do not discontinue Increased risk of
Inhibitors without consulting bleeding
prescribing physician complications.
No spinal or
epidural within
seven days of last
dose.
Factor XA Inhibitor Fondaparinux (Arixtra) Do not discontinue Increased risk of
Apixaban (Eliquis ) without consulting bleeding
Rivaroxaban (Xarelto) prescribing physician complications.
Heparin SQ Heparin SQ At least 4 hours prior to Increased risk of
surgery bleeding
complications
Low molecular Dalteparin (Fragmin) 24 hrs prior to surgery if Increased risk of
weight heparin Enoxaparin (Lovenox) on full anticoagulant bleeding; No
dose (1 mg/kg), 12 hrs spinal or epidural
prior to surgery if on DVT within 12 hrs of
prophylaxis dose (0.5 prophylaxis dose
mg/kg) (0.5 mg/kg) and
24 hrs of
therapeutic dose
(1 mg/kg)
Warfarin Warfarin (Coumadin) Do not discontinue Increased
without consulting bleeding risk.
prescribing physician

Revised 10/26/21
Aspirin Aspirin If no history of CAD or Increased risk of
(and Aspirin- Aspirin/acetaminophen/caffeine stroke: bleeding
containing drugs) (Excedrin®) Discontinue 5-10 days complications
Aspirin/butalbital/caffeine (Fiorinal®) prior to surgery,
Aspirin/carisoprodol (Soma especially for
Compound®) ophthalmologic and
Aspirin/carisoprodol/codeine (Soma neurosurgical
compound w/ codeine®) procedures.
Aspirin/dipyridamole (Aggrenox®)
Aspirin/orphenadrine/caffeine Patients with hx of CAD
(Norgesic®) or stroke:
Aspirin/oxycodone (Percodan®) Continue Aspirin,
including day of surgery
if at all possible. Need
to consult with surgeon
if neuro/ spine/
ophthalmologic surgery.

Anti-Platelet Clopidogrel (Plavix) Do NOT discontinue Increased risk of

Drugs without explicit bleeding
Prasugrel (Effient®) instructions from complications
prescribing physician!
Ticagrelor (Brilinta®) Must be documented by
prescribing physician on
Ticlopidine (Ticlid) form N-372 (Request for
Preoperative Cardiac
Evaluation)

Cilostazol (Pletal) HOLD 4 days preop

Dipyridamole (Persantine) HOLD 2 days preop

Dipyridamole/Aspirin (Aggrenox) HOLD 7 days preop

Short-acting Diclofenac (Cataflam®, Voltaren®) HOLD day prior to Increased risk for
NSAIDs Etodolac (Lodine®) surgery bleeding and renal
Fenoprofen (Nalfon®) complications
Flurbiprofen (Ansaid®)
Ibuprofen (Advil®, Motrin®)
Ibuprofen/Hydrocodone (Vicoprofen®)
Ibuprofen/Oxycodone (Combunox®)
Indomethacin (Indocin®)
ketoprofen (Orudis KT®, Oruvail®)
Revised 10/26/21
 Ketorolac (Toradol®)
Meclofenamate (Meclomen®)
Mefenamic Acid (Ponstel®)
Tolmetin (Tolectin®)
Long-acting NSAIDs Diflunisal (Dolobid®) At least 3 days prior to Increased risk for
Etodolac (Lodine XL®) surgery bleeding and renal
Meloxicam (Mobic®) complications
Nabumetone (Relafen)
Naproxen (Aleve®, Anaprox®,
Naprosyn®)
Oxaprozin (Daypro)
Piroxicam (Feldene)
Sulindac (Clinoril®)
Cox-2 Inhibitors Celecoxib (Celebrex) At least 3 days prior to Increased risk for
Nabumetone (Relafen) surgery renal, thrombo-
embolic
complications
OPIOID PAIN MEDICATIONS
Drug Class Drugs in Class When to hold Reason
Long-Acting Fentanyl Patch (Duragesic) Do NOT hold prior to Discontinuation
Opioids Hydromorphone SR (Exalgo) surgery may result in
Methadone (Dolophine) opioid withdrawal
Morphine SR (MS Contin, Kadian, and difficulty with
Avinza) postoperative
Morphine SR/Naltrexone (Embeda) pain control.
Oxycodone SR (Oxycontin)
Oxymorphone (Opana ER)
Short-Acting Hydrocodone Do NOT hold prior to Discontinuation
Opioids Hydrocodone/Acetaminophen surgery may result in
(Hycet, Lorcet, Lortab, Norco, opioid withdrawal
Vicodin, Zydone) Switch patient from and difficulty with
Hydrocodone/Ibuprofen (Vicoprofen) Aspirin and Ibuprofen postoperative
Hydromorphone (Dilaudid) containing drugs one pain control.
Hydromorphone ER (Exalgo) week preop.
Morphine
Oxycodone (Roxicodone)
Oxycodone/Acetaminophen
(Percocet, Endocet, Roxicet)
Oxycodone/Aspirin (Percodan,
Endodan)
Propoxyphene/Acetaminophen
(Darvocet)
Propoxyphene/Aspirin (Darvon)
Tapentadol (Nucynta)
Opioid Agonist/ Buprenorphine/Naloxone (Suboxone) Advise patient pain
Antagonists Buprenorphine patch (Butrans) control may be a

Revised 10/26/21
 Naltrexone (Vivitrol, ReVia, Depade) challenge; anesthesia
care team will use nerve
blocks/regional
analgesia if and when
possible
Topical local Lidocaine patch Continue
Anesthetic
Skeletal Muscle Carisoprodol Soma Continue
Relaxant Metaxalone (Skelaxin)
Tizanidine (Zanaflex)
STEROID AND IMMUNE MEDICATIONS
Drug Class Drugs in Class When to hold Reason
Steroids Prednisone Do NOT hold prior to Adrenal
Methylprednisolone (Medrol) surgery insufficiency
THYROID MEDICATIONS
Drug Class Drugs in Class When to hold Reason
Thyroid hormone Levothyroxine (Synthroid, Levoxyl) Do NOT hold prior to
Dessicated thyroid (Armour Thyroid) surgery
DIABETES MEDICATIONS
Drug Class Drugs in Class
Short-Acting Regular Insulin (Humulin, Novolin) See Diabetes
Insulin Insulin Aspart (Novolog) Instructions
Insulin Glulisine (Apidra)
Insulin Lispro (Humalog)
Intermediate- Insulin NPH (Humulin N, Novolin N)
Acting Insulin Humulin 70/30
Humalog 50/50
Humalog 75/25
Novolin 70/30
Novolog 70/30
Long-Acting Insulin Insulin Glargine (Lantus, Toujeo)
Insulin Detemir (Levimir)
Insulin Degludec (Tresiba)
Non-Insulin Exenatide (Byetta, Bydureon)
Injections Linagliptin (Tradjenta)
Pramlintide (Symlin)
Liraglutide (Victoza)
Dulaglutide (Trulicity)
Oral Diabetic Drugs Alogliptin (Nesina)
Alogliptin/Pioglitazone (Oseni)
Linagliptin (Tradjenta)
Metformin
Pioglitazone (Actos)
Rosiglitazone (Avandia)
Saxagliptin (Onglyza)
Saxagliptin/Metformin ER (Kombiglyze
Revised 10/26/21
 XR)
Sitagliptin (Januvia)
Sitagliptin/Metformin ER (Janumet)
SGLT 2 inhibitors Canagliflozin (Invakana) Hold 3 days prior to Discontinuing
Dapagliflozin (Farxgia) surgery. (Hold lowers risk of
Empagliflozin (Jardiance) Ertugliflozin 4 days prior) ketoacidosis
Ertugliflozin (Steglatro) intra/postoperati
Empagliflozin and metformin (Synjardy Have patient monitor vely
and Synjardy XR) glucose closely once
medications are
discontinued

CNS AGENTS

Drug Class Drugs in Class When to hold Reason

Benzodiazepines Alprazolam (Xanax®) Do NOT hold prior to Risk of withdrawal
Chlordiazepoxide (Librium®) surgery if stopped
Diazepam (Valium®) abruptly; potential
for additive
effects
Antidepressants - Isocarboxazid (Marplan®) Taper off 2 weeks prior Drug interactions
Monoamine Phenelzine (Nardil®) to surgery if possible (e.g., ephedrine,
Oxidase (MAO) Tranylcypromine (Parnate®) meperidine,
Inhibitors methadone,
Rasagiline (Azilect®) OK to continue tramadol), which
could cause a
Selegiline patch (Emsam®) Discontinue at least 10 hypertensive
days prior to surgery if crisis.
possible

Antidepressants – Citalopram (Celexa®) Do NOT hold prior to Risk of withdrawal

SSRIs and SNRIs Duloxetine (Cymbalta) surgery if stopped
Escitalopram (Lexapro®) abruptly
Fluoxetine (Prozac®)
Fluvoxamine (Luvox®)
Paroxetine (Paxil®)
Sertraline (Zoloft®)
Strattera (Atomoxetine®)
Desvenlafaxine (Pristiq, Khedezla)

Revised 10/26/21
Antidepressants - Amitriptyline (Elavil ) Do NOT hold prior to Risk of withdrawal
Other Bupropion (Wellbutrin) surgery if stopped
Desipramine (Norpramin) abruptly
Doxepin (Sinequan)
Imipramine (Tofranil)
Mirtazapine (Remeron)
Nefazodone (Serzone)
Nortriptyline (Pamelor)
Trazodone (Desyrel)

Lithium Lithium (Eskalith, Lithonate) Do NOT hold prior to

surgery
Acetyl- Donazepil (Aricept) Do NOT hold prior to No documented
cholinesterase Galantamine (Razadyne) surgery interaction with
Inhibitors Rivastigmine (Exelon) anesthesia
(for Alzheimer’s) Tacrine (Cognex) medications

Anticonvulsants Carbamazepine (Tegretol) Do NOT hold prior to

Clonazepam (Klonopin) surgery
Felbamate (Felbatol)
Gabapentin (Neurontin)
Levetiracetam (Keppra)
Lamotrigine (Lamictal)
Oxcarbazepine (Trileptal)
Phenytoin (Dilantin)
Pregabalin (Lyrica)
Primidone (Mysoline)
Tiagabine (Gabitril)
Topiramate (Topamax)
Valproic Acid (Depakote)
Zonisamide (Zonegran)

ADHD Drugs Dextroamphetamine (Adderall) Do NOT hold prior to No documented

(Stimulants) Lisdexamfetamine (Vyvanse) surgery interaction with
Dexmethylphenidate (Focalin) anesthesia
Methylphenidate (Ritalin, medications
Metadate, Concerta, Daytrana
patch)
ADHD Drugs Guanfacine (Intuniv) Do NOT hold prior to Risk of rebound
(non-stimulant) surgery hypertension if
withheld.
Sleep Aids Zolpidem (Ambien) May take night before
Eszopiclone (Lunesta) surgery
Restless legs Ropinirole (Requip) Continue
Pramipexole (Mirapex)

Revised 10/26/21
 REFLUX MEDICATIONS
Drug Class Drugs in Class When to Hold Reason
Proton Pump Esomeprazole (Nexium) Do NOT hold prior to Reflux prevention
Inhibitors Lansoprazole (Prevacid) surgery
Omeprazole (Prilosec)
Pantoprazole (Protonix)
Rabeprazole (Aciphex)
Histamine H2 Cimetidine (Tagamet) Do NOT hold prior to Reflux prevention
blockers Famotidine (Pepcid) surgery
Nizatidine (Axid)
Ranitidine (Zantac)
Particulate Gaviscon HOLD day of surgery Risk of particulate
Antacids Maalox aspiration
OTHER DRUGS
Drug Class Drugs in Class When to Hold Reason
Appetite Phentermine (Adipex®, Suprenza®) Discontinue at least 7 Risk of
Suppressant Phentermine / Topiramate (Qsymia®) days preop! hypotension that
(Diet Drug) is unresponsive to
treatment.
Immunosuppresion Hydroxychloroquine (Plaquenil) Surgeon discretion Risk of post op
infection
Other Medical Estrogen patch Continue
patches Nicotine patch
Herbal See list Discontinue at least one Risk of bleeding,
Supplements week preop blood pressure
problems, slow
awakening from
anesthesia, etc.

Revised 10/26/21
Anticoagulants as relates to minimum time safe for spinal (some of the more popular not a
complete list of all on the market):

Eliquis- 3 days

ASA- No restrictions

Pletal- 2 days

Plavix- 5-7 days no recommended

Pradaxa- 5 days for CrCl 30-49; 4 days CrCl 50-79; 3 days CrCl 80 or
better. If needed in a timeframe less than 3 days consider ECT

Lovenox- therapeutic 24 hrs; Qday or BID dose 12 hrs

Effient- 7-10 days

Xarelto- 3 days

Brilinta- 5-7 days

Ticlid- 10 days

Coumadin- 5 days and normal INR

Revised 10/26/21
Revised 10/26/21
Herbals and Dietary Supplements with the Potential to Increase Bleeding

Agrimony Fenugreek Peony

Andrographis Feverfew Policosanol
Angelica Fish oil Poplar
Anise Flaxseed Prickly Ash (Northern)
Arnica Forskolin Quassia
Asafoetida Forsythia Red Clover
Aspen Garlic Resveratrol
Bilberry Gamma linolenic acid Safflower
Black Haw German Sarsaparilla Saw palmetto
Bladder Wrack (Fucus) Ginger Sea buckthorn
Bogbean Ginkgo Biloba Selenium
Boldo Ginseng (Panax, Siberian) Senega
Borage Green tea Serrapeptase
Bromelain Guggul Swallowroot
Buchu Holy basil Sweet Clover
Burdock Honeysuckle Sweet Vernal grass
Capsicum Horse Chestnut Sweet Woodruff
Carrageenan Horseradish Tamarind
(NEW) Inositol Nicotinate Tiratricol
CBD oil (both THC/nonTHC)?? Japanese apricot Tonka Beans
Celery Jiaogulan Turmeric
Chamomile (German and Krill oil Vanadium
Roman) Kudzu Vinpocetine
Chinese prickly ash Licorice Vitamin E
Cinchona Meadowsweet Wild Carrot
Clove Melatonin Wild Lettuce
Cod liver oil Methoxylated flavones Willow Bark
Coltsfoot Nattokinase Wintergreen
Danshen Onion Yarrow
Deertongue Palm oil
DHA (docosahexaenoic acid) Pantethine
Dong quai Passion Flower
EPA (eicosapentaenoic acid) Pau d’Arco
Epimedium
Evening primrose oil
Evodia

It is recommended that patients discontinue herbal supplements at least

one week prior to surgery.

Revised 10/26/21
Revised 10/26/21