Table 1: Perioperative Management of Medications

Category Medications & Treatments Comment
Continue most medications through surgery.
Continue most anti-hypertensive drugs through surgery with sips of water, or consider non-oral forms [3, 7].
Consider transdermal, IV, or sublingual equivalents.
Avoid abrupt withdrawal of beta-blockersand alpha-blockers.
It is recommended that diuretics be continued in patients with heart failure, but rapid diuresis before surgery must be avoided [3, 7].
Nitrates should be continued if in use.
Perioperative nitroglycerin use for the prevention of adverse ischemic events in high-risk patients may be considered [3, 7].
Angiotensin converting enzyme inhibitors (ACEI):
It is recommended that ACE inhibitors be continued during non-cardiac surgery in stable patients with left ventricular (LV) systolic dysfunction.
Continuation of beta-blockers is recommended in patients previously treated with beta-blockers because of ischemic heart disease (IHD), arrhythmias, or hypertension.
Beta-blockers should be considered for patients scheduled for intermediate-risk surgery if their blood pressure is not controlled.
Heart rate reducing calcium channel blockers, in particular Diltiazem, may be considered before non-cardiac surgery in patients who have contra-indications to beta-blockers [3, 7].
Antiplatelet therapy:
Stop Aspirin and Clopidogril 5-7 days before surgery. Usually may safely resume 24-48 hours postoperatively.
Continue Aspirin preoperatively in patients with a history of ischemic heart disease if the type of surgery allows for this.
May continue the use of cyclooxygenase-2 (COX2) inhibitors [3, 7, 21].
Most patients can safely have surgery as long as the SBP is less than 180 and DBP is less than 110, and there is no evidence of end organ damage [3, 7].

Correct electrolyte disturbances before surgery [3, 7]
Patients taking Aspirin and non steroidal anti inflammatory drugs (NSAID) may have a higher risk for developing peri-operative bleeding complications.
Endocrine Thyroid disease
Continue thyroid supplements with sips of water.
Reduce L-thyroxine dose by 20% for long-term parenteral use, if applicable [3, 7].
For moderate stress procedures (total joint replacement), it is a good practice to provide:
1- Intra-operatively: Hydrocortisone 50 mg intravenously.
2- Postoperative day 1: Hydrocortisone 20 mg intravenously every 8 hours for 3 doses.
3- Postoperative day 2: return to preoperative Glucocorticoid dose or parenteral equivalent.  The glucocorticoid target is 50 to 75 mg per day of Hydrocortisone equivalent for 1 or 2 days [3, 18].
All patients with type 1 and type 2 diabetes should be transitioned to scheduled subcutaneous insulin therapy at least 1-2 h before discontinuation of continuous insulin infusion.
1-Critically ill patients or those going through major surgery require an intravenous insulin therapy for achieving the desired glucose range of 140-180 mg/dL (7.8 - 10 mmol/L) without increasing risk for severe hypoglycemia. Strict glycemic control in critically ill patient is detrimental by increasing mortality and should be avoided [29].
Prolonged anesthetic effect after surgery may suggest hypothyroidism.
All patients with diabetes admitted to the hospital should have their diabetes clearly identified in the medical record, and an order for blood glucose monitoring, with results available to all members of the health care team.
A plan for preventing and treating hypoglycemia should be established for each patient to avoid risky situations.
Obtaining an A1C on patients with diabetes admitted to the hospital should be considered if the result of testing in the previous 2-3 months is not available [19, 20].
2-For non-critically ill patients or those undergoing minor surgery, the preferred method for maintaining glucose control is to schedule subcutaneous insulin with basal, nutritional, and correction components. Pre-meal blood glucose targets140 mg/dL (7.8 mmol/l) and random blood glucose180 mg/dL (10.0 mmol/l).
3- Type 2 Diabetes who is controlled with diet usually do not require perioperative therapy, however blood sugars must be checked and short acting insulin as a correction dose may be given.
4- Type 2 Diabetes treated with oral agents or non-insulin injectables should hold their hypoglycemic agents on the morning of surgery.  Their blood sugar should be checked and correction dose of short acting insulin may be administered subcutaneously.
Glucose must be monitored for all patients and for patients on therapies associated with increased risk for hyperglycemia, including high-dose glucocorticoid therapy.
Enteral or parenteral nutrition, or other medications such as Octreotide or immunosuppressive medications must be initiated [19, 20].
Malabsorption, dysmotility of bowel, and hepatic dysfunction may significantly alter pharmacodynamics of perioperative medications including anesthetic [3]. Nutritional status and liver disease must be assessed and monitored preoperatively.
History of risk factors for hepatitis B or C and history of alcohol use should be determined [3].
Renal Perioperative renal function is the best predictor of postoperative renal failure [3].
Nephrotoxic drugs are to be avoided.
Urine volume status, output, adequate perfusion, and drug levels should be monitored if applicable.
Less nephrotoxic induction protocols should be used.
Nephrology consultation should be considered in patients with worsening renal function or decreased urine output [3].
Patients with chronic kidney diseases (CKD) may have multi-organ dysfunction, general disability, and specific problems associated with renal replacement therapy (RRT).
In patients with mild to moderate CKD, surgical trauma and perioperative hemodynamic instability may precipitate acute kidney injury [3].
Rheumatologic NSAIDs:
1-To be stopped 1-3 days before surgery depending on half-life.
2-They can be started again postoperatively for pain relief.
Codeine, oxycodone, methadone:
Are to be continued until morning of surgery then decision is up to the anesthesiologist to determine narcotic use intraoperatively.
DMARDs see text
Patients with severe SICCA syndrome  (An autoimmune disease, also known as Sjogren syndrome, that classically combines dry eyes, dry mouth, and another disease of connective tissue such as rheumatoid arthritis (most common), lupus, scleroderma or polymyositis) require lubricant eye drops [7, 18].
Hematologic Anticoagulation can be associated with increased risk of bleeding, especially in the immediate post-operative period.
In major orthopedic surgery, physicians should consider low-molecular-weight heparin (LMWH) as venous thromboprophylaxis 12 h prior to surgery and extend to 35 days after surgery [21, 26].
In patients who require temporary interruption of a vitamin K antagonists (VKA) before surgery:
1- VKAs should be stopped 5 days before surgery.
2-VKAs should be resumed 12 to 24h after surgery when there is adequate homeostasis.
In patients who are receiving bridging anticoagulation with therapeutic-dose:
1- The last preoperative dose of LMWH should be administered 24 h before surgery.
2-LMWH can be resumed 48 to 72 h after surgery.
3-Unfractioned Heparin (UFH) should be stopped 4 to 6 hrs before surgery [3, 21].
Patients may have anemia that puts them at risk for requiring blood transfusion during major surgeries associated with significant blood loss.
Anemia in RA patients is a common and dynamic condition that may increase the patients risk for myocardial ischemia.
Physicians should consider autologous blood transfusion requirements well in advance of surgery [3, 21].
Erythropoietin, with or without iron supplement, is recommended preoperatively in patients with a baseline Hct < 34% to avoid or reduce allogeneic blood transfusion preoperatively [30,31].
Neurologic To continue Anti-convulsion therapy.
Treatment with atropine may precipitate delirium in Parkinson's disease [3].
Delirium is a predictor of poor outcome (that is potentially preventable).
Formal assessment of preoperative cognitive function can help target prevention efforts by identifying high-risk patients [3].
Miscellaneous Ask about non-prescription drugs and supplements.
Alcohol and illicit drug use should be considered possible.
Asymptomatic bacteruria in patients undergoing total joint arthroplasty must be treated to avoid risk [32].
Among HIV positive patients, perioperative management should include hands-on pharmacy support [3].
Patient may be unaware of pregnancy.
Patients fears and expectations should be explored.