Author:
Kai Knudsen
Updated:
26 August, 2025
This chapter describes the medication stop times prior to surgery for various anticoagulants and NSAIDs. It includes appropriate discontinuation times for both the insertion and removal of spinal catheters. Additionally, it covers which medications should be administered preoperatively from the common medications the patient typically uses.
- Discontinuation of Anticoagulants Before Surgery and Operation
- Medications that should be given even on the day of surgery
- Medications usually given on the day of surgery
- Medications usually discontinued
- Withdrawal times for NSAIDs (non-steroidal anti-inflammatory drugs) before surgery
- Withdrawal of anticoagulation prior to spinal anesthesia
Discontinuation of Anticoagulants Before Surgery and Operation
Before surgery, it is essential to assess the risks and benefits of discontinuing anticoagulant therapy. The goal is to minimize the risk of thromboembolic events while reducing the risk of perioperative bleeding. The decision to stop anticoagulants depends on the type of anticoagulant, the patient’s underlying condition, and the type of surgery.
Discontinuation of Anticoagulation before Surgery
| Substance | Brand Name | Mechanism of Action | Sort of Inhibition | Half time | Discontinuation time before planned operation |
|---|---|---|---|---|---|
| Abciximab | Reopro | GPIIb/IIIa | Irreversible | 30 min | 48 hours |
| Apixaban | Eliquis | Factor Xa | 12 hours | 24-48 hours. 24 hours only at low risk of bleeding, 48 hours at moderate or high risk of bleeding. | |
| Salicylic Acid | Trombyl | COX-1 | Irreversible | 30 min | 3 days |
| Salicylic Acid in low dose (75-350 mg) as primary prophylaxis (ASA in high dose - see table below) | 30 min | 3 days | |||
| Salicylic Acid as a secondary prophylaxis | Patients with high thrombotic risk using ASA secondary prophylactically may continue with ASA, alternatively, abstain from ASA on the day of operation, after individual assessment. | ||||
| Argatroban | Novastan | Thrombin | Reversible | 1 hour2 | 2–4 hours |
| Bivalirudin | Bivalirudin | Thrombin | Reversible | 30 min | 4 hours |
| Cilostazol | Cilostazol, Pletal | PDE3 | Reversible | 10,5 hours | 5 days |
| Dabigatran | Pradaxa | Thrombin | Reversible | 12–17 hours | 24 hours3 |
| Dipyridamol | Dipyridamol, Asasantin | Adenosine | Reversible | 10–12 hours | Discontinuation not needed |
| Eptifibatid | Integrilin | GPIIb/IIIa | Reversible | 2,5 hours | 8 hours |
| Fondaparinux | Arixtra | Factor Xa | Reversible | 17–21 hours | 36 hours |
| Heparin | Heparin | Factor IIa, IXa, Xa | Reversible | 1–2 hours | 4 hours4 |
| Iloprost | Ilomedin, Ventavis | Prostacycline analogue | Reversible | 30 minuter | 2 hours |
| Clopidogrel | Plavix | ADP-receptor (P2Y12) | Irreversible | 6–8 hours | 5 days |
| Prasugrel | Efient | ADP-receptor (P2Y12) | Irreversible | 7 hours(2–15) | 5 days |
| Rivaroxaban | Xarelto | Factor Xa | Reversible | 7–11 hours | 24 hours |
| Tirofiban | Aggrastat | GPIIb/IIIa | Reversible | 1,5 hours | 8 hours |
| Warfarin | Waran | Prothrombine, Factor VII, IX, X | Reversible | R-warfarin 37–89 hours S-warfarin 21–43 hours | 3 days5 |
| Low molecular weight heparin (therapy doses, subcutaneous), high intensity treatment | |||||
| Dalteparine (>5000 E) | Fragmin | Factor IIa, Xa | Reversible | 3–4 hours6 | 24 hours |
| Enoxaparine (>40 mg) | Klexane | Factor Xa | Reversible | 4 hours6(repeated dose, 7 hours) | 24 hours |
| Tinzaparine (>4500 E) | Inohep | Factor Xa | Reversible | 3–4 hours6 | 24 hours |
| Low molecular weight heparin (therapy doses, subcutaneous), low intensity treatment | |||||
| Dalteparine (≤5000 E) | Fragmin | Factor IIa, Xa | Reversible | 3–4 hours6 | 10 hours |
| Enoxaparine (≤40 mg) | Klexane | Factor Xa | Reversible | 4 hours6 (repeated dose, 7 hours) | 10 hours |
| Tinzaparine (≤4500 E) | Inohep | Factor Xa | Reversible | 3–4 hours6 | 10 hours |
| 1 Patients with high thrombotic risk who use ASA secondary prophylactically may continue with ASA, alternatively, abstain from ASA on the day of operation, after individual assessment. | |||||
| 2 The efficacy of liver disease is greatly prolonged. | |||||
| 3The variation is large between different subpopulations | |||||
| 4Applies to the condition that the aPTT is normalized after the specified release time. | |||||
| 5Applies to therapeutic INR 2-3 and target INR prior to surgery <1.4. | |||||
| 6The task relates to anti-Xa activity. | |||||
You can find detailed recommendations on discontinuing anticoagulants before neuraxial, epidural, and spinal blockade at Anesthguide. It describes withdrawal times for various anticoagulants and what should be taken into account when administering spinal anesthesia. You will find specific guidelines depending on the drug used, such as Fragmin, Xarelto, Waran, and others, as well as recommendations for reinsertion after the procedure. These guidelines are important to minimize the risk of complications such as bleeding.
For a more detailed overview and the exact withdrawal times, see Anesthguide where the national guidelines are collected.
Medications that should be given even on the day of surgery
Recommendations for which regular medications should be taken or discontinued in situations where anesthetic intervention is required to perform surgery, procedures, or examinations. The aim is to facilitate preoperative assessment and make it easier for non-anesthesia personnel to follow these recommendations.
Many patients passing through an operating department are on regular medication. Whether it involves general anesthesia, central blocks, regional blocks, or local anesthesia, it is important to know which of the regular medications should be taken or discontinued before surgery, procedures, or examinations. The anesthetist or nurse with preoperative assessment delegation determines which medications should be taken or discontinued.
The responsible anesthetist/nurse should check in the medical records which medications the patient is regularly taking. It is, of course, important that the patient is informed about which medications should be taken or discontinued. In the table below, a recommendation for the most common drugs is provided. However, note that most patients arrive on the morning of the surgery, and information on how medications should be taken on the morning of the surgery must therefore be communicated during the preoperative assessment. It is important to assess whether the patient needs to have written information.
Administration of drugs on the day of surgery
| Drug | Continue | Refrain |
|---|---|---|
| Beta blocker | X | |
| ACE inhibitors | X | |
| Angiotensin II-inhibitors | X | |
| Alpha-2 receptor antagonist | X | |
| Ca flux inhibitors | X | |
| Diuretics (all types) | X | |
| Statines | X | |
| Nitrates, short and long acting | X | |
| Digoxin | X | |
| Inhalation medicine for lung disease (beta stimulantes) | X | |
| Oral diabetes medications | X | |
| Litium | X | |
| SSRI | X | |
| Antipsychotics (dopamine receptor blockers) | X | |
| Clozapine | X | |
| Parkinson's medication | X | |
| Levothyroxine | X | |
| Cortikosteroides | X | |
| Opioides | X |
Medications usually given on the day of surgery
β-blockers
- Ongoing treatment should be continued perioperatively, in some cases at a reduced dose, e.g., half the normal dose
- Can be initiated in certain patients: high-risk surgery, ≥2 risk factors, known ischemic heart disease. Target HR 60-70/min, SBP >100 mmHg
- Atenolol, bisoprolol – uptitrated to desired effect over 7-30 days preoperatively
- The POISE study showed an increased risk of stroke (bradycardia, hypotension)
Statins (significantly reduce the risk of ischemic events)
- Should be continued perioperatively
- Should be initiated before vascular surgery
- Long-acting agents, preferably ≥ 2 weeks before surgery
- Rosuvastatin – reduces the risk of CI-AKI
Medications usually discontinued
- ACE inhibitors and Angiotensin II antagonists, according to national guidelines, should be discontinued on the day of surgery. Otherwise, there is a risk of severe hypotension that does not respond adequately to adrenergic agonists. Exceptions: Confirmed heart failure and situations where hypertension must be avoided (e.g., known aortic aneurysm, aortic dissection), and poorly controlled malignant hypertension.
- Oral diabetes medications and insulin
- Neuroleptics: Clozapine should be discontinued, but contact with a psychiatrist for management discussion is recommended.
Withdrawal times for NSAIDs (non-steroidal anti-inflammatory drugs) before surgery
Discontinuation Times for Non Steroidal Anti-Inflammatory Agents NSAID before Surgery
| Substance | Brand Name | Mechanism of Action | Sort of Inhibition | Half time | Discontinuation time before planned operation |
|---|---|---|---|---|---|
| Salicylic Acid, high dose | Bamyl, Aspirin, Treo | COX-1 | Irreversible | Dose dependent, approximately 12 hours at therapeutic doses | 7 days |
| Celecoxib | Celecoxib, Celebra | COX-2 | Reversible | 8–12 hours | Discontinuation not needed |
| Dexibuprofen | Tradil | COX-1 | Reversible | 2 hours | 12 hours |
| Diclofenac | Diclofenac, Voltaren, Arthrotec, Eeze, Dicuno | COX-1 | Reversible | 1–2 hours | 12 hours |
| Etoricoxib | Etoricoxib, Arcoxia | COX-2 | Reversible | 22 hours | Discontinuation not needed |
| Ibuprofen | Brufen, Ipren, Ibumetin, Iprensa, Nurofen, Ibumax | COX-1 | Reversible | 2 hours | 12 hours |
| Ketoprofen | Orudis, Siduro | COX-1 | Reversible | 2–3 hours | 12 hours |
| Ketorolak | Toradol | COX-1 | Reversible | 5,3 hours | 24 hours |
| Meloxicam | Meloxicam | COX-1 | Reversible | 20 hours | Discontinuation not needed |
| Nabumeton | Relifex | COX-2 | Reversible | 20–25 hours | Discontinuation not needed |
| Naproxen | Naproxen, Naprosyn, Pronaxa, Vimovo | COX-1 | Reversible | 10–17 hours | 48 hours |
| Parecoxib | Dynastat | COX-2 | Reversible | 22 min | Discontinuation not needed |
| Piroxicam | Brexidol | COX-1 | Reversible | 50 hours | 2 weeks |
| Tenoxicam | Alganex | COX-1 | Reversible | 72 hours | 2 weeks |
Withdrawal of anticoagulation prior to spinal anesthesia
Discontinuation of Anticoagulation Before Spinal Anesthesia
| Medication (Brand name) | Substance | Recommended time from intake of pharmaceuticals to spinal anaesthesia/manipulation | Recommended time from spinal anaesthesia/manipulation to intake of medication |
|---|---|---|---|
| Fragmin ≤ 5000 E Fragmin > 5000 E | Dalteparin | 10 hours 24 hours | 6 hours recommended (2-4 hours usual practice) |
| Arixtra | Fondaparinux | 36 hours | 6 hours |
| Xarelto | Rivaroxaban | 2 days according to SSTHS Clinical Council | 6-24 hours (according to risk) |
| Waran, Coumadin, Jantoven ** | Warfarin | 1-4 days depending on dose | Reinsert after removal of epidural catheter |
| Aspirin, Acetylsalicylic acid Aggrenox, Alka-seltzer, and more | Acetylsalicylic acid | 12 hours in patients with secondary prevention indication 3 days with others | Resume as soon as possible after surgery |
| Voltaren, Aleve Arthritis Pain, Arthrotec, and more | Diclofenac | 12 hours | Should be avoided – COX-2 inhibitors are recommended instead |
| Toradol, Acular, Acuvail, Omidria, and more | Ketorolac | 24 hours | Should be avoided – COX-2 inhibitors are recommended instead |
| Naproxen, Aleve, Naprelan, Naprosyn, and more | Naproxen | 48 hours | Should be avoided – COX-2 inhibitors are recommended instead |
| Plavix, Duoplavin, Zyllt | Clopidogrel | 5 days | After catheter removal |
| Ticlide | Ticlopidine | 5 days | After catheter removal |
| Effient, Efient | Prasurgrel | 7 days according to. SSTHS Clinical Council | After catheter removal |
| Eliquis | Apixaban | 2 days according to. SSTHS Clinical Council | 6-24 hours (according to risk) |
| Pradaxa | Dabigatran | 2 days according to. SSTHS Clinical Council | 6-24 hours (according to risk) |
| Brilinta, Brilique | Tiacagrelor | 5 days | 6 hours |
*NOTE! Regarding patients with new oral anticoagulants/Non-vitamin K antagonist oral anticoagulants (NOAC) (Eliquis, Pradaxa, Xarelto, etc.), the clinical advice from the Swedish Society for Thrombosis and Haemostasis (SSTH), which is regularly updated, is recommended.
Link to Recommendations on discontinuing anticoagulants before neuraxial, epidural, and spinal blockade. Click here!
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