/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/cpg/,/clinical/cckm-tools/content/cpg/medications/,

/clinical/cckm-tools/content/cpg/medications/name-110651-en.cckm

20180124

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Clinical Practice Guidelines,Medications

Perioperative Medication Management - Adult/Pediatric - Inpatient/Ambulatory

Perioperative Medication Management - Adult/Pediatric - Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Medications


1
Perioperative Medication Management –
Adult/Pediatric – Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
SCOPE ............................................................................................................................ 3
METHODOLOGY ............................................................................................................ 4
DEFINITIONS ................................................................................................................. 5
INTRODUCTION ............................................................................................................. 5
RECOMMENDATIONS ................................................................................................... 5
UW HEALTH IMPLEMENTATION................................................................................ 29
APPENDIX A: EVIDENCE GRADING SCHEMES ...................................................... 31
APPENDIX B: PERIOPERATIVE MEDICATION MANAGEMENT.............................. 33
APPENDIX C: TREATMENT ALGORITHM FOR THE TIMING OF ELECTIVE
NONCARDIAC SURGERY IN PATIENTS WITH CORONARY STENTS ..................... 61
APPENDIX D: METHYLENE BLUE AND SEROTONIN SYNDROME ......................... 62
REFERENCES .............................................................................................................. 63
Contact for Content:
Name: Scott Springman, MD - Anesthesiology
Phone Number: (608) 263-8100
Email Address: srspring@wisc.edu
Contact for Changes:
Name: Philip J. Trapskin, PharmD, BCPS – Pharmacy, Drug Policy Program
Phone Number: (608) 263-1328
Email Address: ptrapskin@uwhealth.org
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

2
Guideline Authors:
Scott Springman, MD - Anesthesiology
Philip J. Trapskin, PharmD, BCPS – Pharmacy, Drug Policy Program
Sara Shull, PharmD, MBA – Pharmacy, Drug Policy Program
Anthony Hennes, PharmD – Pharmacy
Joshua Vanderloo, PharmD – Pharmacy, Drug Policy Program
Review Individuals/Bodies:
Christi Albert, PharmD, BCPS – Pharmacy
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
Paul Rutecki, MD – Neurology
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 (Last Periodic Review: 10/20/16)
• Interim revisions: 7/2017, 1/2018
Medical Board (Last Periodic Review: 11/10/16)
Release Date: December 2016 | Next Review Date: December 2017
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

3
Executive Summary
Guideline Overview
The purpose of this guideline is to provide guidance to clinicians on the management of a
patient’s prior to surgery medication regimen.
January 2018 Interim Revisions
1. Addition of new FDA approved medications from July 2017 to December 2017.
2. Revised sucralfate to hold day of surgery
3. Revise buprenorphine to consider planned procedures and patient-specific factors while
consulting with surgeon, Advanced Pain Service, and/or the prescribing physician.
4. Add injectable buprenorphine with instructions to coordinate management.
July 2017 Interim Revisions
1. Addition of more specific recommendations for when to hold ACE/ARBs and a change in the
language of what is “significant heart failure”.
2. Addition of all new molecular entities since September 2016
Key Practice Recommendations
Please see Appendix B for summary of the key practice recommendations.
Companion Resources
1. Standards of Medical Care in Diabetes – Pediatric/Adult – Inpatient/Ambulatory
2. Diabetes Medication Adjustment (Inpatient Procedures)
3. Diabetes Medication Adjustment (Ambulatory Procedures)
4. Periprocedural and Regional Anesthesia Management with Antithrombotic Therapy – Adult
– Inpatient/Ambulatory
5. Assessment of Tobacco Use or Secondhand Exposure – Adult/Pediatric –
Inpatient/Ambulatory
6. Management of Patients with Non-ST Elevation Acute Coronary Syndromes – Adult -
Inpatient
7. Mechanical Circulatory Device (MCD) – Adult – Inpatient/Ambulatory
8. Lexicomp Drug Information Database
9. Natural Medicines Database
Scope
Disease/Conditions: Perioperative medication management
Clinical Specialty: Anesthesiology, Cardiovascular Surgery, Dermatology, Emergency
Medicine, Family Medicine, General Surgery, Human Oncology, Medicine, Neurological
Surgery, Neurology, Obstetrics and Gynecology, Ophthalmology, Orthopedics and
Rehabilitation, Otolaryngology- Head and Neck Surgery, Medicine, Pediatrics, Plastic Surgery,
Psychiatry, Radiology, Transplantation, Urology, Vascular Surgery
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
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

4



Interventions and Practices Considered:
• Continuing a medication regimen
• Holding a medication regimen
• Modifying a medication regimen
• Coordination of a medication regimen with anesthesiologist and/or surgeon and
prescribing provider

Major Outcomes Considered:
• Perioperative medication-related complications (e.g. hypotension, bleeding, infection)
• Delay or cancellation of surgeries because of a failure to modify/hold a medication
preoperatively

Methodology
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 arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees.

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 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating schemes used within this document.

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.
1,2
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.
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

5
Definitions
• Perioperative: The three phases of surgery, preoperative, intraoperative, and
postoperative.
• Hold: A temporary interruption of therapy
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.
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.
3

1.2.1.1.2 Calcium lowering medications may alter intraoperative
parathyroid hormone kinetics which may lead to post-
operative hypocalcemia.
4

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.
5
(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)
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

6


2 Alpha
1
-blockers: alfuzosin, doxazosin, phenoxybenzamine, phentolamine, prazosin, silodosin,
tamsulosin, terazosin
2.1 Cataract surgery
2.1.1 Recommend to coordinate perioperative alpha1-blocker medication management
plan with surgeon. (UW Health strong recommendation, low quality of evidence)
2.1.1.1 Intraoperative floppy iris syndrome has been associated with
adrenergic alpha
1
-blockers in the setting of cataract surgery.
6,7

2.2 All other surgeries
2.2.1 Recommend to continue alpha1-blocker regimens throughout the perioperative
period.
5
(UW Health strong recommendation, low quality of evidence)

3 Alpha-2 agonists: clonidine, guanfacine, methyldopa, tizanidine
3.1 Recommend to continue alpha-2 agonist regimens throughout the perioperative period. (UW
Health strong recommendation, low quality of evidence)
3.1.1 Abrupt discontinuation of clonidine (both oral and transdermal) can result in
rebound tachycardia and hypertension.
8-10

3.1.2 Although less likely due to a slower onset of actions, withdrawal symptoms have
also been reported with methyldopa and guanfacine.
11

3.1.3 It is not recommended to initiate alpha-2 agonists perioperatively for the
prevention of cardiac events.
12
(AHA Class III, Level of Evidence B)

4 Analgesics
4.1 Acetaminophen
4.1.1 It is reasonable to continue acetaminophen regimens throughout the
perioperative period. (UW Health weak recommendation, low quality of evidence)
4.1.1.1 Multimodal pain management using acetaminophen is one of many
multimodal options for acute pain management in the perioperative
setting.
13

4.2 N-type calcium channel blockers: ziconotide
4.2.1 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)
4.3 Nonsteroidal anti-inflammatory drugs (NSAIDs)
4.3.1 Salicylates: aspirin, choline magnesium trisalicylate, diflunisal, magnesium
salicylate, salsalate
4.3.2 Acetic acids: diclofenac, etodolac, indomethacin, ketorolac, nabumetone,
sulindac, tolmetin
4.3.3 Propionic acids: fenoprofen, flurbiprofen, ibuprofen, ketoprofen, naproxen,
oxaprozin
4.3.4 Fenamic acids: mefenamic acid, meclofenamate
4.3.5 Sulfonamides: celecoxib
4.3.6 Enolic acids: piroxicam, meloxicam
4.3.7 COX-2 selective: celecoxib, diclofenac, etodolac, meloxicam
4.3.7.1 For aspirin recommendations, refer to the Anti-platelet section
of this guideline.
4.3.7.2 For non-aspirin NSAIDS, coordinate with surgeon and prescribing
provider. (UW Health strong recommendation, low quality of
evidence)
4.3.7.2.1 The beneficial analgesic, anti-inflammatory, and antipyretic
effects of NSAIDs must be weighed against the
thrombotic, arrthymogenic, bleeding, and nephrotoxic
risks.
5,14,15

4.4 Opioid agonists: alfentanil, codeine, fentanyl, hydrocodone, hydromorphone, levorphanol,
meperidine, methadone, morphine, opium, oxycodone, oxymorphone, paregoric, remifentanil,
sufentanil, tapentadol, tramadol
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

7
4.4.1 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.
5,13
(UW Health weak recommendation, low quality of evidence)
4.5 Opioid partial agonists
4.5.1 Buprenorphine (Suboxone®), buprenorphine injection (Sublocade®),
butorphanol, nalbuphine, pentazocine
4.5.1.1 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)
4.5.1.1.1 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.
16
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.
5 Anorexiants
5.1 Serotonin 2C receptor agonist: lorcaserin
5.2 Sympathomimetic anorexiants: benzphetamine hydrochloride, diethylpropion hydrochloride,
phendimetrazine tartrate, phentermine hydrochloride
5.2.1 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)
5.2.1.1 A case report has documented the potential for sympathomimetic
anorexiants to cause unstable perioperative blood pressure.
17

6 Anti-addiction agents
6.1 Antialcoholic agents: acamprosate calcium, disulfiram
6.1.1 Recommend to continue acamprosate regimens throughout the perioperative
period. (UW Health weak recommendation, low quality of evidence)
6.1.2 Recommend to hold disulfiram 7-14 days prior to surgery. (UW Health strong
recommendation, low quality of evidence)
6.1.2.1 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.
18

6.2 Opioid antagonist: naltrexone
6.2.1 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)
6.2.2 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.
19
(UW Health strong
recommendation, low quality of evidence)
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 01/2018CCKM@uwhealth.org

8


6.3 Nicotine replacement: nicotine gum, lozenges, patches, inhalers
6.3.1 Recommend abstinence from smoking in the perioperative period to reduce
respiratory, cardiac, and healing complications. (UW Health strong
recommendation, strong quality of evidence)
20

6.3.2 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)
21


7 Anti-Dementia (Alzheimer’s) agents
7.1 Cholinesterase inhibitors: donepezil, galantamine, rivastigmine
7.1.1 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)
7.1.1.1 Cholinesterase inhibitors may diminish the neuromuscular blocking
effects of nondepolarizing neuromuscular blockers.
18,22

7.1.1.2 Cholinesterase inhibitors may prolong neuromuscular blocking
effects (increase serum concentrations) of succinylcholine.
18

7.1.1.3 The duration to hold the medication is based upon the half-life of the
medication (donepezil=15 days, galantamine =7hrs, rivastigmine
=3hrs)
18

7.2 NMDA receptor antagonist :memantine
7.2.1 It is reasonable to continue NMDA receptor antagonist regimens throughout the
perioperative period. (UW Health weak recommendation, low quality of evidence)

8 Antiarrhythmics: amiodarone, disopyramide, dofetilide, dronedarone, flecainide, ibutilide, lidocaine
(systemic), mexiletine, procainamide, propafenone, quinidine
8.1 Electrophysiology surgeries/procedures
8.1.1 Recommend to coordinate antiarrhythmic perioperative medication management
plan with cardiologist and prescribing provider. (UW Health strong
recommendation, low quality of evidence)
8.2 Non-electrophysiology surgeries/procedures
8.2.1 Recommend to continue antiarrhythmic regimens throughout the perioperative
period.
5,15,23
(UW Health strong recommendation, low quality of evidence)

9 Anticholinergics: cyclizine, dimenhydrinate, meclizine, scopolamine, trimethobenzamide
9.1 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)

10 Anticoagulants
10.1 Vitamin K antagonist: warfarin
10.2 Direct oral anticoagulants: apixaban, betrixaban, dabigatran, edoxaban, rivaroxaban
10.3 Parenteral anticoagulants: argatroban, bivalirudin, enoxaparin, fondaparinux,
unfractionated heparin
10.3.1 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)
10.3.2 Additional information can be found in Periprocedural and Regional
Anesthesia Management with Antithrombotic Therapy – Adult – Inpatient
and Ambulatory – Clinical Practice Guideline

11 Anticonvulsants: acetazolamide, brivaracetam, carbamazepine, divalproex, eslicarbazepine
acetate, ethosuximide, ethotoin, ezogabine, lacosamide, lamotrigine, levetiracetam, methsuximide,
oxcarbazepine, perampanel, phenytoin, pregabalin, primidone, rufinamide, tiagabine, topiramate,
valproic acid, vigabatrin, zonisamide
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

9


11.1 Neuromonitoring or Neuromapping
11.1.1 Recommend to coordinate anticonvulsant perioperative medication management
plan with surgeon, anesthesiologist, and prescribing provider. (UW Health strong
recommendation, low quality of evidence)
11.2 All other procedures
11.2.1 Recommend to continue anticonvulsant regimens throughout the perioperative
period.
24,25
(UW Health strong recommendation, low quality of evidence.
11.2.1.1 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.
25


12 Anti-diabetic agents
12.1 See Diabetes Medication Adjustment: Ambulatory Procedures and Diabetes
Medication Adjustment: Inpatient Procedures for recommendations
12.2 Alpha-glucosidase inhibitors: acarbose, miglitol
12.3 Amylinomimetics: pramlintide
12.4 Biguanides: metformin
12.5 Dipeptidyl peptidase IV inhibitors: alogliptin, linagliptin, saxagliptin, sitagliptin
12.6 Glucagon-like peptide-1 receptor agonist: albiglutide, dulaglutide, exenatide, liraglutide,
lixisenatide, semaglutide
12.7 Insulins: insulin aspart, insulin degludec, insulin detemir, insulin glargine, insulin
isophane, insulin lispro, insulin regular
12.8 Meglitinide analogs: nateglinide, repaglinide
12.9 Sodium-glucose cotransporter-2 inhibitors: canagliflozin, dapagliflozin, empagliflozin,
ertugliflozin
12.10 Sulfonylureas: chlorpropamide, glimepiride, glipizide, glyburide, tolazamide, tolbutamide
12.11 Thiazolidinediones: pioglitazone, rosiglitazone)

13 Anti-dopaminergics: chlorpromazine, metoclopramide, perphenazine, prochlorperazine,
promethazine
13.1 It is reasonable to continue anti-dopaminergic regimens throughout perioperative period.
(UW Health weak recommendation, low quality of evidence)

14 Antiemetics
14.1 5HT3 antagonists: alosetron, dolasetron, granisetron, ondansetron, palonosetron
14.2 Phenothiazines: chlorpromazine, prochlorperazine, promethazine
14.3 Substance P/Neurokinin 1 receptor antagonist: aprepitant, fosaprepitant, netupitant,
rolapitant
14.3.1 It is reasonable to continue antiemetic regimens throughout the peri-operative
period. (UW Health weak recommendation, low quality of evidence)

15 Anti-glaucoma ophthalmics
15.1 Cholinesterase inhibitors: acetylcholine, carbachol, echothiophate iodide, pilocarpine
15.1.1 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)
15.2 Alpha adrenergic agonists: apraclonidine, brimonidine
15.3 Beta-adrenergic blocking agents (beta-blockers): betaxolol, carteolol, levobunolol,
metipranolol, timolol
15.4 Carbonic anhydrase inhibitors: brinzolamide, dorzolamide
15.5 Docosanoid, synthetic: unoprostone isopropyl
15.6 Prostaglandin analogues: bimatoprost, latanoprost, latanoprostene bunod, tafluprost,
travoprost
15.7 Rho kinase inhibitors: netarsudil
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

10


15.7.1 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)

16 Antihistamines
16.1 Peripherally selective: cetirizine, desloratadine, fexofenadine, loratadine, levocetirizine
16.2 Nonselective: brompheniramine, carbinoxamine, chlorcyclizine, chlorpheniramine,
clemastine, cyproheptadine, dexbrompheniramine, dexchlorpheniramine,
diphenhydramine, doxylamine, hydroxyzine, triprolidine
16.2.1 Recommend to continue antihistamine regimens throughout the perioperative
period. (UW Health weak recommendation, low quality evidence)

17 Anti-hyperlipemia agents (non-statins): alirocumab, cholestyramine, colesevelam, colestipol,
evolocumab, ezetimibe, fenofibrate, gemfibrozil, niacin, lomitapide, mipomersen
17.1 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.
5,15
(UW Health weak recommendation, low quality evidence)

18 Anti-hyperlipemia agents (HMG-CoA Reductase Inhibitors; statins): atorvastatin, fluvastatin,
lovastatin, pravastatin, rosuvastatin, simvastatin
18.1 Recommend to continue statin regimens throughout the perioperative period, particularly
in patients at high risk for cardiovascular disease.
26-31
(UW Health strong
recommendation, low quality evidence)
18.2 Perioperative initiation of statin use is reasonable in patients undergoing vascular
surgery.
26,32
(AHA Class IIa Level B)
18.3 Perioperative initiation of statins may be considered in patients with a clinical risk factor
who are undergoing elevated-risk procedures.
26
(AHA Class IIb Level C)

19 Anti-infective agents
19.1 Amebicides: iodoquinol
19.2 Aminoglycosides (oral): neomycin, paromomycin
19.3 Aminoglycosides (parenteral): amikacin, gentamicin, streptomycin, tobramycin
19.4 Anthelmintics: albendazole, ivermectin, praziquantel, pyrantel
19.5 Antibiotic combinations: erythromycin/sulfisoxazole, sulfamethoxazole/trimethoprim
19.6 Antifungal (Allylamine): terbinafine
19.7 Antifungal (Echinocandins): anidulafungin, caspofungin, flucytosine, griseofulvin,
micafungin
19.8 Antifungal (Imidazole) : ketoconazole
19.9 Antifungal (Polyene): amphotericin B, nystatin
19.10 Antifungal (Triazole): fluconazole, isavuconazole, itraconazole, posaconazole,
voriconazole
19.11 Antimalarial (4-Aminoquinoline): chloroquine, hydroxychloroquine
19.12 Antimalarial (8-Aminoquinoline): artemether/lumefantrine, atovaquone/proguanil,
primaquine
19.13 Antimalarial (Cinchona Alkaloid): quinine sulfate
19.14 Antimalarial (Folic Acid Antagonist): pyrimethamine, mefloquine
19.15 Antiprotozoals: atovaquone, miltefosine, nitazoxanide pentamidine, tinidazole
19.16 Antiretroviral agents: abacavir, atazanavir, cobicistat, darunavir, delavirdine, didanosine,
dolutegravir, efavirenz, elvitegravir, emtricitabine, enfuvirtide, etravirine, fosamprenavir,
indinavir, lamivudine, lopinavir, maraviroc, nelfinavir, nevirapine, raltegravir, rilpivirine,
ritonavir, saquinavir, stavudine, tenofovir, tipranavir, zidovudine
19.17 Antituberculosis Agents: aminosalicylic acid, bedaquiline, capreomycin, cycloserine,
ethambutol, ethionamide, isoniazid, pyrazinamide, rifabutin, rifampin, rifapentine,
streptomycin
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

11


19.18 Antiviral Agents: adefovir, amantadine, acyclovir, boceprevir, cidofovir, daclatasvir,
elbasvir/grazoprevir, entecavir, famciclovir, foscarnet, ganciclovir,
glecaprevir/pibrentasvir, ledipasvir/sofosbuvir, letermovir,
ombitasvir/paritaprevir/ritonavir/dasabuvir, oseltamivir, peramivir, ribavirin, rimantadine,
simeprevir, sofosbuvir, telaprevir, telbivudine, valacyclovir, valganciclovir, velpatasvir,
voxilaprevir, zanamivir
19.19 Bacitracin
19.20 Carbapenems: doripenem, ertapenem, imipenem/cilastatin, meropenem,
meropenem/vaborbactam
19.21 Cephalosporins: cefaclor, cefadroxil, cefazolin, cefdinir, cefditoren, cefepime, cefixime,
cefotaxime, cefotetan, cefoxitin, cefpodoxime, cefprozil, ceftaroline, ceftazidime,
ceftazidime/avibactam, ceftriaxone, cefuroxime, cephalexin
19.22 Chloramphenicol
19.23 Colistimethate
19.24 Fluoroquinolones: ciprofloxacin, delafloxacin, gemifloxacin, levofloxacin, moxifloxacin,
norfloxacin, ofloxacin, ozenoxacin
19.25 Folate Antagonists: trimethoprim
19.26 Glycylcyclines: tigecycline
19.27 Ketolides: telithromycin
19.28 Leprostatics: dapsone
19.29 Lincosamides: clindamycin, lincomycin
19.30 Lipoglycopeptides: dalbavancin, oritavancin, telavancin
19.31 Lipopeptides: Daptomycin
19.32 Macrolides: azithromycin, clarithromycin, erythromycin
19.33 Fidaxomicin
19.34 Methenamines: methenamine hippurate, methenamine mandelate
19.35 Metronidazole
19.36 Miscellaneous anti-infectives/antiseptics: benznidazole, fosfomycin, secnidazole
19.37 Monobactams: aztreonam
19.38 Monoclonal antibodies: bezlotoxumab
19.39 Nitrofurans: nitrofurantoin
19.40 Oxazolidinones: linezolid, tedizolid
19.41 Penicillins: amoxicillin, amoxicillin/clavulanate, ampicillin, ampicillin/sulbactam,
dicloxacillin, nafcillin, oxacillin, penicillin G, penicillin V, piperacillin/tazobactam,
ticarcillin/clavulanate
19.42 Polymyxin B Sulfate
19.43 Rifaximin
19.44 Streptogramins: quinupristin/dalfopristin
19.45 Sulfadiazine
19.46 Tetracyclines: demeclocycline, doxycycline, minocycline, tetracycline
19.47 Vancomycin
19.47.1 Active infections
19.47.1.1 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)
19.47.2 Infection prophylaxis(medical)
19.47.2.1 Recommend to coordinate anti-infectives for prophylaxis indications
with surgeon and prescribing provider. (UW Health weak
recommendation, low quality of evidence)

20 Anti-overactive bladder agents
20.1 Anticholinergic: oxybutynin
20.2 Muscarinic receptor antagonists: darifenacin, fesoterodine, solifenacin, tolterodine,
trospium
20.3 M3 muscarinic agonist: mirabegron
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

12


20.4 Phosphodiesterase inhibitor: flavoxate
20.4.1 It is reasonable to continue anti-overactive bladder agent regimens throughout
the perioperative period. (UW Health weak recommendation, low quality of
evidence)

21 Anti-neoplastics
21.1 Alkylating agents: altretamine, busulfan, carmustine, chlorambucil, dacarbazine,
estramustine, ifosfamide, lomustine, mechlorethamine, melphalan, streptozocin, thiotepa
21.2 Anthracenedione: mitoxantrone
21.3 Antibody-drug conjugates: ado-trastuzumab emtansine, brentuximab vedotin
21.4 Antimetabolites: allopurinol, capecitabine, cladribine, clofarabine, cytarabine, floxuridine,
fludarabine, fluorouracil, gemcitabine, mercaptopurine, methotrexate, pemetrexed,
pentostatin, pralatrexate, rasburicase, thioguanine
21.5 Antimitotic agents: cabazitaxel, docetaxel, eribulin, ixabepilone, paclitaxel, vinblastine,
vincristine, vinorelbine
21.6 Antineoplastic antibiotics: bleomycin, dactinomycin, daunorubicin, doxorubicin, epirubicin,
idarubicin, mitomycin, valrubicin
21.7 BCL-2 Inhibitor: venetoclax
21.8 Biologic response modifiers: aldesleukin, BCG live
21.9 Cytoprotective agents: amifostine, dexrazoxane, leucovorin, levoleucovorin, mesna
21.10 DNA demethylation agents: azacitidine, decitabine, nelarabine
21.11 DNA topoisomerase inhibitors: irinotecan, topotecan
21.12 Enzymes: asparaginase, pegaspargase
21.13 Epipodophyllotoxins: etoposide, teniposide
21.14 Histone deacetylase inhibitors: belinostat, panobinostat, romidepsin, vorinostat
21.15 Hormones: abiraterone, anastrazole, bicalutamide, buserelin, enzalutamide, exemestane,
flutamide, fulvestrant, goserelin, histrelin, letrozole, leuprolide, medroxyprogesterone,
megestrol, nilutamide, tamoxifen, toremifene, triptorelin
21.16 Hedgehog Pathway Inhibitor: sonidegib, vismodegib
21.17 Imidazotetrazine derivatives: temozolomide
21.18 Kinase inhibitors: abemaciclib, acalabrutinib, afatinib, alectinib, axitinib, bosutinib,
brigatinib, cabozantinib, ceritinib, copanlisib, crizotinib, cobimetinib, dabrafenib, dasatinib,
enasidenib, erlotinib, everolimus, gefitinib, ibrutinib, idelalisib, imatinib, lapatinib,
lenvatinib, midostaurin, neratinib, nilotinib, osimertinib, palbociclib, pazopanib, ponatinib,
regorafenib, ribociclib, ruxolitinib, sorafenib, sunitinib, temsirolimus, trametinib,
vandetanib, vemurafenib
21.19 Methylhydrazine derivatives: procarbazine
21.20 Miscellaneous antineoplastics: arsenic trioxide, mitotane, porfimer, sipuleucel-T, sterile
talc powder, trabectedin, trifluridine/tipiracil
21.21 Monoclonal antibodies: alemtuzumab, atezolizumab, avelumab, bevacizumab and
biosimilars, blinatumomab, cetuximab, daratumumab, dinutuximab, elotuzumab,
gemtuzumab, ibritumomab, inotuzumab, ipilimumab, necitumumab, nivolumab,
obinutuzumab, ofatumumab, olaratumab panitumumab, pertuzumab, ramucirumab,
rituximab, trastuzumab (and biosimilars)
21.22 PARP enzymes inhibitor: olaparib, rucaparib
21.23 Platinum coordination complex: carboplatin, cisplatin, oxaliplatin
21.24 Proteasome inhibitors: bortezomib, carfilzomib, ixazomib
21.25 Protein synthesis inhibitor: omacetaxine
21.26 Radiopharmaceuticals: Radium RA 223, samarium SM 153, sodium iodide I 131,
strontium-89 chloride
21.27 Retinoids: tretinoin
21.28 Rexinoids: bexarotene
21.29 Substituted ureas: hydroxyurea
21.30 Vascular endothelial growth factor inhibitor: ZIV-aflibercept
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

13


21.30.1 Recommend to coordinate perioperative medication management plan of all
antineoplastics with surgeon and prescribing provider. (UW Health strong
recommendation, low quality of evidence)

22 Anti-osteoporosis agents
22.1 Bisphosphonates: alendronate, etidronate, ibandronate, pamidronate, risedronate,
tiludronate, zolendronic acid
22.2 Calcitonin-salmon
22.3 Denosumab
22.3.1 Dental surgery
22.3.1.1 Recommend to coordinate anti-osteoporosis perioperative
medication management plan with surgeon and prescribing provider.
(UW Health strong recommendation, low quality of evidence)
22.3.1.1.1 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.
33

22.3.2 All other surgeries:
22.3.2.1 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)
22.3.2.2 Recommend to coordinate calcitonin and denosumab perioperative
plans with surgeon and prescribing provider. (UW Health strong
recommendation, low quality of evidence)

23 Anti-Parkinson’s agents: amantadine, apomorphine, belladonna alkaloids, benztropine,
bromocriptine, carbidopa, carbidopa/levodopa, carbidopa/levodopa/entacapone, entacapone,
pramipexole, rasagiline, ropinirole, rotigotine, selegiline, tolcapone
23.1 Recommend to continue anti-Parkinson’s agent regimens throughout the perioperative
period.
5,34
(UW Health strong recommendation, low quality evidence)
23.1.1 Abrupt withdrawal of anti-Parkinson drugs may lead to exacerbation of Parkinson
symptoms and other withdrawal related syndromes, including, rarely, neuroleptic
malignant syndrome.
35-38


24 Anti-platelet agents
24.1 Adenosine reuptake inhibitor: dipyridamole
24.2 Combination agents: dipyridamole and aspirin (Aggrenox®)
24.3 Phosphodiesterase-3 enzyme inhibitors: anagrelide, cilostazol
24.4 Protease-activated receptor-1 (PAR-1) antagonist: vorapaxar
24.5 Salicylate: aspirin
24.6 P2Y12 platelet receptor inhibitors: cangrelor, clopidogrel, prasugrel, ticagrelor, ticlopidine
24.6.1 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)
24.6.2 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)
24.6.3 All patients with percutaneous coronary intervention (PCI) in the last 12 months
should have timing of surgery and antiplatelet medication administration
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

14


coordinated with surgeon, anesthesiologist and cardiologist. (UW Health strong
recommendation, low quality evidence)
24.6.4 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
24.6.5 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)
24.6.6 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)
39

24.6.7 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)
39

24.6.8 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)
39
It is recommended that this decision and
discussion with patient be documented in the medical record.
24.6.9 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)
39
It is recommended that this decision
and discussion with the patient be documented in the medical record.
24.6.10 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)
39

24.6.11 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.
12
(AHA Class III, Level C)

25 Anti-psychotics
25.1 First generation – typical: chlorpromazine, fluphenazine, haloperidol, loxapine,
perphenazine, pimozide, prochlorperazine, thioridazine, thiothixene, trifluoperazine
25.2 Second generation – atypical: aripiprazole, asenapine, brexpiprazole, cariprazine,
clozapine, iloperidone, lurasidone, olanzapine, paliperidone, pimavanserin, quetiapine,
risperidone, ziprasidone
25.2.1 Recommend to continue anti-psychotic regimens throughout the perioperative
period.
5,15
(UW Health strong recommendation, low quality evidence)

26 Anti-rheumatics
26.1 General
26.1.1 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.
40,41

26.2 Janus associated kinase (JAK) inhibitors: tofacitinib
26.2.1 Orthopedic surgery
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

15


26.2.1.1 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.
40,41
(UW Health
strong recommendation, low quality of evidence)
26.2.2 All other surgery
26.2.2.1 Recommend to coordinate JAK inhibitor perioperative medication
management plan with surgeon and prescribing provider.
38,39
(UW
Health strong recommendation, low quality of evidence)
26.3 Antimetabolites: methotrexate
26.3.1 Orthopedic surgery
26.3.1.1 Recommend to continue antimetabolite regimens throughout the
perioperative period.
38,39
(UW Health strong recommendation, low
quality of evidence)
26.3.1.2 In a prospective randomized controlled trial of 388 patients with
rheumatoid arthritis (RA) undergoing orthopedic surgery, patients
were randomized to continue or withhold methotrexate.
42
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.
43
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.
26.3.2 All other surgery
26.3.2.1 Recommend to coordinate antimetabolite perioperative medication
management plan with surgeon and prescribing provider.
38,39
(UW
Health strong recommendation, low quality of evidence)
26.4 Anti-TNF-alpha agents: adalimumab, certolizumab, etanercept, golimumab, infliximab
(and biosimilars)
26.4.1 Orthopedic surgery
26.4.1.1 Recommend to hold etanercept 2 weeks prior to surgery.
38,39
(UW
Health strong recommendation, low quality of evidence)
26.4.1.2 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)
26.4.2 All other surgery
26.4.2.1 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)
26.4.2.2 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.
44

26.5 Gold compounds: auranofin, gold sodium thiomalate
26.5.1 Orthopedic surgery
26.5.1.1 Recommend to continue gold compound regimens throughout the
perioperative period.
38,39
(UW Health weak recommendation, low
quality of evidence)
26.5.2 All other surgery
26.5.2.1 Recommend to coordinate gold compound perioperative medication
management plan with surgeon and prescribing provider.
38,39
(UW
Health strong recommendation, low quality of evidence)
26.6 Interleukin-6 blockers: tocilizumab
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

16


26.6.1 Orthopedic surgery
26.6.1.1 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)
26.6.2 All other surgery
26.6.2.1 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)
26.6.2.2 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.
45
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.
46
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.
26.7 Interleukin-1 blockers: anakinra
26.7.1 Orthopedic surgery
26.7.1.1 Recommend to hold subcutaneous anakinra 7 days prior to surgery.

38,39,47
(UW Health strong recommendation, low quality of evidence)
26.7.2 All other surgery
26.7.2.1 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)
26.8 Phosphodiesterase-4 enzyme inhibitor: apremilast
26.8.1 Recommend to coordinate phosphodiesterase-4 enzyme inhibitor perioperative
medication management plan with surgeon and prescribing provider. (UW Health
strong recommendation, low quality of evidence)
26.9 Pyrimidine synthesis inhibitors: leflunomide
26.9.1 Orthopedic surgery
26.9.1.1 Recommend to hold leflunomide 14 days prior to surgery.
38,39,47
(UW
Health strong recommendation, low quality of evidence)
26.9.2 All other surgery
26.9.2.1 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)
26.10 Selective T-cell costimulation blocker: abatacept
26.10.1 Orthopedic surgery
26.10.1.1 Recommend to hold subcutaneous abatacept 2 weeks prior to
surgery and intravenous abatacept 4 weeks prior to surgery.
38,39,47

(UW Health strong recommendation, low quality of evidence)
26.10.2 All other surgery
26.10.2.1 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)

27 Beta-blockers
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

17


27.1 Alpha/beta-adrenergic blocking agents: carvedilol, labetalol
27.2 Beta-adrenergic blocking agents (beta-blockers): acebutolol, atenolol, betaxolol,
bisoprolol, esmolol, metoprolol, nadolol, nebivolol, penbutolol, pindolol, propranolol,
sotalol, timolol
27.2.1 Recommend to continue beta-blocker regimens throughout the perioperative
period unless contraindicated by hemodynamic instability or profound
bronchospasm.
48,49
(AHA Grade I Level B)
27.2.1.1 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.
50


28 Benzodiazepines: alprazolam, chlordiazepoxide, clobazam, clonazepam, clorazepate, diazepam,
lorazepam, oxazepam
28.1 Recommend to continue benzodiazepine regimens throughout the perioperative
period.
5,15,23
(UW Health strong recommendation, low quality evidence)

29 Calcium channel blockers
29.1 Dihydropyridines: amlodipine, clevidipine, felodipine, isradipine, nicardipine, nifedipine,
nimodipine, nisoldipine
29.2 Non-dihydropyridines: diltiazem, verapamil
29.2.1 Recommend to continue calcium channel blocker regimens throughout the
perioperative period.
5
(UW Health strong recommendation, low quality of
evidence)

30 Cardiovascular agents – Miscellaneous
30.1 Alpha
1
-agonist: midodrine
30.1.1 Recommend to continue alpha1-agonist regimens throughout the perioperative
period.
5
(UW Health strong recommendation, low quality evidence)
30.2 Cardiac glycosides: digoxin
30.2.1 Recommend to continue cardiac glycoside regimens throughout the perioperative
period.
5,15
(UW Health strong recommendation, low quality evidence)
30.3 Central monoamine-depleting agents: deutetrabenazine, reserpine, tetrabenazine,
valbenazine
30.3.1 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)
30.4 Cyclic nucleotide-gated (HCN) channels (f-channel): ivabradine
30.4.1 Recommend to continue cyclic nucleotide-gated (HCN) channels (f-channel )
regimens throughout the perioperative period. (UW Health strong
recommendation, low quality evidence)
30.5 Dopamine agonist: fenoldopam
30.5.1 Recommend to coordinate dopamine agonist perioperative medication
management plan with anesthesiologist, surgeon and prescribing provider. (UW
Health strong recommendation, low quality of evidence)
30.6 Ganglionic Blocker: mecamylamine
30.6.1 Recommend to coordinate ganglionic blocker perioperative medication
management plan with anesthesiologist, surgeon, and prescribing provider. (UW
Health strong recommendation, low quality evidence)
30.7 Inotropics: inamrinone, milrinone
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

18


30.7.1 Recommend to coordinate inotropic perioperative medication management plan
with anesthesiologist, surgeon, and prescribing provider. (UW Health strong
recommendation, low quality evidence)
30.8 Inward sodium channel inhibitors: ranolazine
30.8.1 Recommend to continue inward sodium channel inhibitor regimens throughout
the perioperative period. (UW Health strong recommendation, low quality
evidence)
30.8.1.1 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.
51

30.9 Potassium removing resins: patiromer, sodium polystyrene sulfonate
30.9.1 Recommend to coordinate potassium removing resin perioperative medication
management plan with anesthesiologist, surgeon, and prescribing provider. (UW
Health strong recommendation, low quality evidence)

31 Central nervous system (CNS) miscellaneous
31.1 Antianxiety agents: buspirone, meprobamate
31.1.1 Recommend to continue antianxiety agent regimens throughout the perioperative
period. (UW Health strong recommendation, low quality evidence)
31.2 Antidepressants: bupropion, nefazodone, trazodone, vortioxetine
31.2.1 Recommend coordination of antidepressant perioperative medication
management plan with surgeon, anesthesiologist, and prescribing provider.
5,15,23

(UW Health strong recommendation, low quality evidence)
31.2.1.1 See Appendix D – Methylene Blue and Serotonin Syndrome
31.3 Anticholinesterase muscle stimulants: edrophonium, neostigmine, pyridostigmine
31.3.1 Recommend to coordinate anticholinesterase muscle stimulant perioperative
medication management plan with anesthesiologist, surgeon, and prescribing
provider. (UW Health strong recommendation, low quality evidence)
31.4 Antioxidants: edaravone
31.4.1 Recommend to coordinate anticholinesterase muscle stimulant perioperative
medication management plan with anesthesiologist, surgeon, and prescribing
provider. (UW Health strong recommendation, low quality evidence)
31.5 Antisense Oligonucleotide: eteplirsen, nusinersin
31.5.1 Recommend to coordinate antisense oligonucleotide management plan with
anesthesiologist, surgeon, and prescribing provider. (UW Health strong
recommendation, low quality evidence)
31.6 Cholinergic muscle stimulant: guanidine
31.6.1 Recommend to coordinate cholinergic muscle stimulant perioperative medication
management plan with anesthesiologist, surgeon, and prescribing provider. (UW
Health strong recommendation, low quality evidence)
31.7 CNS stimulants: armodafinil, amphetamine, caffeine, dexmethylphenidate,
dextroamphetamine, lisdexamfetamine, methamphetamine, methylphenidate modafinil
31.7.1 Recommend to coordinate armodafinil and modafinil perioperative medication
management plan with anesthesiologist, surgeon, and prescribing provider.
5
(UW
Health strong recommendation, low quality evidence)
31.7.2 It may be reasonable to continue chronic amphetamine, caffeine,
dexmethylphenidate, dextroamphetamine, lisdexamfetamine, methamphetamine,
and methylphenidate regimens throughout the perioperative period.
5
(UW Health
weak recommendation, low quality evidence)
31.8 Glutamate inhibitor: riluzole
31.8.1 Recommend to continue glutamate inhibitor regimens throughout the
perioperative period. (UW Health strong recommendation, low quality evidence)
31.9 Lithium
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

19


31.9.1 Recommend to continue lithium regimens throughout the perioperative period.
5,15

(UW Health strong recommendation, low quality evidence)
31.10 Miscellaneous psychotherapeutic agents: atomoxetine, sodium oxybate
31.10.1 Recommend to continue atomoxetine regimens throughout the perioperative
period. (UW Health strong recommendation, low quality evidence)
31.10.2 Recommend to coordinate sodium oxybate perioperative management plan with
anesthesiologist, surgeon, and prescribing provider. (UW Health strong
recommendation, low quality evidence)
31.11 Mixed 5HT
1A
agonist/5HT
2A
antagonists: flibanserin
31.11.1 Recommend to coordinate mixed 5HT
1A
agonist/5HT
2A
antagonist perioperative
management plan with anesthesiologist, surgeon, and prescribing provider. (UW
Health strong recommendation, low quality evidence)
31.12 Partial neuronal α4 β2 nicotinic receptor agonist: varenicline
31.12.1 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)
31.13 Potassium channel blocker: dalfampridine
31.13.1 Recommend to continue potassium channel blocker regimens throughout the
perioperative period. (UW Health weak recommendation, low quality evidence)
31.14 Tripeptidyl peptidase-1 (TPP-1) analog: Cerliponase alfa
31.14.1 Recommend to coordinate cerliponase alfa perioperative management plan with
anesthesiologist, surgeon, and prescribing provider. (UW Health strong
recommendation, low quality evidence)

32 Corticosteroid: betamethasone, budesonide, cortisone, cosyntropin, deflazacort, dexamethasone,
fludrocortisone, hydrocortisone, methylprednisolone, prednisolone, prednisone, triamcinolone
32.1 Recommend to continue corticosteroid regimens throughout the perioperative period.
5,15

(UW Health strong recommendation, low quality evidence)

33 Diuretics
33.1 Carbonic anhydrase inhibitors: acetazolamide, methazolamide
33.2 Loop diuretics: bumetanide, ethacrynic acid, furosemide, torsemide
33.3 Osmotic: mannitol
33.4 Potassium sparing: amiloride, spironolactone, triamterene
33.5 Thiazides: chlorothiazide, chlorthalidone, hydrochlorothiazide, indapamide,
methyclothiazide, metolazone
33.6 Heart failure with volume overload indication
33.6.1 Recommend to coordinate diuretic perioperative management plan with
anesthesiologist, surgeon, and prescribing provider.
5,15
(UW Health strong
recommendation, low quality of evidence)
33.7 Hypertension indication
33.7.1 Recommend to hold diuretic the day of surgery.
5,15
(UW Health weak
recommendation, low quality of evidence)
33.7.1.1 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.
50


34 Estrogens and Progestins
34.1 Estrogens: conjugated estrogens, ethinyl estradiol, estradiol valerate, esterified
estrogens, estradiol, estradiol cypionate, estropipate
34.2 Progestins: desogestrel, drospirenone, etonogestrel, ethynodiol diacetate,
hydroxyprogesterone caproate, levonorgestrel, medroxyprogesterone acetate, megestrol
acetate, norelgestromin, norgestimate, norgestrel, norethindrone acetate, progesterone,
ulipristal
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

20


34.3 Selective estrogen receptor modulators: bazedoxifene, clomiphene citrate, ospemifene,
raloxifene
34.3.1 Recommend to coordinate estrogen and progestin perioperative management
plan with surgeon, and prescribing provider.
5,15
(UW Health strong
recommendation, low quality of evidence)

35 Endocrine and metabolic agents – miscellaneous
35.1 4-Hydroxyphenylpyruvate dioxygenase inhibitors: nitisinone
35.2 5-Alpha reductase inhibitors: dutasteride, finasteride
35.3 Enzyme replacement: asfotase, agalsidase beta, alglucosidase alfa, elosulfase alfa,
galsulfase, idursulfase, imiglucerase, laronidase, sebelipase, taliglucerase alfa,
velaglucerase alfa
35.4 Anabolic steroid: oxymetholone
35.5 Androgens: danazol, oxandrolone, fluoxymesterone, methyltestosterone, testosterone
35.6 Anti-androgen: cyproterone, dienogest
35.7 Anti-ammonia agent: carglumic acid, glycerol phenylbutyrate, sodium benzoate and
sodium phenylacetate, sodium phenylbutyrate
35.8 Anti-cystine agent: cysteamine
35.9 Anti-prolactin agents: bromocriptine, cabergoline
35.10 Antithyroid agents: methimazole, propylthiouracil, sodium iodide
35.11 Betaine anhydrous
35.12 Bile acids: cholic acid
35.13 Calcimimetics: cinacalcet, etelcalcetide
35.14 Chelating agents: deferasirox, deferiprone, deferoxamine
35.15 Detoxification agents: dimercaprol, edetate calcium disodium, pentetate calcium
trisodium, pentetate zinc trisodium, Prussian blue (ferric hexacyanoferrate succimer
(DMSA)), trientine hydrochloride
35.16 Glucosylceramide synthase inhibitor: eliglustat, miglustat
35.17 Gonadotropin releasing hormone agonist: nafarelin
35.18 Gonadotropin releasing hormone antagonist: cetrorelix, degarelix, ganirelix
35.19 Growth hormone: somatropin
35.20 Growth hormone agonists: macimorelin
35.21 Insulin-like growth factor: mecasermin
35.22 Ivacaftor
35.23 Lipodystrophy agents: metreleptin, tesamorelin
35.24 Lipolytic: deoxycholic acid
35.25 Ovulation stimulator: choriogonadotropin alfa, chorionic gonadotropin, follitropin alfa,
follitropin beta, lutropin alpha, menotropins, urofollitropin
35.26 Parathyroid hormone analogues: abaloparatide, parathyroid, teriparatide
35.27 Pegvisomant
35.28 Phenylketonuria agents: sapropterin dichloride
35.29 Phosphate binders: lanthanum, sevelamer
35.30 Posterior pituitary hormones: desmopressin, vasopressin
35.31 Somatostatin analogs: lanreotide, octreotide, pasireotide
35.32 Thyroid drugs: potassium iodide, levothyroxine sodium, liothyronine sodium, liotrix,
thyroid desiccated
35.33 Tryptophan hydroxylase inhibitors: telotristat
35.34 Uridine Triacetate
35.35 Uterine active agents: carboprost, dinoprostone, methylergonovine maleate, mifepristone,
oxytocin
35.36 Vasopressin receptor antagonists: conivaptan, tolvaptan
35.37 It is reasonable to continue regimens listed in 35.1- 35.35 throughout the perioperative
period, unless specific instructions provided by surgeon or prescribing provider.
15
(UW
Health weak recommendation, low quality evidence)

36 Gastrointestinal agents
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

21


36.1 5-aminosalicylic acid derivatives: balsalazide, mesalamine, olsalazine, sulfasalazine
36.1.1 Recommend to continue 5-aminosalicylic acid derivative regimens throughout the
perioperative period.
52
(UW Health strong recommendation, low quality evidence)
36.2 Antidiarrheals: bismuth subsalicylate, crofelemer, difenoxin/atropine,
diphenoxylate/atropine, loperamide, loperamide/simethicone
36.2.1 Recommend to hold bismuth subsalicylate the day of surgery due to the potential
to cause black stools. (UW Health strong recommendation, low quality evidence)
36.2.2 It is reasonable to continue other antidiarrheals throughout the perioperative
period. (UW Health weak recommendation, low quality evidence)
36.3 Laxatives
36.3.1 Bowel evacuants: polyethylene glycol, PEG-electrolyte combination, sodium
phosphate, sodium phosphate/magnesium oxide/citric acid
36.3.2 Bulk producing laxatives: calcium polycarbophil, methylcellulose, psyllium
36.3.3 Emollients: mineral oil
36.3.4 Surfactants: docusate calcium, docusate sodium
36.3.5 Hyperosmotic agents: glycerin, lactulose, sorbitol
36.3.6 Stimulants: bisacodyl, cascara sagrada, sennosides
36.3.6.1 Recommend to coordinate laxative perioperative medication
management plan with surgeon and prescribing provider (UW Health
strong recommendation, low quality evidence)
36.4 Anti-TNF-alpha agents: adalimumab, certolizumab, golimumab, infliximab (and
biosimilars)
36.4.1 Recommend to coordinate anti-TNF-alpha agents perioperative medication
management plan with surgeon and prescribing provider.
52
(UW Health strong
recommendation, low quality evidence)
36.5 Anti-integrins: natalizumab, vedolizumab
36.5.1 Recommend to coordinate anti-integrin perioperative medication management
plan with surgeon and prescribing provider. (UW Health strong recommendation,
low quality evidence)
36.5.1.1 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.
53

36.6 Other gastrointestinal agents
36.6.1 Antiflatulents: alpha-d-galactosidase, simethicone
36.6.2 Antispasmodics: dicyclomine
36.6.3 Belladonna alkaloids: atropine sulfate, hyoscyamine sulfate, scopolamine
36.6.4 Cholinergic agonists: cevimeline, pilocarpine
36.6.5 Chloride channel activator: lubiprostone
36.6.6 Digestive enzymes: pancreatic enzymes, pancrelipase
36.6.7 Gastrointestinal anticholinergic combinations: clidinium/chlordiazepoxide,
atropine/scopolamine/hyoscyamine/phenobarbital
36.6.8 Gastrointestinal quaternary anticholinergics – antispasmodics: glycopyrrolate,
mepenzolate, methscopolamine, propantheline
36.6.9 GI Stimulants: dexpanthenol, metoclopramide
36.6.10 GLP-2 analogs: teduglutide
36.6.11 Glutamine: L-glutamine
36.6.12 Guanylate cyclase-C agonist: linaclotide, plecanatide
36.6.13 Miscellaneous: eluxadoline, sucralfate, chenodiol, ursodiol, alvimopan,
methylnaltrexone, naloxegol
36.6.14 Systemic deodorizers: bismuth subgallate, chlorophyll derivatives, chlorophyllin
36.6.14.1 Recommend to coordinate perioperative medication management
plan of regimens containing agents in 36.6.1-36.6.14 with surgeon
and prescribing provider except sucralfate (see 36.6.14.2) (UW
Health strong recommendation, low quality evidence)
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

22


36.6.14.2 Recommend to hold sucralfate the day of surgery (UW Health strong
recommendation, low quality evidence)

37 Genitourinary and renal agents – miscellaneous
37.1 Phosphodiesterase Type 5 (PDE-5) Inhibitors: avanafil, sildenafil, tadalafil, vardenafil
(see section 46)
37.2 Cystine depleting agents: cysteamine bitartrate, penicillamine, tiopronin
37.3 Interstitial cystitis agents: dimethyl sulfoxide, pentosan polysulfate sodium,
phenazopyridine, phenazopyridine/butabarbital/hyoscyamine
37.4 Urinary acidifiers: ascorbic acid
37.5 Urinary cholinergics: bethanechol
37.6 Urinary alkalinizers: potassium citrate, sodium bicarbonate, sodium bicarb/citric acid
37.7 Miscellaneous genitourinary agents: acetohydroxamic acid, cellulose sodium phosphate
37.7.1 It is reasonable to continue regimens containing agents in 37.2-37.7 throughout
the perioperative period. (UW Health weak recommendation, low quality
evidence)
38 Gout agents
38.1 β-tubulin polymerization inhibitor: colchicine
38.1.1 Recommend to coordinate colchicine perioperative medication management plan
with surgeon and prescribing provider (UW Health strong recommendation, low
quality evidence)
38.2 Uric acid transporter-1(URAT-1) inhibitor: lesinurad
38.2.1 It is reasonable to continue uric acid transporter-1(URAT-1) inhibitor regimens
throughout the perioperative period. (UW Health weak recommendation, low
quality evidence)
38.3 Urate oxidase: pegloticase
38.3.1 It is reasonable to continue urate oxidase regimens throughout the perioperative
period. (UW Health weak recommendation, low quality evidence)
38.4 Xanthine oxidase inhibitors: allopurinol, febuxostat
38.4.1 It is reasonable to continue xanthine oxidase inhibitors regimens throughout the
perioperative period. (UW Health weak recommendation, low quality evidence)
38.5 Uricosuric agents: probenecid
38.5.1 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)

39 Hematological agents
Additional information can be found in Periprocedural and Regional Anesthesia Management
with Antithrombotic Therapy – Adult – Inpatient and Ambulatory – Clinical Practice Guideline
39.1 Antihemophilic agents: anti-inhibitor coagulant complex, antihemophilic Factor VIII,
coagulation Factor XIIIa, Factor IX, Factor VIIa, Factor XIII, antihemophilic factor/von
Willebrand factor complex
39.1.1 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)
39.2 Antisickling agents: hydroxyurea
39.2.1 Recommend to continue antisickling agent regimens throughout the perioperative
period. (UW Health strong recommendation, low quality of evidence)
39.3 Bradykinin inhibitors: icatibant
39.3.1 It is reasonable to continue bradykinin inhibitor regimens throughout the
perioperative period. (UW Health weak recommendation, low quality evidence)
39.4 Coagulants: protamine
39.4.1 Recommend to coordinate protamine perioperative medication management plan
with anesthesiologist, surgeon, and prescribing provider. (UW strong
recommendation, low quality of evidence)
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

23


39.5 Erythropoiesis-stimulating agents (ESA): darbepoetin, epoetin alfa, epoetin beta,
methoxy polyethylene glycol-epoetin beta
39.5.1 It is reasonable to continue erythropoiesis-stimulating agent regimens throughout
the perioperative period. (UW Health weak recommendation, low quality
evidence)
39.6 Hematopoietic stem cell mobilizer: plerixafor
39.6.1 Recommend to coordinate plerixafor perioperative medication management plan
with surgeon and prescribing provider (UW Health strong recommendation, low
quality evidence)
39.7 Granulocyte-colony stimulating factors: filgrastim, pegfilgrastim
39.7.1 Recommend to coordinate granulocyte-colony stimulating factor perioperative
medication management plan with surgeon and prescribing provider (UW Health
strong recommendation, low quality evidence)
39.8 Granulocyte macrophage colony-stimulating factor: sargramostim
39.8.1 Recommend to coordinate granulocyte macrophage colony-stimulating factor
perioperative medication management plan with surgeon and prescribing
provider (UW Health strong recommendation, low quality evidence)
39.9 Thrombopoietic agents: eltrombopag, oprelvekin, romiplostim
39.9.1 Recommend to coordinate thrombopoietic agent perioperative medication
management plan with surgeon and prescribing provider (UW Health strong
recommendation, low quality evidence)
39.10 Hemin
39.10.1 Recommend to coordinate hemin perioperative medication management plan
with surgeon and prescribing provider (UW Health strong recommendation, low
quality evidence)
39.11 Hemorrheologic agents: pentoxifylline
39.11.1 Recommend to coordinate pentoxifylline perioperative medication management
plan with surgeon and prescribing provider (UW Health strong recommendation,
low quality evidence)
39.12 Hemostatics: absorbable gelatin, aminocaproic acid, ferric subsulfate, fibrinogen
concentrate, microfibrillar collagen hemostat, oxidized cellulose, prothrombin complex
concentrate, thrombin, tranexamic acid
39.12.1 Recommend to coordinate hemostatic perioperative medication management
plan with anesthesiologist, surgeon, and prescribing provider (UW Health strong
recommendation, low quality evidence)
39.13 Kallikrein Inhibitor: ecallantide
39.13.1 It is reasonable to continue kallikrein inhibitor regimens throughout the
perioperative period. (UW Health weak recommendation, low quality evidence)
39.14 Plasma expanders: albumin human, dextran 40, hetastarch, plasma protein fraction,
tetrastarch
39.14.1 It is reasonable to continue plasma expander regimens throughout the
perioperative period. (UW Health weak recommendation, low quality evidence)
39.15 Protein C1 esterase inhibitor: C1 esterase inhibitor (Cinryze)
39.15.1 Recommend to continue C1 esterase inhibitor regimens throughout the
perioperative period. (UW Health strong recommendation, low quality evidence)
39.16 Thrombolytic agents: alteplase, defibrotide, protein C concentrate, reteplase,
tenecteplase, urokinase
39.16.1 Recommend to coordinate thrombolytic agents perioperative medication
management plan with anesthesiologist, surgeon, and prescribing provider (UW
Health strong recommendation, low quality evidence)
40 Herbals and Supplements
40.1 Amino Acids: levocarnitine, L-lysine, methionine, threonine
40.2 Electrolytes: potassium, sodium chloride
40.3 Fish Oils: omega-3 fatty acids
40.4 Lipotropics: choline, inositol
40.5 Minerals: calcium, magnesium, phosphorus
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

24


40.6 Miscellaneous: coenzyme q10, lactase, sacrosidase
40.7 Systemic Alkalinizers: citric acid, citrate, tromethamine
40.8 Trace Elements: chromium, copper, fluoride, iron, manganese, selenium, zinc
40.9 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
40.10 Inborn errors of metabolism
40.10.1 Recommend to coordinate use of supplements and perioperative medication
management plan with anesthesiologist, surgeon, and prescribing provider (UW
Health strong recommendation, low quality evidence)
40.11 All other patients
40.11.1 Recommend to hold herbals and supplements 7 days prior to surgery.
5,15,23
(UW
Health strong recommendation, low quality evidence)

41 Immunologic agents
41.1 Immunomodulators: abatacept, adalimumab, anakinra, apremilast, brodalumab,
canakinumab, certolizumab, daclizumab, dimethyl fumarate, etanercept, fingolimod,
golimumab, guselkumab, infliximab (and biosimilars), interferons, ixekizumab,
lenalidomide, mitoxantrone, natalizumab, pembrolizumab, pomalidomide, rilonacept,
secukinumab, teriflunomide, thalidomide, tocilizumab, ustekinumab, vedolizumab
41.2 Immunostimulants: pegademase bovine
41.3 Immunosuppressives: alefacept, azathioprine, basiliximab, belatacept, cyclosporine,
dupilumab, durvalumab, glatiramer, mycophenolate, ocrelizumab, sirolimus, tacrolimus
41.4 Keratinocyte Growth Factors: palifermin
41.5 Miscellaneous Monoclonal Antibodies: belimumab, denosumab, eculizumab,
palivizumab, raxibacumab, sarilumab, siltuximab
41.6 Recommend to coordinate immunologic agent perioperative medication management
plan with surgeon and prescribing provider. (UW Health strong recommendation, low
quality evidence)

42 Intranasal anti-allergy: azelastine, olopatadine
42.1 It is reasonable to continue intranasal anti-allergy regimens throughout the perioperative
period. (UW Health weak recommendation, low quality evidence)

43 Migraine agents: isometheptene, almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan,
sumatriptan, zolmitriptan
43.1 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 D – Methylene Blue and Serotonin Syndrome
43.1.1 Drug-drug interactions between serotonin agonists “triptans” and common
perioperative medications (e.g. ondansetron, methylene blue) may result in
serotonin syndrome.
18


44 Monoamine Oxidase Inhibitors (MAOIs): isocarboxazid, phenelzine, selegiline, tranylcypromine
44.1 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 D – Methylene Blue and
Serotonin Syndrome

45 Ophthalmic/Otic agents (miscellaneous); see above for anti-glaucoma agents
45.1 Cycloplegic mydriatics: atropine sulfate, cyclopentolate HCl, homatropine hydrobromide,
scopolamine hydrobromide, tropicamide, cyclopentolate/phenylephrine
hydroxyamphetamine, hydrobromide/tropicamide
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

25


45.2 Antibiotics: azithromycin, bacitracin, besifloxacin, ciprofloxacin HCl, erythromycin,
gatifloxacin, gentamicin, levofloxacin, moxifloxacin, ofloxacin, sulfacetamide Na,
tobramycin
45.3 Antihistamines: alcaftadine, azelastine HCl, emedastine difumarate, epinastine HCl,
ketotifen, olopatadine HCl
45.4 Corticosteroids: dexamethasone, difluprednate, fluocinolone acetonide, fluorometholone
acetate, loteprednol etabonate, prednisolone, rimexolone, triamcinolone acetonide
45.5 Decongestants: naphazoline HCl, oxymetazoline HCl, phenylephrine HCl,
tetrahydrozoline HCl
45.6 Immunologic: cyclosporine
45.7 Mast Cell Stabilizer: bepotastine besilate, cromolyn Na, lodoxamide tromethamine,
nedocromil Na
45.8 Nonsteroidal Anti-Inflammatories: bromfenac, diclofenac Na, flurbiprofen Na, ketorolac
tromethamine, nepafenac
45.9 Otic Preparations (Miscellaneous): antipyrine/benzocaine, ciprofloxacin, ofloxacin,
fluocinolone acetonide, ciprofloxacin HCl/hydrocortisone, ciprofloxacin/dexamethasone,
neomycin/polymyxin b/hydrocortisone
45.10 Selective Vascular Endothelial Growth Factor Antagonists: aflibercept, pegaptanib Na,
ranibizumab
45.11 It is reasonable to continue regimens using agents in 45.1-45.11 throughout the
perioperative period. (UW Health weak recommendation, low quality evidence)

46 Phosphodiesterase Type 5 (PDE-5) Inhibitors: avanafil, sildenafil, tadalafil, vardenafil
46.1 Erectile dysfunction
46.1.1 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)
46.2 Pulmonary artery hypertension (PAH)
46.2.1 Recommend to continue phosphodiesterase type 5 (PDE-5) inhibitor
regimens when used for PAH throughout the perioperative period as
discontinuation may be fatal.
54-57
(UW Health strong recommendation, low
quality of evidence)
46.3 Benign prostatic hyperplasia (BPH)
46.3.1 Recommend to coordinate phosphodiesterase type 5 (PDE-5) inhibitor
perioperative medication management plan when used for BPH with
anesthesiologist, surgeon, and prescribing provider.
54-57
(UW Health strong
recommendation, low quality of evidence)

47 Pheochromocytoma agents
47.1 Tyrosine Hydroxylase Inhibitor: metyrosine
47.2 Alpha 1-Blocker: phenoxybenzamine hydrochloride, phentolamine mesylate
47.2.1 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)

48 Renin Angiotensin System Antagonists
48.1 Angiotensin Converting Enzyme Inhibitor (ACE): benazepril, captopril, cilazapril enalapril,
enalaprilat, fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, trandolapril
48.2 Angiotensin II receptor blockers (ARB): candesartan, losartan, olmesartan, valsartan
48.3 Direct renin inhibitors: aliskiren
48.4 Recommend holding ACE, ARB, and direct renin inhibitor regimens 24 hours prior to
surgery and the day of surgery.
58
(UW Health strong recommendation, low quality
evidence)
48.5 Sample patient instructions
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

26



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

48.6 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)
48.6.1 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

48.7 Neprilysin inhibitor: sacubitril
48.7.1 Recommend to coordinate neprilysin inhibitor regimens with anesthesiologist and
prescribing physician. (UW Health strong recommendation, low quality evidence)
48.8 Aldosterone Receptor Antagonists: eplerenone, spironolactone
48.8.1 It is reasonable to continue aldosterone receptor antagonist regimens throughout
the perioperative period. (UW Health weak recommendation, low quality
evidence)

49 Respiratory agents
49.1 Inhaled (oral) sympathomimetics: albuterol, arformoterol, ephedrine, epinephrine,
formoterol, indacaterol, isoproterenol, levalbuterol, metaproterenol, olodaterol, pirbuterol,
salmeterol, terbutaline, vilanterol
49.1.1 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

49.2 Inhaled (oral) anticholinergics: aclidinium, ipratropium , tiotropium, umeclidinium
49.2.1 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)
49.3 Xanthine derivatives: aminophylline, dyphylline, theophylline
49.3.1 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)
49.3.1.1 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
49.4 Inhaled corticosteroids: beclomethasone, budesonide, ciclesonide, flunisolide,
fluticasone, mometasone
49.4.1 Recommend to continue inhaled corticosteroid regimens throughout the
perioperative period.
65
(UW Health strong recommendation, moderate quality of
evidence)
49.5 Interleukin-5 receptor antagonists: mepolizumab, reslizumab
49.5.1 Recommend to continue interleukin-5 receptor antagonist regimens throughout
the perioperative period. (UW Health strong recommendation; low quality
evidence)
49.6 Leukotriene inhibitors/ modifiers: montelukast, zafirlukast, zileuton
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

27


49.6.1 Recommend to continue leukotriene inhibitor/ modifier regimens throughout the
perioperative period and administer on the morning of surgery.
15
(UW Health
strong recommendation, low quality evidence).
49.7 Monoclonal antibody (IgE): omalizumab
49.7.1 Recommend to continue monoclonal antibody (IgE) regimens throughout the
perioperative period. (UW Health strong recommendation; low quality evidence)
49.8 Antifibrotic agent: pirfenidone
49.8.1 Recommend to coordinate pirfenidone perioperative medication management
plan with surgeon and prescribing provider. (UW Health strong recommendation,
low quality evidence)
49.9 Arylalkylamine decongestants: phenylephrine, pseudoephedrine
49.9.1 Recommend to hold arylalkylamine decongestants the day of surgery. (UW
Health strong recommendation, low quality evidence)
49.10 Expectorants: guaifenesin, potassium iodide
49.10.1 It is reasonable to continue expectorant regimens throughout the perioperative
period. (UW Health weak recommendation; low quality evidence)
49.11 Lung surfactant: beractant, calfactant, lucinactant, poractant
49.11.1 It is reasonable to continue lung surfactant regimens throughout the perioperative
period. (UW Health weak recommendation; low quality evidence)
49.12 Mucolytic: acetylcysteine, dornase alfa
49.12.1 Recommend to continue mucolytic regimens throughout the perioperative
period. (UW Health strong recommendation, low quality of evidence)
49.13 Non-narcotic anti-tussive: benzonatate, dextromethorphan
49.13.1 It is reasonable to continue non-narcotic anti-tussive regimens throughout the
perioperative period. (UW Health weak recommendation; low quality evidence)
49.14 Phosphodiesterase 4 inhibitor: roflumilast
49.14.1 Recommend to continue phosphodiesterase 4 inhibitor regimens throughout the
perioperative period. (UW Health strong recommendation, low quality evidence)
49.15 Respiratory enzymes: alpha 1- proteinase inhibitor
49.15.1 Recommend to continue respiratory enzyme regimens throughout the
perioperative period. (UW Health strong recommendation, low quality of
evidence)
49.16 Tyrosine kinase inhibitor: nintedanib
49.16.1 Recommend to continue tyrosine kinase inhibitor regimens throughout the
perioperative period. (UW Health strong recommendation, low quality of
evidence)

50 Sedatives and Hypnotics
50.1 Barbiturates: amobarbital, butabarbital, pentobarbital, phenobarbital, secobarbital
50.2 Nonbarbiturates: chloral hydrate, dexmedetomidine, eszopiclone, ramelteon, suvorexant,
tasimelteon, zaleplon, zolpidem
50.3 Recommend to coordinate sedative and hypnotic perioperative medication management
plan with anesthesiologist, surgeon, and prescribing provider. (UW Health strong
recommendation, low quality evidence)

51 Selective Serotonin Reuptake Inhibitors (SSRIs): citalopram, escitalopram, fluoxetine,
fluvoxamine, paroxetine, sertraline, vilazodone
51.1 Recommend to coordinate SSRI perioperative medication management plan with
surgeon, anesthesiologist, and prescribing provider.
5,15,23
(UW Health strong
recommendation, low quality evidence) See Appendix D – Methylene Blue and Serotonin
Syndrome
51.1.1 Drug interactions between SSRIs and antiplatelet therapy for secondary
prevention (aspirin or thienopyridine therapy) may increase the risk of
bleeding.
66,67,68


Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

28


52 Selective Norepinephrine Reuptake Inhibitors (SNRIs): desvenlafaxine, duloxetine,
levomilnacipran, milnacipran, venlafaxine
52.1 Recommend to coordinate SNRI perioperative medication management plan with
surgeon, anesthesiologist, and prescribing provider.
5,15,23
(UW Health strong
recommendation, low quality evidence) See Appendix D – Methylene Blue and Serotonin
Syndrome

53 Skeletal Muscle Relaxants
53.1 Direct Acting: dantrolene
53.1.1 Recommend to continue dantrolene regimens throughout the perioperative
period. (UW Health strong recommendation, low quality evidence)
53.2 Centrally Acting: baclofen, carisoprodol, chlorzoxazone, cyclobenzaprine, diazepam,
metaxalone, methocarbamol, orphenadrine, tizanidine
53.2.1 Recommend to continue baclofen regimens throughout the perioperative
period.
69,70
(UW Health strong recommendation, low quality evidence)
53.2.1.1 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

53.2.2 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)

54 Tetracyclic antidepressants: maprotiline, mirtazapine
54.1 It is reasonable to continue tetracyclic antidepressant regimens throughout the
perioperative period. (UW Health weak recommendation, low quality of evidence)

55 Toxins
55.1 Botulinum Type A toxin: abobotulinum, incobotulinum, onabotulinum
55.2 Type B toxin: rimabotulinum
55.2.1 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)

56 Tricyclic antidepressants: amitriptyline, amoxapine, clomipramine, desipramine, doxepin,
imipramine, nortriptyline, protriptyline, trimipramine
56.1 It is reasonable to continue tricyclic antidepressant regimens throughout the perioperative
period.
5,15,23
(UW Health weak recommendation, low quality of evidence)
56.1.1 Due to effects on the cardiac conduction system, tricyclic antidepressants may
increase the risk of cardiac arrhythmia.
71

56.1.2 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


57 Vasodilators
57.1 Endothelin Receptor Antagonist: ambrisentan, bosentan, macitentan
57.1.1 Recommend to continue endothelin receptor antagonist regimens throughout the
perioperative period. (UW Health strong recommendation, low quality evidence)
57.2 Human B-Type Natriuretic Peptide: nesiritide
57.2.1 Recommend to continue nesiritide regimens throughout the perioperative period.
(UW Health strong recommendation, low quality evidence)
57.3 Nitrates: amyl nitrate, isosorbide dinitrate, isosorbide mononitrate, nitroglycerin
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

29


57.3.1 Recommend to continue nitrate regimens throughout the perioperative period.
5,15

(UW Health strong recommendation, low quality evidence)
57.4 Peripheral Vasodilators: hydralazine, isoxsuprine, minoxidil, papaverine
57.4.1 Recommend to coordinate peripheral vasodilator perioperative medication
management plan with surgeon, anesthesiologist and prescribing provider. (UW
Health strong recommendation, low quality evidence)
57.5 Prostanoids: epoprostenol, iloprost, selexipag, treprostinil
57.5.1 Recommend to coordinate prostanoid perioperative medication management
plan with surgeon, anesthesiologist and prescribing provider. (UW Health strong
recommendation, low quality evidence)
57.6 Soluble Guanylate Cyclase Stimulator : riociguat
57.6.1 Recommend to coordinate riociguat perioperative medication management plan
with surgeon, anesthesiologist and prescribing provider. (UW Health strong
recommendation, low quality evidence)

58 Vasopressors: dobutamine, dopamine, droxidopa, ephedrine, epinephrine, isoproterenol,
norepinephrine, phenylephrine
58.1 Recommend to coordinate vasopressor perioperative medication management plan with
surgeon, anesthesiologist and prescribing provider. (UW Health strong recommendation,
low quality evidence)

UW Health Implementation
Potential Benefits:
• Improved coordination of care related to perioperative medications
• Reduction in surgery delays or cancellations resulting from inappropriate administration of
medications in the pre-operative period.

Potential Harms:
• Medications held perioperative are not resumed appropriately when indicated postoperatively.

Qualifying Statements:
• There is a paucity of high-quality evidence; rather recommendations are based upon expert
opinion and clinical experience.

Pertinent UW Health Policies & Procedures
• None identified

Patient Resources
• None identified

Guideline Metrics
• None planned

Implementation Plan/Clinical Tools
1. Guideline will be posted on uConnect in a dedicated location for Clinical Practice Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the guideline
recommendations (such as the following) will be reviewed for consistency and modified as
appropriate.

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
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

30


the clinical condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

31


Appendix A: Evidence Grading Schemes

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
The net benefit of the treatment is clear, patient values and circumstances are
unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and preferences, the
resources available, or the setting in which the intervention will be implemented.


Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

32






Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

33


Appendix B: Perioperative Medication Management
From: Perioperative Medication Management – Adult/Pediatric – Inpatient/Ambulatory
Clinical Practice Guideline
Last Reviewed 12/2016; Last Updated 1/2018
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



H
2
-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



Alpha
1
blockers
Alpha
1
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

Alpha
2
adrenergic agonists
Alpha
2
- agonists Clonidine
Guanfacine
Methyldopa
Tizanidine
Recommend to continue regimen throughout
the perioperative period

Analgesics
Acetaminophen It is reasonable to continue regimen
throughout the perioperative period

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

34


Class Medication Recommendation
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
Hydromorpho
ne
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


Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

35


Class Medication Recommendation
Recommend coordination of post-operative
pain management plan with anesthesiologist,
surgeon, and primary care physician in order
to minimize use of opioids
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
Procainamid
e
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

Anti-convulsants
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

36


Class Medication Recommendation
Anticonvulsants Acetazolamide
Brivaracetam
Carbamazepine
Divalproex
Eslicarbazepine
Felbamate
Lacosamide
Lamotrigine
Levetiracetam
Oxcarbazepi
ne
Perampanel
Primidone
Rufinamide
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
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

37


Class Medication Recommendation
Antidopaminergics
Chlorpromazine
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
Netupitant
Rolapitant

Class Medication Recommendation
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
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

38


Class Medication Recommendation
Anti-hyperlipidemia agents (non-statins)
Alirocumab
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


Class Medication Recommendation
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
Streptomycin
Tobramycin
Anthelmintics Albendazole (Albenza)
Ivermectin (Stromectol)
Praziquantel (Biltricide)
Pyrantel (Pin-X)
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
Hydroxychloroquin
e
Artemether/Lumef
antrine
Atovaquone/Progu
anil
Primaquine
Quinine sulfate
Pyrimethamine
Mefloquine
Antiprotozoals Atovaquone
Miltefosine
Nitazoxanide
Pentamidine
Tinidazole
Antiretroviral
agents
Abacavir
Atazanavir
Cobicistat
Darunavir
Delavirdine
Didanosine
Dolutegravir
Efavirenz
Lamivudine
Lopinavir
Maraviroc
Nefinavir
Nevirapine
Raltegravir
Rilpivirine
Ritonavir
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

39


Elvitegravir
Emtricitabine
Enfuvirtide
Etravirine
Fosamprenavir
Indinavir
Saquinavir
Stavudine
Tenofovir
Tipranavir
Zidovudine
Antituberculosis
Agents
Aminosalicylic
acid
Benaquiline
Capreomycin
Cycloserine
Ethambutol
Ethionamide
Isoniazid
Pyrazinamide
Rifabutin
Rifampin
Rifapentine
Streptomycin
Antiviral Agents Adefovir
Amantadine
Acyclovir
Boceprevir
Cidofovir
Daclatasvir
Elbasvir/grazoprev
ir
Entecavir
Famciclovir
Foscarnet
Ganciclovir
Glecaprevir/pibren
tasvir
Ledipasvir/Sofosb
uvir
Letermovir
Ombitasvir/Paritaprev
ir/Ritonavir/Dasabuvir
Oseltamivir
Peramivir
Ribavirin
Rimantadine
Simeprevir
Sofosbuvir
Telaprevir
Telbivudine
Valacyclovir
Valganciclovir
Velpatasvir
Voxilaprevir
Zanamivir
Bacitracin Bacitracin
Carbapenems Doripenem
Ertapenem
Imipenem/Cilastatin
Meropenem
Meropenem/vaborbac
tam
Cephalosporins Cefaclor
Cefadroxil
Cefazolin
Cefdinir
Cefditoren
Cefepime
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
Lipoglycopeptide
s
Dalbavancin
Oritavancin
Telavancin
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

40



Lipopeptides Daptomycin
Macrolides Azithromycin
Clarithromycin
Erythromycin
Fidaxomicin
Methenamines Methenamine Hippurate
Methenamine Mandelate
Miscellaneous Benznidazole
Fosfomycin
Metronidazole
Secnidazole
Monobactams Aztreonam
Monoclonal
antibodies
Bezlotoxumab
Nitrofurans Nitrofurantoin
Oxazolidinones Linezolid Tedizolid
Penicillins Amoxicillin
Amoxicillin/Clavulanate
Ampicillin
Ampicillin/sulbactam
Dicloxacillin
Nafcillin
Oxacillin
Penicillin G
Penicillin V
Piperacillin/Tazobactam
Ticarcillin/Clavulanate
Polymyxin B Sulfate
Rifaximin
Streptogramins Quinupristin/Dalfopristin
Sulfadiazine Sulfadiazine
Tetracyclines Demeclocycline
Doxycycline
Minocycline
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
Phosphodiestera
se inhibitor
Flavoxate

Anti-neoplastics
Alkylating Agents Altretamine
Busulfan
Carmustine
Chlorambucil
Dacarbazine
Estramustine
Ifosfamide
Lomustine
Mechlorethamin
e
Melphalan
Streptozocin
Thiotepa
Recommend to coordinate
antineoplastic perioperative
medication management plan
with surgeon and prescribing
provider










Anthracenedione Mitoxantrone
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

41


Antibody-Drug
Conjugates
ADO-Trastuzumab Emtansine
Brentuximab Vedotin










































Recommend to coordinate
antineoplastic perioperative
medication management plan
with surgeon and prescribing
provider








































































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
DNA Demethylation
Agents
Azacitidine
Decitabine
Nelarabine
DNA
Topoisomerase
Inhibitors
Irinotecan
Topotecan
Enzymes Asparaginase
Pegaspargase
Epipodophyllotoxins Etoposide
Teniposide
Histone
Deacetylase
Inhibitors
Belinostat
Panobinostat
Romidepsin
Vorinostat
Hormones Abiraterone
Anastrazole
Bicalutamide
Buserelin
Enzalutamide
Exemestane
Flutamide
Fulvestrant
Goserelin
Histrelin
Letrozole
Leuprolide
Medroxyprogest
erone
Megestrol
Nilutamide
Tamoxifen
Toremifene
Triptorelin
Hedgehog Pathway
Inhibitor
Sonidegib
Vismodegib
Imidazotetrazine
derivatives
Temozolomide
Kinase inhibitors Abemaciclib
Acalabrutinib
Afatinib
Lapatinib
Lenvatinib
Midostaurin
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

42


Alectinib
Axitinib
Bosutinib
Brigatinib
Cabozantinib
Ceritinib
Cobimetinib
Copanlisib
Crizotinib
Dabrafenib
Dasatinib
Enasidenib
Erlotinib
Everolimus
Gefitinib
Ibrutinib
Idelalisib
Imatinib

Neratinib
Nilotinib
Osimertinib
Palbociclib
Pazopanib
Ponatinib
Regorafenib
Ribociclib
Ruxolitinib
Sorafenib
Sunitinib
Temsirolimus
Trametinib
Vandetanib
Vemurafenib
















Recommend to coordinate
antineoplastic perioperative
medication management plan
with surgeon and prescribing
provider







































Methylhydrazine
derivatives
Procarbazine
Miscellaneous
Antineoplastics
Arsenic Trioxide
Mitotane
Porfimer
Sipuleucel-T
Sterile Talc Powder
Trabectedin
Trifluridine/tipiracil
Monoclonal
antibodies
Alemtuzumab
Atezolizumab
Avelumab
Bevacizumab and
biosimilars
Blinatumomab
Cetuximab
Daratumumab
Dinutuximab
Elotuzumab
Gemtuzumab
Ibritumomab
Inotuzumab
Ipilimumab
Necitumumab
Nivolumab
Obinutuzumab
Ofatumumab
Olaratumab
Panitumumab
Pertuzumab
Ramucirumab
Rituximab
Trastuzumab
(and
biosimilars)
PARP Enzymes
Inhibitor
Olaparib
Rucaparib
Platinum
Coordination
Complex
Carboplatin
Cisplatin
Oxaliplatin
Proteasome
Inhibitors
Bortezomib
Carfilzomib
Ixazomib
Protein Synthesis
Inhibitor
Omacetaxine
Radiopharmaceutic
als
Radium RA 223
Samarium SM 153
Sodium Iodide I 131
Strontium-89 Chloride
Retinoids Tretinoin
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

43



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
Anti-Parkinson’s Agents
Antiparkinson
agents
Amantadine
Apomorphine
Belladonna alkaloids
Benztropine
Bromocriptine
Carbidopa
Carbidopa/Levodopa
Carbidopa/Levodopa/
Entacapone
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
cardiologist, neurosurgeon,
vascular surgeon)

Anti-psychotics
1
st
generation –
Typical
Chlorpromazine
Fluphenazine
Haloperidol
Loxapine
Perphenazine
Pimozide
Prochlorperazin
e
Thioridazine
Thiothixene
Trifluoperazine
Recommend to continue regimen
throughout the perioperative
period

2
nd
generation –
Atypical

Aripiprazole
Asenapine
Brexpiprazole
Cariprazine
Clozapine
Iloperidone
Lurasidone
Olanzapine
Paliperidone
Pimavanserin
Quetiapine
Risperidone
Ziprasidone
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

44


Antirheumatic Agents
Janus associated
kinase (JAK)
inhibitors
Tofacitinib 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
Certolizumab
Etanercept
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

Interleukin-6
blockers
Tocilizumab Orthopedic surgery: Recommend to
• hold subcutaneous tocilizumab 3 weeks prior to
surgery
• hold intravenous tocilizumab 4 weeks prior to
surgery

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

45


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

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

46


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
Alpha
1
-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

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

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

47



Anticholinesteras
e 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
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

Glutamate
Inhibitor
Riluzole Recommend to continue regimen
throughout the perioperative
period

Lithium Lithium Recommend to continue regimen
throughout the perioperative
period

Miscellaneous
psychotherapeuti
c agents
Atomoxetine
Sodium oxybate
Atomoxetine: Recommend to
continue regimen throughout the
perioperative period

Sodium oxybate: Recommend
to coordinate sodium oxybate
perioperative management plan
with anesthesiologist, surgeon,
and prescribing provider

Mixed 5HT
1A

agonist/5HT
2A

antagonist
Flibanserin 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

Potassium
Channel Blocker
Dalfampridine Recommend to continue regimen
throughout the perioperative
period

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

48



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
Ulipristal
Selective
Estrogen
Receptor
Modulator
Bazedoxifene
Clomiphene Citrate
Ospemifene
Raloxifene
Endocrine and Metabolic Agents – Miscellaneous
4-
Hydroxyphenylpy
ruvate
dioxygenase
inhibitor
Nitisinone It is reasonable continue regimen
throughout the perioperative
period.

5-Alpha
Reductase
Inhibitor
Dutasteride
Finasteride

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

49


Anabolic Steroid Oxymetholone

Androgens Danazol
Oxandrolone
Fluoxymesterone
Methyltestosterone
Testosterone

Anti-androgen Cyproterone Dienogest
Antithyroid
Agents
Methimazole
Propylthiouracil
Sodium Iodide
Betaine
Anhydrous
Betaine Anhydrous
Bile Acids Cholic Acid
Bromocriptine
Mesylate
Bromocriptine Mesylate
Cabergoline Cabergoline
Calcimimetics Cinacalcet
Etelcalcetide
Carglumic acid Carglumic acid
Chelating Agent Deferasirox
Deferiprone
Deferoxamine
Cysteamine Cysteamine
Detoxification
agents
Dimercaprol
Edetate Calcium
Disodium
Pentetate Calcium
Trisodium
Pentetate Zinc
Trisodium
Prussian Blue
(Ferric
Hexacyanoferra
te)
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
Glucosylceramid
e Synthase
Inhibitor
Eliglustat
Miglustat
Glycerol
Phenylbutyrate
Glycerol Phenylbutyrate
Gonadotropin
Releasing
Hormone Agonist
Nafarelin
Gonadotropin
Releasing
Hormone
Antagonist
Cetrorelix
Degarelix
Ganirelix

Growth Hormone Somatropin
Growth Hormone
Agonists
Macimorelin
Insulin-like
growth factor
Mecasermin
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

50


Ivacaftor Ivacaftor
Lipodystrophy
agents
Metreleptin
Tesamorelin
Lipolytic Deoxycholic acid
Ovulation
Stimulator
Choriogonadotropin Alfa
Chorionic Gonadotropin
Follitropin alfa
Follitropin beta
Lutropin Alpha
Menotropins
Urofollitropin

Parathyroid
hormone
analogues
Abaloparatide
Parathyroid
Teriparatide
Pegvisomant Pegvisomant
Phenylketonuria
agents
Sapropterin Dichloride
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
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

51




Surfactants Docusate calcium
Docusate sodium
Hyperosmotic
agents
Glycerin
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





All other medications:
Recommend to continue regimen
throughout the perioperative
period




Antispasmodics Dicyclomine
Belladonna
alkaloids
Atropine sulfate
Hyoscyamine sulfate
Scopolamine
Cholinergic
Agonist
Cevimeline
Pilocarpine
Chloride Channel
Activator
Lubiprostone
Digestive
Enzymes
Pancreatic Enzymes
Pancrelipase
GI Anticholinergic
Combinations
Atropine/scopolamine/hyoscyamine/pheno
barbital
Clidinium/chlordiazepoxide
GI Quaternary
Anticholinergics
Glycopyrrolate
Mepenzolate
Methscopolamine
Propantheline
GI stimulants Dexpanthenol
Metoclopramide
GLP-2 analogs Teduglutide
Glutamine L-glutamine
Guanylate
cyclase-C agonist
Linaclotide
Plecanatidecalci
Miscellaneous Eluxadoline
Sucralfate
Chenodiol
Ursodiol
Alvimopan
Methylnaltrexone
Naloxegol
Systemic
Deodorizers
Bismuth subgallate
Chlorophyll
derivatives
Chlorophyllin
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

52


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/butabarbital/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

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
Antisickling
agents
Hydroxyurea Recommend to continue regimen in
the perioperative period

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

53


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
Epoetin Alfa
Epoetin Beta
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
Pegfilgrastim

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
Eltrombopag
Oprelvekin
Romiplostim

Recommend to coordinate
perioperative medication
management plan with surgeon and
prescribing provider

Hemin Hemin 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

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 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

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

54




Thrombolytic
agents
Alteplase
Defibrotide
Protein C Concentrate
Reteplase
Tenecteplase
Urokinase
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.







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
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
Immunologic Agents
Immunomodulato
rs
Abatacept
Adalimumab
Anakinra
Apremilast
Brodalumab
Canakinumab
Certolizumab
Daclizumab
Dimethyl Fumarate
Etanercept
Fingolimod
Interferons
Ixekizumab
Lenalidomide
Mitoxantrone
Natalizumab
Pembrolizumab
Pomalidomide
Rilonacept
Secukinumab
Teriflunomide
Thalidomide
Recommend to coordinate
perioperative medication
management plan with surgeon and
prescribing provider

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

55



Golimumab
Guselkumab
Infliximab (and
biosimilars)
Tocilizumab
Ustekinumab
Vedolizumab
Immunostimulant
s
Pegademase Bovine
Immunosuppressi
ves
Alefacept
Azathioprine
Basiliximab
Belatacept
Cyclosporine
Dupilumab
Durvalumab
Glatiramer
Mycophenolate
Ocrelizumab
Sirolimus
Tacrolimus
Keratinocyte
Growth Factors
Palifermin
Miscellaneous
Monoclonal
Antibodies
Belimumab
Denosumab
Eculizumab
Palivizumab
Raxibacumab
Sarilumab
Siltuximab
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
Sympathomimeti
c
Isometheptene Recommend to hold therapy the day
of surgery, although may be
approved with coordination of
anesthesiologist

Serotonin
5HT
1B,1D
Agonist
(triptans)
Almotriptan
Eletriptan Frovatriptan
Naratriptan
Rizatriptan,
Sumatriptan,
Zolmitriptan
Ergot Derivatives Dihydroergotamine mesylate
Ergotamine tartrate
Monoamine Oxidase Inhibitors
Monoamine
Oxidase
Inhibitors (MAOI)
Isocarboxazid
Phenelzine
Tranylcypromine
Recommend to coordinate
perioperative medication
management plan with
anesthesiologist, surgeon, and
prescribing provider

Ophthalmic Agents – Miscellaneous
Cycloplegic
Mydriatics
Atropine Sulfate
Cyclopentolate HCl
Homatropine HBr
Scopolamine HBr
Tropicamide
Cyclopentolate/Phenylephrine
Hydroxyamphetamine
Hydrobromide/Tropicamide
Recommend to continue regimen
throughout the perioperative period

Antibiotics Azithromycin
Bacitracin
Besifloxacin
Ciprofloxacin HCl
Erythromycin
Gentamicin
Levofloxacin
Moxifloxacin
Ofloxacin
Sulfacetamide
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

56


Gatifloxacin 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
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
Phosphodiestera
se-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

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

57


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

Alpha
1
-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
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

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

58


Inhaled
corticosteroids
Beclomethasone
Budesonide
Ciclesonide
Flunisolide
Fluticasone
Mometasone
Recommend to continue regimen
throughout the perioperative period

Inhaled
sympathomimetic
s
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
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
Ramelteon
Suvorexant
Tasimelteon
Zaleplon
Zolpidem
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

59



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
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

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

60




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

Vasopressors Dobutamine
Dopamine
Droxidopa
Ephedrine
Epinephrine
Isoproterenol
Norepinephrine
Phenylephrine

Recommend to coordinate
perioperative medication management
plan with surgeon, anesthesiologist
and prescribing provider

Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

61


Appendix C: 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 12/2016; 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.


Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

62


Appendix D: Methylene Blue and Serotonin Syndrome
From: Perioperative Medication Management – Adult/Pediatric – Inpatient/Ambulatory
Clinical Practice Guideline
Last Reviewed 12/2016; Last Updated 4/2016
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.
• 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
































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.




Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

63


References
1. De Oliveira GS, McCarthy RJ, Wolf MS, Holl J. The impact of health literacy in the care of surgical patients:
a qualitative systematic review. BMC Surgery. 2015 2015;15:86.
2. Mantwill S, Monestel-Umaña S, Schulz PJ. The Relationship between Health Literacy and Health
Disparities: A Systematic Review. PLoS ONE. 2015 2015;10(12):e0145455.
3. Kopic S, Geibel JP. Gastric acid, calcium absorption, and their impact on bone health. Physiol Rev. Jan
2013;93(1):189-268.
4. Schneider DF, Day GM, De Jong SA. Calcium-lowering medications in patients with primary
hyperparathyroidism: intraoperative findings and postoperative hypocalcemia. Am J Surg. Mar
2012;203(3):357-360; discussion 360.
5. Hollevoet I, Herregods S, Vereecke H, Vandermeulen E, Herregods L. Medication in the perioperative
period: stop or continue? A review. Acta Anaesthesiol Belg. 2011;62(4):193-201.
6. Cantrell MA, Bream-Rouwenhorst HR, Steffensmeier A, Hemerson P, Rogers M, Stamper B. Intraoperative
floppy iris syndrome associated with alpha1-adrenergic receptor antagonists. Ann Pharmacother. Apr
2008;42(4):558-563.
7. Chang DF, Braga-Mele R, Mamalis N, et al. ASCRS White Paper: clinical review of intraoperative floppy-iris
syndrome. J Cataract Refract Surg. Dec 2008;34(12):2153-2162.
8. Lilja M, Jounela AJ, Juustila H. Withdrawal syndromes and the cessation of antihypertensive therapy. Arch
Intern Med. Apr 1982;142(4):839-840.
9. Hart GR, Anderson RJ. Withdrawal syndromes and the cessation of antihypertensive therapy. Arch Intern
Med. Aug 1981;141(9):1125-1127.
10. Bruce DL, Croley TF, Lee JS. Preoperative clonidine withdrawal syndrome. Anesthesiology. Jul
1979;51(1):90-92.
11. Ram CV, Holland OB, Fairchild C, Gomez-Sanchez CE. Withdrawal syndrome following cessation of
guanabenz therapy. J Clin Pharmacol. Feb-Mar 1979;19(2-3):148-150.
12. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA Guideline on Perioperative
Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac SurgeryA Report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of
the American College of Cardiology. 2014;64(22):e77-e137.
13. Practice guidelines for acute pain management in the perioperative setting: an updated report by the
American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. Feb
2012;116(2):248-273.
14. Stuart Gerstein N, Hawks Gerstein W, Christopher Carey M, et al. The thrombotic and arrhythmogenic risks
of perioperative NSAIDs. J Cardiothorac Vasc Anesth. Apr 2014;28(2):369-378.
15. Nagelhout J, Elisha S, Waters E. Should I continue or discontinue that medication? AANA J. Feb
2009;77(1):59-73.
16. Bryson EO. The perioperative management of patients maintained on medications used to manage opioid
addiction. Curr Opin Anaesthesiol. Jun 2014;27(3):359-364.
17. Stephens LC, Katz SG. Phentermine and anaesthesia. Anaesth Intensive Care. Aug 2005;33(4):525-527.
18. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc.; 2016. https://online.lexi.com/lco/action/home/switch.
Accessed April 2016.
19. Shah S, Kapoor S, Durkin B. Analgesic management of acute pain in the opioid-tolerant patient. Curr Opin
Anaesthesiol. Aug 2015;28(4):398-402.
20. Gronkjaer M, Eliasen M, Skov-Ettrup LS, et al. Preoperative smoking status and postoperative
complications: a systematic review and meta-analysis. Ann Surg. Jan 2014;259(1):52-71.
21. Nolan MB, Warner DO. Safety and Efficacy of Nicotine Replacement Therapy in the Perioperative Period: A
Narrative Review. Mayo Clin Proc. Nov 2015;90(11):1553-1561.
22. Bhardwaj A, Dharmavaram S, Wadhawan S, Sethi A, Bhadoria P. Donepezil: A cause of inadequate muscle
relaxation and delayed neuromuscular recovery. J Anaesthesiol Clin Pharmacol. Apr 2011;27(2):247-248.
23. Pass SE, Simpson RW. Discontinuation and reinstitution of medications during the perioperative period. Am
J Health Syst Pharm. May 1 2004;61(9):899-912; quiz 913-894.
24. Benish SM, Cascino GD, Warner ME, Worrell GA, Wass CT. Effect of general anesthesia in patients with
epilepsy: a population-based study. Epilepsy Behav. Jan 2010;17(1):87-89.
25. Perks A, Cheema S, Mohanraj R. Anaesthesia and epilepsy. Br J Anaesth. Apr 2012;108(4):562-571.
26. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular
evaluation and management of patients undergoing noncardiac surgery: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. Dec 9
2014;130(24):e278-333.
27. Lindenauer PK, Pekow P, Wang K, Gutierrez B, Benjamin EM. Lipid-lowering therapy and in-hospital
mortality following major noncardiac surgery. JAMA. May 5 2004;291(17):2092-2099.
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

64


28. Kennedy J, Quan H, Buchan AM, Ghali WA, Feasby TE. Statins are associated with better outcomes after
carotid endarterectomy in symptomatic patients. Stroke. Oct 2005;36(10):2072-2076.
29. Raju MG, Pachika A, Punnam SR, et al. Statin therapy in the reduction of cardiovascular events in patients
undergoing intermediate-risk noncardiac, nonvascular surgery. Clin Cardiol. Aug 2013;36(8):456-461.
30. Desai H, Aronow WS, Ahn C, et al. Incidence of perioperative myocardial infarction and of 2-year mortality in
577 elderly patients undergoing noncardiac vascular surgery treated with and without statins. Arch Gerontol
Geriatr. Sep-Oct 2010;51(2):149-151.
31. London MJ, Schwartz GG, Hur K, Henderson WG. Association of Perioperative Statin Use With Mortality
and Morbidity After Major Noncardiac Surgery. JAMA Intern Med. Dec 19 2016.
32. Durazzo AE, Machado FS, Ikeoka DT, et al. Reduction in cardiovascular events after vascular surgery with
atorvastatin: a randomized trial. J Vasc Surg. May 2004;39(5):967-975; discussion 975-966.
33. Ruggiero SL, Dodson TB, Fantasia J, et al. American Association of Oral and Maxillofacial Surgeons
position paper on medication-related osteonecrosis of the jaw--2014 update. J Oral Maxillofac Surg. Oct
2014;72(10):1938-1956.
34. Katus L, Shtilbans A. Perioperative management of patients with Parkinson's disease. Am J Med. Apr
2014;127(4):275-280.
35. Nicholson G, Pereira AC, Hall GM. Parkinson's disease and anaesthesia. Br J Anaesth. Dec
2002;89(6):904-916.
36. Reed AP, Han DG. Intraoperative exacerbation of Parkinson's disease. Anesth Analg. Nov 1992;75(5):850-
853.
37. Shaikh SI, Verma H. Parkinson's disease and anaesthesia. Indian J Anaesth. May 2011;55(3):228-234.
38. Raz A, Lev N, Orbach-Zinger S, Djaldetti R. Safety of perioperative treatment with intravenous amantadine
in patients with Parkinson disease. Clin Neuropharmacol. Sep-Oct 2013;36(5):166-169.
39. 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.
40. Krause ML, Matteson EL. Perioperative management of the patient with rheumatoid arthritis. World J
Orthop. Jul 18 2014;5(3):283-291.
41. Goodman SM. Rheumatoid arthritis: Perioperative management of biologics and DMARDs. Semin Arthritis
Rheum. Jun 2015;44(6):627-632.
42. Grennan DM, Gray J, Loudon J, Fear S. Methotrexate and early postoperative complications in patients with
rheumatoid arthritis undergoing elective orthopaedic surgery. Ann Rheum Dis. Mar 2001;60(3):214-217.
43. Sany J, Anaya JM, Canovas F, et al. Influence of methotrexate on the frequency of postoperative infectious
complications in patients with rheumatoid arthritis. J Rheumatol. Jul 1993;20(7):1129-1132.
44. Ito H, Kojima M, Nishida K, et al. Postoperative complications in patients with rheumatoid arthritis using a
biological agent-A systematic review and meta-analysis. Mod Rheumatol. Mar 12 2015:1-7.
45. Momohara S, Hashimoto J, Tsuboi H, et al. Analysis of perioperative clinical features and complications
after orthopaedic surgery in rheumatoid arthritis patients treated with tocilizumab in a real-world setting:
results from the multicentre TOcilizumab in Perioperative Period (TOPP) study. Mod Rheumatol. May
2013;23(3):440-449.
46. Hirao M, Yamasaki N, Oze H, et al. Serum level of oxidative stress marker is dramatically low in patients
with rheumatoid arthritis treated with tocilizumab. Rheumatol Int. Dec 2012;32(12):4041-4045.
47. Rosandich PA, Kelley JT, 3rd, Conn DL. Perioperative management of patients with rheumatoid arthritis in
the era of biologic response modifiers. Curr Opin Rheumatol. May 2004;16(3):192-198.
48. Shammash JB, Trost JC, Gold JM, Berlin JA, Golden MA, Kimmel SE. Perioperative β-blocker withdrawal
and mortality in vascular surgical patients. American Heart Journal. 1// 2001;141(1):148-153.
49. Wallace AW, Au S, Cason BA. Association of the pattern of use of perioperative beta-blockade and
postoperative mortality. Anesthesiology. Oct 2010;113(4):794-805.
50. Muluk V, Macpherson DS, Cohn SL, et al. Perioperative medication management UpToDate 2015.
Accessed May 12, 2015.
51. Tagarakis GI, Aidonidis I, Daskalopoulou SS, et al. Effect of ranolazine in preventing postoperative atrial
fibrillation in patients undergoing coronary revascularization surgery. Curr Vasc Pharmacol. Nov
2013;11(6):988-991.
52. Kumar A, Auron M, Aneja A, Mohr F, Jain A, Shen B. Inflammatory bowel disease: perioperative
pharmacological considerations. Mayo Clin Proc. Aug 2011;86(8):748-757.
53. Yamada A, Komaki Y, Patel N, et al. Risk of Postoperative Complications Among Inflammatory Bowel
Disease Patients Treated Preoperatively With Vedolizumab. Am J Gastroenterol. Sep 2017;112(9):1423-
1429.
54. Edwards AF, Roy RC. Preoperative administration of PDE-5 Inhibitors. J Clin Anesth. Mar 2009;21(2):149;
author reply 149-150.
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org

65


55. McAllister RK, Meyer TA, Bittenbinder TM. Are guidelines needed for the perioperative discontinuation of
phosphodiesterase type 5 inhibitors? J Clin Anesth. Nov 2008;20(7):560-561.
56. Shim JK, Choi YS, Oh YJ, Kim DH, Hong YW, Kwak YL. Effect of oral sildenafil citrate on intraoperative
hemodynamics in patients with pulmonary hypertension undergoing valvular heart surgery. J Thorac
Cardiovasc Surg. Dec 2006;132(6):1420-1425.
57. Blaise G, Langleben D, Hubert B. Pulmonary arterial hypertension: pathophysiology and anesthetic
approach. Anesthesiology. Dec 2003;99(6):1415-1432.
58. Roshanov PS, Rochwerg B, Patel A, et al. Withholding versus Continuing Angiotensin-converting Enzyme
Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery: An Analysis of the Vascular
events In noncardiac Surgery patIents cOhort evaluatioN Prospective Cohort. Anesthesiology. Oct 24 2016.
59. Comfere T, Sprung J, Kumar MM, et al. Angiotensin system inhibitors in a general surgical population.
Anesth Analg. Mar 2005;100(3):636-644, table of contents.
60. Brabant SM, Bertrand M, Eyraud D, Darmon PL, Coriat P. The hemodynamic effects of anesthetic induction
in vascular surgical patients chronically treated with angiotensin II receptor antagonists. Anesth Analg. Dec
1999;89(6):1388-1392.
61. Castanheira L, Fresco P, Macedo AF. Guidelines for the management of chronic medication in the
perioperative period: systematic review and formal consensus. J Clin Pharm Ther. Aug 2011;36(4):446-467.
62. Woods BD, Sladen RN. Perioperative considerations for the patient with asthma and bronchospasm. Br J
Anaesth. Dec 2009;103 Suppl 1:i57-65.
63. Licker M, Schweizer A, Ellenberger C, Tschopp JM, Diaper J, Clergue F. Perioperative medical
management of patients with COPD. Int J Chron Obstruct Pulmon Dis. 2007;2(4):493-515.
64. Vestbo J, Hurd SS, Agusti AG, et al. Global strategy for the diagnosis, management, and prevention of
chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. Feb 15
2013;187(4):347-365.
65. Silvanus MT, Groeben H, Peters J. Corticosteroids and inhaled salbutamol in patients with reversible airway
obstruction markedly decrease the incidence of bronchospasm after tracheal intubation. Anesthesiology.
May 2004;100(5):1052-1057.
66. Labos C, Dasgupta K, Nedjar H, Turecki G, Rahme E. Risk of bleeding associated with combined use of
selective serotonin reuptake inhibitors and antiplatelet therapy following acute myocardial infarction. CMAJ.
Nov 8 2011;183(16):1835-1843.
67. Ziegelstein RC, Meuchel J, Kim TJ, et al. Selective serotonin reuptake inhibitor use by patients with acute
coronary syndromes. Am J Med. Jun 2007;120(6):525-530.
68. Yuan Y, Tsoi K, Hunt RH. Selective serotonin reuptake inhibitors and risk of upper GI bleeding: confusion or
confounding? Am J Med. Sep 2006;119(9):719-727.
69. Nolan J, Chalkiadis GA, Low J, Olesch CA, Brown TC. Anaesthesia and pain management in cerebral palsy.
Anaesthesia. Jan 2000;55(1):32-41.
70. Albright AL. Intrathecal baclofen in cerebral palsy movement disorders. J Child Neurol. Nov 1996;11 Suppl
1:S29-35.
71. Huyse FJ, Touw DJ, van Schijndel RS, de Lange JJ, Slaets JP. Psychotropic drugs and the perioperative
period: a proposal for a guideline in elective surgery. Psychosomatics. Jan-Feb 2006;47(1):8-22.


Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
01/2018CCKM@uwhealth.org