Antiplatelet Medications: ASA, clopidogrel, ticagrelor, prasugrel

** | | Prasugrel (Effient) | Hold for 7 full days, LAST DOSE 8 days before surgery   ** |

Parenteral Anticoagulants: low molecular weight heparin, unfractionated heparin, fondaparinux

Oral Anticoagulants: warfarin, dabigatran, apixaban, rivaroxaban, edoxaban

Hold warfarin for 5 full days, LAST DOSE 6 days before surgery | | | If bridging is required (high thrombosis risk patients):

1. Hold warfarin for 5 full days, LAST DOSE 6 days before surgery 2. Start enoxaparin 3 days before OR at a dose of 1.5 mg/kg sc daily in the morning (for patients with normal renal function) 3. LAST DOSE of enoxaparin to be given 1 day before surgery   Criteria for bridging may include: DVT less than 3 months ago, prosthetic mitral heart valves, high risk aortic valves (previous TIA/stroke, atrial fibrillation, severe LV dysfunction), cardiac thrombus presumed to be present less than 3 months  | | Direct Oral Anticoagulants (DOACs) | No overlapping is required between DOACs and LMWH Start therapeutic LMWH or IV heparin only If DOAC is held for longer than the following stated days | | Dabigatran (Pradaxa)   | *Determine patient’s renal function (eGFR, mL/min/1.73$m^2$)

-* eGFR equal or greater than 80, hold dose 3 days before surgery

- eGFR 50-70, hold 4 days before surgery

• eGFR 30-49, hold 5 days before surgery

In patients with severe renal dysfunction (CrCl less than 30 mL/min) who are generally ineligible for DOACs, peri-operative management is unclear. | | Apixaban (Eliquis) | Determine patient’s renal function (eGFR, mL/min/1.73$m^2$)

• 5 mg BID, hold 3 days before surgery

• 2.5 mg BID, eGFR equal or greater than 30, hold 2 days before surgery

• 2.5 mg BID, eGFR Less than 30, hold 3 days before surgery

In patients with severe renal dysfunction (CrCl less than 30 mL/min) who are generally ineligible for DOACs, peri-operative management is unclear. | | Rivaroxaban (Xarelto) | **20 mg once daily, hold 4 days before surgery

10 mg once daily, hold 3 days before surgery ** | | Edoxaban (Lixiana) | *Determine patient’s renal function (eGFR, mL/min/1.73$m^2$)

-* 60 mg once daily, eGFR equal or greater than 30, hold 4 days before surgery

• 60 mg once daily, eGFR less than 30, hold 5 days before surgery

• 30 mg once daily, eGFR equal or greater than 30, hold 2 days before surgery

• 30 mg once daily, eGFR less than 30, hold 3 days before surgery  ** |

Anti-hypertensives: beta blockers, ACEis, ARBs, Entresto, CCBs, vasodilators, diuretics, MRAs, alpha agonists, alpha blockers, vasodilators, nitrates, direct rening inhibitors

CONTINUE on the morning of surgery (prevents POAF) | | RAAS Inhibitors:   ACE-Inhibitors: Ramipril, perindopril, fosinopril, lisinopril, quinapril, trandolapril, enalapril, cilazapril, benazepril, captopril   ARBs: Candesartan, eprosartan,  irbesartan, losartan, , olmesartan, telmisartan, valsartan   ARB/Neprilysin Inhibitor: Sacubitril/valsartan (Entresto)  **** Direct Renin Inhibitor: Aliskerin (Rasilez) |         LAST DOSE day before surgery. (Risk of vasoplegia post-op) | | Diuretics: Amiloride, chlorthalidone, furosemide, hydrochlorothiazide, indapamide, metolazone,   MRAs: Eplerenone, spironolactone **** | HOLD on the morning of surgery   | | Alpha blocker: Doxazosin, terazosin,   Alpha 2 agonists: Clonidine, methyldopa  **** Calcium channel blockers: Amlodipine, diltiazem, felodipine, nifedipine, verapamil   Nitrates: Isosorbide dinitrate, nitroglycerin patch   Vasodilators: Hydralazine |       CONTINUE on the morning of surgery |

Anti-hyperglycemic agents: Insulins, metformin, SGLT2is, GLP1s, DPP4is, sulfunylureas, acarbose, thiazolidinediones

• For outpatients: Refer to RADAR clinic if A1C >8.5% and surgery more than one week away
• Consensus with Endocrinology and Diabetes Educators

Intermediate-acting e.g: Humulin N Novolin ge NPH   Mixed insulin e.g: Humalog Mix25 Humalog Mix40 Humulin 30/70 Novomix30   Short-acting e.g: Aspart (Novorapid, Trurapi, Fiap) Lispro (Humalog, Admelog) Glulisine (Apidra) Humulin R Novolin ge Toronto | · Insulin pump: Consult Endocrinology   · Type I diabetes: Consult Endocrinology   · Long-acting basal or intermediate insulin: Give 75% of patient’s usual dose the night before AND on the morning of surgery

· Mixed insulins: HOLD on the morning of surgery   · Short-acting meal insulin: HOLD on the morning of surgery | | SGLT2 inhibitors  **** canagliflozin (Invokana) Dapagliflozin (Forxiga Empagliflozin (Jardiance) Canagliflozin/Metformin (Invokamet) Empagliflozin/Metformin (synjardy) Empagliflozin/Linagliptin (Giyxambi) Dapagliflozin/Metformin (Xigduo) Dapagliflozin/Saxagliptin (Qtern) Ertugliflozin (Steglatto) Ertugliflozin/Metformin (Segluromet) Ertugliflozin/Sitagliptin (Steglujan)   **** |  ** (HOLD for 3 full days before and on morning of surgery. LAST DOSE 4 days before surgery - Risk of euglycemic DKA)  ** | | Metformin  **** Sulfonylureas: Gliclazide (Diamicron), glyburide, glimepiride (Amaryl)   DPP4 inhibitors: Linagliptin (Trajenta), sitagliptin (Januvia), saxagliptin (Onglyza)   Thiazolidinediones; Rosiglitazone, pioglitazone (Actos)  ****  Alpha-glucosidase Inhibitor: Acarbose  **** Meglitinides: Repaglinide (Gluconorm), nateglinide (Starlix) **** |     HOLD on the morning of surgery (Consider holding longer in renal dysfunction or AKI) | | GLP1 agonist:  **** Semaglutide (Ozempic, Rybelsus)   Dulaglutide (Trulicity)   Liraglutide (Viktoza, Saxenda)   Tirzepatide (Mounjaro)   Glargine/Lixisenatide (Soliqua®) | HOLD for ALL IN PATIENTS (Risk of delayed gastric emptying and pulmonary aspiration during anesthesia)  ** · Weekly dosing: semaglutide sc (Ozempic), dulaglutide (Trulicity), Trizapatide (Mounjaro) o If for weight loss: HOLD for 3 weeks preop if time allows o If for diabetes: SKIP one dose preop

· Daily dosing: semaglutide po (Rybelsus), liraglutide (Viktoza or Saxenda), Soliqua o HOLD for 2 days before surgery (last dose 3 days preop)   For Type 2 DM:  If HbA1C > 8.5% and NOT taking insulin, refer to RADAR clinic preoperatively.   If no HbA1C available, please order one in PAC and refer to RADAR clinic as necessary. |

Disease Modifying Agents DMARDs and Biologics:

**Consider risk of discontinuing therapy (disease flare-up) VS continuing therapy (increased risk of SSIs and wound healing) **