Preoperative Medication Management: Drugs to Avoid, Continue, or Modify Before oral surgical procedure

5 Classification of Medications Based on Perioperative Management

Successful perioperative medication management requires careful evaluation of the benefits and risks associated with continuing, modifying, or temporarily discontinuing medications before dental and oral surgical procedures. The decision should be individualized according to the patient's systemic health, indication for the medication, pharmacological profile, and the complexity of the planned surgical procedure. The primary objective is to minimize perioperative complications such as excessive bleeding, thromboembolic events, adverse drug interactions, impaired wound healing, delayed osseointegration, infection, and anesthetic complications while ensuring optimal patient safety.

For practical clinical application, medications can be broadly classified into four categories according to their perioperative management.

1. Medications Temporarily Withheld Before Surgery

Knowing which medications to avoid before surgery is essential for ensuring a safe and successful operation.

You should always talk openly with your healthcare provider about all the medications and supplements you’re taking. If you’re on a lot of medication, it may be worth making a list to make sure you don’t miss anything off. Your healthcare provider will give you specific instructions on what to stop and what you can continue to take. In the meantime, here are some general guidelines:

1. Blood thinners

Common medications: Aspirin, Warfarin, Clopidogrel, Heparin, Prasugrel, Ticagrelor and newer anticoagulants(7-9)

Why to avoid: Blood thinners can increase the risk of excessive bleeding during and after surgery. While they’re great for preventing clots in everyday life, they’re not so great when you’re about to have a procedure that needs precise blood control. Aspirin can sometimes be taken before surgery, but always ask your healthcare provider before doing so.10,11

2. Non-steroidal Anti-Inflammatory Drugs (NSAIDs)

Common medications: Ibuprofen, Naproxen, Diclofenac.

Why to avoid: NSAIDs can thin your blood too, making you bleed more. They can also interfere with your kidney function. NSAIDS are best avoided if you are undergoing neuro, spinal, cardiac, or orthopaedic surgery.(16,17)

3. Herbal supplements

Common supplements: Ginkgo Biloba, Garlic, Ginseng, St. John’s Wort, Echinacea.

Why to avoid: Herbal supplements can interfere with anaesthesia and other meds used during surgery. Some can increase bleeding risk or mess with your blood pressure and heart rate. It’s best to stop taking these at least two weeks before surgery (3) but always check with your doctor or surgeon first.

4. Certain antidepressants

Common medications: MAOIs (Monoamine Oxidase Inhibitors) like Phenelzine and Tranylcypromine.

Why to avoid: MAOIs can negatively affect anaesthesia and other surgery meds. This can lead to dangerous spikes in blood pressure or other issues.

5. Diabetes medications

Common medications: Insulin, Metformin, and other oral hypoglycemic agents.

Why to avoid: These meds affect your blood sugar levels, which need to be stable during surgery. Your doctor might tweak your dosage or timing. Diabetic patients will be given specific advice.(12-15)

6. ACE inhibitors and ARBs

Common medications: Lisinopril, Ramipril, Enalapril, Perindopril, Captopril, Fosinopril, Trandolapril

Why to avoid: These meds can sometimes cause a drop in blood pressure when combined with anaesthesia. This can lead to complications.

Importantly, medications should never be discontinued without appropriate medical advice, as unnecessary interruption may increase the risk of serious systemic complications.

2. Medications Generally Continued Before Surgery

We’ve looked at the medications you may need to avoid before surgery, now it’s time for those considered to be safe. The information below is general guidance on medication you can continue to take but remember – always consult with your healthcare provider for personalised advice.

1. Blood pressure medications

Common medications: Beta-blockers (e.g., Metoprolol, Atenolol) and Calcium channel blockers (e.g., Amlodipine, Diltiazem).

Why you can take them: Managing your blood pressure is crucial, even before surgery. These medications help keep your blood pressure stable, which is important for a safe surgical procedure.

2. Thyroid medications before surgery

Common medications: Levothyroxine, Carbimazole.

Why you can take them: Thyroid hormones are essential for maintaining your body’s metabolism. Continuing to take these medications helps avoid fluctuations in your hormone levels, which can complicate surgery and recovery.

3. Asthma medications

Common medications: Inhalers and Steroids.

Why you can take them: Keeping your airways open and reducing inflammation is vital, especially during surgery when you need optimal lung function. Continue using your prescribed inhalers and steroids unless advised otherwise by your doctor.

4. Anti-seizure medications

Common medications: Phenytoin, Levetiracetam, Sodium valproate.

Why you can take them: Maintaining control over seizures is crucial. Stopping these medications can increase the risk of a seizure. This can be particularly dangerous during surgery.

5. Pain medications before surgery

Common Medications: Codeine/co-codamol (Zapain), tramadol, morphine (MST, Zomorph), oxycodone (Longtec/Shortec), buprenorphine patches, paracetamol

Why you can take them: Unlike NSAIDs, opiates don’t affect blood clotting and are generally safe to take for pain relief leading up to surgery. Always confirm with your doctor, as your specific condition may have different requirements.

6. Antidepressants

Common medications: SSRIs (e.g., Sertraline), SNRIs (e.g., Venlafaxine).

Why you can take them: Mental health is just as important as physical health. Most antidepressants are safe to continue before surgery. Always check with your team, especially if you’re taking Monoamine Oxidase Inhibitors (MAOIs).

3. Medications Requiring Dose Modification or Individualized Assessment

Certain medications require careful perioperative evaluation because their continuation or discontinuation depends on the patient's medical condition, surgical bleeding risk, and the potential consequences of interrupting therapy.

This group includes:

• Anticoagulants (Warfarin, Apixaban, Rivaroxaban, Dabigatran)
• Antiplatelet agents (Aspirin, Clopidogrel, Ticagrelor, Prasugrel)
• Insulin and oral antidiabetic medications
• ACE inhibitors
• Angiotensin receptor blockers (ARBs)
• Corticosteroids
• Selected antidepressants

Management decisions should be individualized after assessing bleeding risk, thromboembolic risk, glycemic control, cardiovascular status, and the type of planned dental procedure. When necessary, consultation with the patient's physician or relevant medical specialist is recommended before modifying therapy.

4. Medications Used as Part of Preoperative Management

Several medications are intentionally administered before dental surgery to reduce perioperative complications and improve patient comfort.

These include:

• Sedatives: these may be given to help you relax. This can help reduce anxiety before surgery and make you feel more comfortable
• Antibiotics: to prevent infections, you might receive an antibiotic through your IV. This is typically given shortly before surgery begins
• Antiemetics: these are medications to prevent nausea and vomiting, especially if you’re prone to motion sickness or have had issues with anaesthesia in the past

• Blood pressure medications: If you take blood pressure medication, you might be instructed to take it on the morning of surgery, depending on your doctor’s guidance.

6 General Principles for Medication Management

Your journey to the operating room starts with a pre-operative consultation. This is an important meeting where you’ll discuss your health history, current medications, and any concerns you may have with your surgeon and / or healthcare team.

You’ll receive detailed guidance on which medications to continue and which to stop in the weeks before your surgery.

Your healthcare team may ask you to follow an NBM (Nil-by-Mouth) policy. This means you should not eat or drink for a certain period while preparing for surgery.

• Fasting guidelines: usually, you’ll be asked to stop eating and drinking at least 6-8 hours before surgery
• Clear liquids: in some cases, you may be allowed to drink clear liquids (such as water or black coffee) up to a few hours before surgery
• Medication with water: if you need to take essential medication during this fasting period, you can usually do so with a small sip of water, but only if your doctor approves.

This meeting is the perfect time to ask any questions about the surgery, the anaesthesia, and the recovery process.

• Medication given during surgery

Once in the operating room, the surgical team will administer several medications to ensure your procedure goes smoothly.

• Anaesthesia: the anaesthetist will administer anaesthesia, which may be general (putting you to sleep), regional (numbing a large area of your body), or local (numbing a small area). This ensures you don’t feel any pain during surgery
• Muscle relaxants: If necessary, muscle relaxants might be given to ensure your muscles are completely relaxed during the procedure
• Pain management: Depending on the surgery, additional pain relief medication might be given to keep you comfortable.

• Medication given after surgery

After the surgery, you’ll be given medications to help with recovery and to help manage any discomfort.

1. Pain relief: Once you’re in the recovery room, you’ll receive pain relief medications. This will either be through an IV or orally
2. Antibiotics: If there’s a risk of infection, you might continue to receive antibiotics after surgery to prevent complications
3. Antiemetics: To prevent postoperative nausea, you may be given antiemetic medications. You’re more likely to be given this if you received general anaesthesia

•           Blood thinners: Depending on the type of surgery, blood thinners might be prescribed to prevent blood clots during your recovery.(18-23)

 7 Lifestyle Factors Influencing Perioperative Outcomes

Although not classified as medications, tobacco use, alcohol consumption, and recreational drug use significantly influence surgical outcomes.

Nicotine impairs angiogenesis and bone healing, alcohol may interact with anesthetic and analgesic agents, and recreational drugs can alter cardiovascular responses and anesthetic requirements. Patients should be encouraged to discontinue or minimize these substances before surgery and disclose their use during the preoperative evaluation.

8 Recent Evidence and Guideline Recommendations (2023–2026)

1. Anticoagulants and Antiplatelet Therapy

Recent Recommendation

Current evidence suggests that routine discontinuation of anticoagulants or antiplatelet agents before most minor dental procedures is generally unnecessary. Bleeding can usually be managed effectively with local hemostatic measures, whereas interruption of therapy may substantially increase the risk of thromboembolic complications. 

Clinical Recommendation

• Continue therapy for most minor dental procedures.
• Assess both bleeding risk and thromboembolic risk individually.
• Consult the patient's physician for high-risk patients or major oral surgical procedures.

2. Direct Oral Anticoagulants (DOACs)

Recent reviews recommend individualized management rather than routine discontinuation. For procedures with minimal bleeding risk, interruption is often unnecessary; for higher-risk procedures, timing of the last dose depends on renal function and procedural bleeding risk. 

Clinical Recommendation

• Consider renal function.
• Evaluate procedural bleeding risk.
• Avoid unnecessary heparin bridging in most dental procedures.

3. Diabetes Medications

The 2023 Centre for Perioperative Care (CPOC) guideline emphasizes optimization of glycemic control before surgery and individualized adjustment of insulin and oral hypoglycemic agents. 

Clinical Recommendation

• Optimize HbA1c and blood glucose preoperatively.
• Individualize insulin dosing.
• Monitor perioperative blood glucose.

4. SGLT2 Inhibitors

One of the most important updates from recent perioperative guidance concerns SGLT2 inhibitors (e.g., empagliflozin, dapagliflozin), which have been associated with euglycemic diabetic ketoacidosis (eDKA) during the perioperative period. Recent recommendations support withholding these medications several days before surgery. 

Clinical Recommendation

• Identify patients taking SGLT2 inhibitors during medication reconciliation.
• Follow current perioperative guidance regarding temporary discontinuation.
• Resume only when the patient is clinically stable and eating normally.

5. GLP-1 Receptor Agonists

Recent multidisciplinary guidance (2025) highlights concerns regarding delayed gastric emptying and aspiration risk during anesthesia or deep sedation. Management should be individualized according to the patient's risk profile and the planned procedure. 

Clinical Recommendation

• Review GLP-1 receptor agonist use during the preoperative assessment.
• Coordinate management with the anesthesiologist and treating physician when sedation or general anesthesia is planned.

6. Herbal Supplements

Recent perioperative recommendations continue to advise careful documentation of herbal supplement use because products such as garlic, ginkgo biloba, ginseng, turmeric, and fish oil may increase bleeding risk or interact with anesthetic drugs. 

Clinical Recommendation

• Obtain a complete supplement history.
• Consider temporary discontinuation before surgery according to current institutional protocols.

7. Medication Reconciliation

Recent perioperative guidance emphasizes that medication reconciliation is a patient safety priority. Every patient should have a complete review of prescription drugs, over-the-counter medications, herbal products, and dietary supplements before surgery. 

Clinical Recommendation

• Verify all medications.
• Document allergies and adverse drug reactions.
• Identify medications requiring continuation, modification, or temporary interruption.

8. General Principle of Perioperative Medication Management

Modern perioperative recommendations emphasize that medication management should be patient-centered and risk-based, balancing:

• Bleeding risk
• Thromboembolic risk
• Surgical complexity
• Comorbidities
• Drug interactions
• Type of anesthesia

Abrupt discontinuation of chronic medications should generally be avoided unless there is a clear clinical indication.( 24-26)

Current Guideline Highlights (2023–2026)

• Routine discontinuation of anticoagulants before most minor dental procedures is generally not recommended.
• SGLT2 inhibitors require specific perioperative consideration because of the risk of euglycemic ketoacidosis.
• Medication reconciliation should include prescription drugs, OTC medications, and herbal supplements.
• Perioperative medication decisions should be individualized based on bleeding risk, thromboembolic risk, and procedural complexity.

CONCLUSION

Preoperative medication management represents a cornerstone of safe and successful dental and oral surgical practice. With the growing number of medically compromised patients receiving long-term pharmacotherapy, clinicians must carefully evaluate the potential effects of medications on bleeding, hemostasis, anesthesia, bone metabolism, wound healing, and postoperative recovery. Comprehensive preoperative assessment, medication reconciliation, and risk stratification enable clinicians to identify patients at increased risk of perioperative complications and facilitate individualized treatment planning.

Current evidence emphasizes that routine discontinuation of chronic medications is often unnecessary and may expose patients to significant thromboembolic, cardiovascular, or metabolic complications. Instead, perioperative medication management should be guided by a balanced assessment of patient-specific risk factors, pharmacological characteristics, procedural complexity, and the latest evidence-based recommendations.

Recent guideline updates (2023–2026) advocate individualized, patient-centered decision-making, particularly for anticoagulants, antiplatelet agents, direct oral anticoagulants, antidiabetic medications, and herbal supplements. The incorporation of contemporary evidence into clinical practice can reduce perioperative morbidity while preserving the therapeutic benefits of essential medications.

Future research should focus on developing procedure-specific protocols for dental and oral surgery, strengthening the evidence base for emerging pharmacological agents, and promoting standardized international guidelines for perioperative medication management. Ultimately, an evidence-based, multidisciplinary approach remains fundamental to improving patient safety, optimizing surgical outcomes, and ensuring high-quality perioperative care in modern dental practice.

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