In view of the fact that preoperative medications are written in too general a manner, I found an article on preoperative medication management specifically from UpToDate, which is briefly translated. I. Principles of preoperative medication management 1. Medication use provided by the patient should be verified to refine the name and dosage of the medication, which includes prescription, over-the-counter, and herbal medications. In addition, the patient’s use of sensitive substances (including alcohol, nicotine, and illegal substances) should also be explored. 2. If the sudden discontinuation of a drug causes morbidity, the drug should be continued preoperatively, or a feasible reduction in dosage should be performed. When the loss of gastrointestinal function or prohibition of oral intake and drug absorption is impaired, there should be intravenous injection, transdermal injection and transmucosal administration to replace. When a drug increases the risk of anesthesia and surgical complications, and is not necessary for a short period of time, the drug should be discontinued before surgery. 3, Multiple drugs administered preoperatively in a relatively short period of time increase the likelihood of drug interactions. 4. During the perioperative period, the metabolic clearance of the drug and its metabolites will be altered. In addition, the gastrointestinal absorption of oral drugs may be impaired due to altered visceral hemodynamics and body fluids. II. Cardiovascular Drugs For elective surgery, preoperative adjustments and care should be made to optimal status to reduce risk and minimize the potential for acute changes. For example, if time permits, we recommend extending clinical symptom control in patients with heart failure to one week or longer. Beta-blockers 1. Pros and cons: There are many potential benefits to taking this drug preoperatively. This drug reduces the occurrence of ischemia by decreasing oxygen consumption. It can also prevent and control arrhythmias. Patients who have been taking this drug for a long time to treat angina pectoris are at increased risk of ischemia if it is suddenly discontinued. Abrupt discontinuation of this drug before and after surgery can also lead to serious complications or even death. When the drug is used to treat hypertension and migraine, abrupt discontinuation is less of a problem. The main adverse effects of preoperative use of this drug are bradycardia and hypotension. Non-selective beta-blockers can interact with epinephrine used for infiltration anesthesia and intraoperative allergic reaction treatment. 2. Continuation or discontinuation: In view of the benefits of preoperative use of this drug, the minor adverse effects and the consequences of abrupt discontinuation, we recommend that this drug should be continued preoperatively, including the entire hospitalization period. The dose of this drug should be taken regularly before surgery to maintain blood pressure and heart rate. 3. Preparations/replaceable drugs: If the patient cannot take it orally, it is recommended to administer it by sedation, such as metoprolol, propranolol, labetalol. Esmolol can also be used intraoperatively and in ICU. β₁-blockers are preferred due to their high cardioselectivity, mild effect on lung and peripheral vasculature, and may reduce the risk of postoperative stroke. A number of studies have shown that the risk of preoperative stroke varies with the use of some specific beta-blocker classes of drugs and that metoprolol may increase the risk of preoperative stroke compared with atenolol. However, there is no need to switch to a selective beta blocker preoperatively in patients previously taking a non-selective beta blocker. Alpha₂ receptor antagonists (read alpha₂ agonists) 1. Pros and cons: Although early small randomized trials have shown that drugs used for central sympathetic blockade, such as colistin, improve preoperative conditions, recent large randomized trials have shown that preoperative administration of small doses of colistin may have adverse effects and that colistin, which is used to reduce the risk of acute kidney injury, is not beneficial when used preoperatively. For those patients already taking colistin, abrupt discontinuation of the drug can cause acute rebound hypertension. Withdrawal syndrome has also been reported with methotrexate and guanfacine, but the incidence is extremely low because of their slow onset. 2.Continuation OR discontinuation: For patients already taking α₂ blockers, we recommend continuing this drug before surgery in view of the possibility of withdrawal syndrome with sudden discontinuation; for patients who have not taken this drug, it is recommended not to use it. 3. Preparations/replaceable drugs: transdermal colistin injection is optional; if this modality is to be changed, the decision is made three days before surgery. An equivalent dose of transdermal colistin is to be started three days prior to surgery, at which time oral colistin is to be tapered. The maintenance time for transdermal colistin is 24-48 h. This should be taken into account when changing to an oral preparation. Calcium channel blockers 1. Pros and cons: There are few data on the pros and cons of preoperative use of calcium channel blockers. Data from small trials suggest that in coronary artery bypass surgery, continued administration of diltiazem results in more stable intraoperative hemodynamics compared to placebo. However, there is also little data to verify this claim. Mate’s analysis found that in non-cardiac surgery, continued calcium channel blockers reduced the incidence of ischemia and atrial arrhythmias. There were also no serious interactions between this class of drugs and anesthetics. Withdrawal syndromes for this drug are also atypical. One caveat is that such drugs may increase the risk of bleeding. Evidence is currently insufficient and is to be explored in trials. 2.Continuation OR discontinuation: Although there are fewer data on these drugs and the risk regarding bleeding remains to be explored, they are safer to use, so we recommend that patients who are already taking these drugs preoperatively, continue to take them. 3. Preparations/replaceable drugs: If oral administration is not tolerated, silent diltiazem is an option. Most oral medications belong to the extended-release class and cannot be crushed. Short-acting drugs such as verapamil and diltiazem are also available, as long as the dose is appropriate. However, avoid nifedipine because it can cause an acute drop in blood pressure. Amlodipine has a long clearance period, and there is no need to replace short-acting drugs. ACEI and ARB drugs 1. Pros and cons: For patients taking ACEI drugs, the preoperative management of this drug is controversial. Theoretically, both drugs will suppress the renin-angiotensin system intraoperatively and cause a prolonged drop in blood pressure. Moreover, the effects of these two drugs are different in cardiac surgery and non-cardiac surgery, under local and general anesthesia. A number of trials have shown that their continued administration leads to preoperative and postoperative hypotension, but does not have much effect on cardiac surgery or prognosis. There are many more trials, so I won’t go into them here. 2. Continuation OR discontinuation: Although controversial, the findings of these trials all suggest that perioperative continuation of these two drugs will lead to preoperative hypotension but will reduce the risk of postoperative hypertension. Although there is a possibility of hypotension, there is insufficient evidence from these randomized trials to suggest that either drug increases myocardial ischemia or mortality. According to the 2014 American Heart Association guidelines, continuation is reasonable, especially for patients with congestive heart failure and hypertension. Individualized decision making is recommended based on the indication of the drug, the patient’s blood pressure, the type of procedure, and the anesthesia plan. Some anesthesiologists choose to discontinue such medications in the morning of the operation due to the possibility of hypotension. However, if ARBs are not restarted within 48 h postoperatively, there is an increased perioperative 30-day mortality. 3. Agents/replaceable drugs: Enalapril is a short-acting drug and can be intermittently administered by sedation. Diuretics 1. Pros and cons: The two major physiological effects of the tabs and thiazide diuretics are hypokalemia and hypovolemia. Theoretically, hypokalemia increases the risk of preoperative arrhythmias, although no relationship was found between the two in trials of patients with organic heart disease. In addition, during anesthesia, hypokalemia can potentiate the effects of inotropes and cause paralytic bowel obstruction. In those patients already on diuretics, anesthetic drugs can also cause systemic vasodilation. However, there are also trials that have shown that patients who have been taking furosemide for a long time and continue to take it on the day of surgery did not result in intraoperative hypotension. 2. Continuation OR discontinuation: For elective surgery, there is no consensus on whether to discontinue diuretics before surgery. Given that diuretics may increase the risk of intraoperative hypotension, it is recommended that they be discontinued on the morning of the operative day and that they be activated when the patient can take them orally. If these drugs are used to control hypertension in patients with heart failure, it is also recommended that they be discontinued on the morning of surgery. If these drugs are used to treat heart failure, their use and preoperative volume management should be based on volume status and corrected to the best possible preoperative status. 3. Agents/substitutable drugs: If necessary, sedative tab diuretics are sufficient. 3. Non-inhibitor lipid-lowering drugs 1. Pros and cons: Niacin and fibrate derivatives (gemfibert, fenofibrate) can cause myopathy and rhabdomyolysis, and this risk is increased when these drugs are combined with inhibitors. Surgery itself also increases the risk of myopathy. Lipid-lowering drugs that are bile chelators (cloacenamide, clofibrate) interfere with the intestinal absorption of many preoperative medications that must be administered. The advantages and disadvantages of preoperative use of ezetimibe are not yet clear. 2. Continuation OR discontinuation: Preoperative suspension of niacin, fibrate derivatives, bile chelators, ezetimibe and other drugs is recommended. The interval of preoperative suspension is currently unclear, and it is recommended to discontinue them one day before surgery to allow complete drug metabolism. Digoxin 1. Pros and cons: There are limited studies on preoperative digoxin. Digoxin use reduces hospitalization rates and controls ventricular response in patients with atrial fibrillation. One study suggests that preoperative digoxin use may be a predictor of postoperative ischemia, possibly because digoxin use is a marker for the presence of underlying cardiac disease. Another study found that digoxin reduced the probability of postoperative supraventricular arrhythmias. 2. Continuation OR discontinuation: Continued use of digoxin is recommended. 3.Preparation/replaceable drug: If needed, digoxin can be injected quietly. IV. Gastrointestinal drugs H2 receptor blockers and proton pump inhibitors 1. Pros and cons: Preoperative application of H2 receptor blockers and proton pump inhibitors is quite beneficial. The stimulation of surgery and some other stressful conditions can increase the risk of mucosal stress injury. The preoperative use of these drugs minimizes the risk. A small amount of gastric absorption can also occur during anesthesia, causing reflux aspiration and serious lung damage. In contrast, these two types of drugs reduce the gastric volume and increase the PH in the stomach, which can reduce the risk of lung injury. Although preoperative application of H2-blockers is generally safe, this drug can cause rare postoperative central reactions including confusion and delirium in patients with severe disease. Risk factors for this central reaction include age, organ dysfunction, and pre-existing disorders of consciousness. Preoperative use of proton pump inhibitors increases the risk of C. difficile infection. Although cimetidine can alter the metabolism of many drugs, the vast majority of H2 receptor blockers and proton pumps do not interact with anesthetic drugs. 2.Continuation OR discontinuation: Patients taking these two classes of drugs preoperatively are advised to continue taking them. 3.Preparation/replaceable drugs: Those who cannot tolerate oral administration can be injected quietly. V. Pulmonary drugs Inhaled beta agonists and anticholinergics 1. Pros and cons: Beta agonists (e.g., salbutamol, salmeterol, formoterol) and anticholinergics (e.g., ipratropium bromide, tiotropium bromide), which are inhaled drugs used to control obstructive lung disease, can reduce postoperative pulmonary complications in patients with asthma and obstructive lung disease. 2.Continuation OR discontinuation: It is recommended to continue their use before surgery, including the day of surgery. 3.Preparation/replaceable drugs: Inhalation type can be used, when it can not be used when dosimeter inhalation type, spray can be used. Theophylline drugs 1, pros and cons: whether preoperative application of theophylline drugs can reduce postoperative pulmonary complications, there is no data on this. Above the therapeutic dose, theophylline drugs can cause arrhythmia and neurotoxicity. Moreover, the metabolism of this drug is affected by many drugs applied preoperatively. 2.Continue OR stop: Preoperative discontinuation is recommended. Glucocorticoids 1. Pros and cons: Patients who use glucocorticoids to control obstructive pulmonary disease can cause adrenocortical insufficiency if the drug is suddenly stopped, especially when faced with such a great stress as surgery. In addition, it is necessary for patients on glucocorticosteroids to have their lung function optimally adjusted preoperatively. The probability of preoperative complications related to glucocorticoids, including wound infection, is low. 2. Continue OR discontinue: Both inhaled and systemically applied ones are continued preoperatively. Leukotriene inhibitors 1. Pros and cons: Leukotriene inhibitors, such as zafirluca and montelukast sodium, can be used for asthma control but not for acute treatment of asthma. These drugs have a relatively short clearance period, but they can have a controlling effect on asthma and lung function for up to 3 weeks after dosing is stopped. It is not clear whether this drug has a withdrawal syndrome. These drugs also have no adverse interactions with narcotics. 2. Continue OR discontinue: It is recommended that these drugs be taken until the morning of the day of surgery. Postoperatively, they are activated when the patient can tolerate oral administration. 3.Preparation/replaceable drugs: as long as they are not administered via the intestine, or give long-acting drugs. VI. Endocrine drugs Glucocorticoids The preoperative management of glucocorticoids is discussed below in two cases. 1. If glucocorticosteroids are taken for less than 3 weeks, or if they are on long-term interval therapy, it is unlikely that the hypothalamic-pituitary-adrenal (HPA) axis is suppressed in this group of patients, and they should be continued preoperatively. 2, daily dose of prednisone more than 20mg for more than 3 weeks, or the application of the drug to control Cushing’s syndrome, then the HPA axis of these patients will be suppressed, preoperative increase the application of corticosteroids. Oral contraceptives 1. Pros and cons: Oral contraceptives can cause thrombosis in young women. The risk of thrombosis increases after 4 months of use and decreases after 3 months of discontinuation. And surgery itself is a risk factor for thrombosis. Birth control pills with high estrogen content (>35mg) increase the risk of thrombosis compared to oral contraceptives with low estrogen content (<30mg). However, even very low estrogen content poses a risk of thrombosis. Progestin is the same as estrogen. The risk of thrombosis from progestin is related to the type of progestin. 2. Continue OR stop: The key to stopping or not stopping this drug is the trade-off between the two risks of pregnancy and thrombosis. For low-risk procedures, oral contraceptives can be continued before surgery. Overall, stop taking oral contraceptives 4-6 weeks before surgery, during which time other alternative medicines can be used to prevent pregnancy. For those women who cannot tolerate other contraceptive pills, they may continue to take them, but they should be informed of the increased risk of thrombosis and planned thromboembolic prophylaxis. Pre-operative serum program testing for pregnancy is recommended for all women of childbearing age, especially for women who have stopped taking oral contraceptives. VII. Postmenopausal hormonal medications 1. Pros and cons: The estrogen content of hormonal medications used for postmenopause is lower than that of oral contraceptives. However, whether estrogen alone or estrogen in combination with progestin increases the risk of venous thromboembolism VTE, suspension of this class of drugs presents minimal problems with discomfort related to menopausal syndrome. 2. Continue OR discontinue: It is recommended that this drug be suspended 6 weeks prior to surgery. For low-risk surgery, it can be continued. Selective estrogen receptor modulation 1. Pros and cons: These drugs (e.g. tamoxifen, raloxifene) are used in the treatment and prevention of breast cancer, and raloxifene is also used in the treatment and prevention of osteoporosis. These drugs can also increase the risk of VTE. 2. Continue OR discontinue: When these drugs are used for breast cancer and osteoporosis prevention, it is recommended to discontinue them 4 weeks before surgery. They can be continued for low-risk surgery. When these drugs are used in the treatment of breast cancer, it is recommended to discuss with oncologists. VIII. Thyroid medication May continue to be taken. Those who cannot take it orally can be injected intravenously or subcutaneously. Note that the dose of non-intestinal medication is 80% of the usual oral dose. Nine, osteoporosis drugs 1, pros and cons: diphosphonates may cause necrosis of the jaw in patients undergoing dental surgery. The absolute risk is very low, but osteoporosis is indeed difficult to manage. The duration of action of diphosphonates for bone reconstruction is long, and discontinuing this drug weeks or even months before surgery does not reduce the risk of osteoporosis. Likewise, there is no evidence that suspending the drug reduces its efficacy for fracture prevention. The American College of Physicians recommends that for elective surgery, the drug be discontinued three months prior to surgery. X. Hemostatic drugs Aspirin 1. Pros and cons: Aspirin irreversibly inhibits platelet cyclooxygenase, which can cause intraoperative blood loss. However, this pharmacological effect will also prevent preoperative vascular complications, especially cardiac and vascular thrombosis. The pros and cons of preoperative aspirin application depend on the patient's indication for the drug and the type of surgery. For example, observational studies have found that preoperative discontinuation of aspirin increases in-hospital mortality in patients undergoing cardiac bypass surgery. However, another study showed that in patients undergoing non-cardiac surgery, preoperative aspirin increased the risk of intraoperative blood loss and did not have a cardiovascular or mortality impact. Despite preoperative anticoagulation in 2/3 of patients and an overall low incidence of VET, preoperative aspirin does not provide benefit for acute kidney injury, prophylactic thromboembolism. 2. Continue OR stop: Stopping or not depends on the type of surgery and the patient's medication purpose. For minor dental procedures or skin treatments, aspirin does not need to be discontinued. 3.Preparation/replaceable drugs: can be administered via rectum. Other antiplatelet drugs 1. Pros and cons: ①ADP receptor antagonists (clopidogrel, prasugrel, tigretol, ticlopidine) are used in patients with cerebrovascular accidents, recent coronary syndromes and after coronary stent implantation. The incidence of in-stent thrombosis is low in those taking clopidogrel after coronary stenting, but the risk is still increased and, if it occurs, the consequences are severe. Elective procedures should be postponed until the minimum therapeutic window for such drugs is over. There is no difference between continuing the drug and discontinuing it when performing peripheral vascular and cervical vascular procedures. ② Dipyridamole has antiplatelet and vasodilatory effects. This drug is widely used in patients with stroke and transient ischemic TIA. The half-life is about 10h. ③Cilostazol is a selective phosphodiesterase inhibitor and reversibly inhibits platelets. It is currently used mainly for the treatment of claudication syndrome with a half-life of about 21h. 2. Continue OR stop: ①These drugs are mainly used to prevent thrombosis in coronary stents. Except for emergency surgery, it is recommended to postpone the surgery. Depending on the stent condition, aspirin and ADP receptor antagonists should be taken for the shortest effective time to effectively prevent in-stent thrombosis. ②If surgery must be performed during this period, it should be discussed with the cardiovascular surgeon and the surgeon. It is recommended that the procedure be performed with 24 interventions in the heart (indicating that this was not read). If the risk of bleeding is greater than the risk of in-stent thrombosis, it is recommended that clopidogrel be discontinued 5 days before surgery, prasugrel 7 days before surgery, and tigretol 10 days before surgery, and that aspirin be continued during this period. Resume it as soon as possible after the surgery. ③If the patient has been taking such drugs for longer than the minimum treatment period, discontinue them and make surgery feasible. ④It is not necessary to stop clopidogrel when performing peripheral vascular and cervical vascularization. ⑤ There is no consistent conclusion about whether to discontinue dipyridamole before surgery. As with aspirin, the key to discontinuing this drug is the trade-off between the risk of bleeding and the risk of ischemia. If discontinued, it is recommended to discontinue dipyridamole 2 days prior to surgery; and to discontinue cerebroconfin (aspirin) 7-10 days prior to surgery. For elective surgery, it is recommended to stop cilostazol 5 days before surgery. XI. Non-steroidal anti-inflammatory drugs NSAIDs 1. Pros and cons: The anti-platelet effect of NSAIDs is due to the inhibition of COX-1 release, which leads to the reduction of thromboxane A₂ (TXA₂) release. the effect of TXA₂ is to cause the aggregation of platelets. As with aspirin, this effect can cause bleeding and additionally reduce preoperative vascular complications. The selective COX-2 inhibitor celecoxib has the least antiplatelet effect, but has potential nephrotoxicity. Most of the selective COX-2 and non-selective NSAIDs have adverse cardiovascular effects. Non-acetylsalicylic acid has no antiplatelet effect. 2. Continue OR discontinue: ① It is recommended to discontinue NSAIDs, including selective COX-2 inhibitors, before surgery. ②But for patients whose pain is controlled with these drugs, it is recommended to discuss with the surgeon. If the patient's pain is more sensitive to selective COX-2 inhibitors, then preoperative continuation may be considered. ③In consideration of the drug elimination half-life and platelet function recovery time, some experts recommend discontinuing most NSAIDs 3 days before surgery and stopping ibuprofen 24h before surgery. ④ non-acetyl NSAIDs (diflunisal, bisalicylic acid, choline magnesium trisalicylate) can continue to be taken before surgery, and these drugs can be used to control pain. 3.Preparation/replaceable drugs: When oral administration is not tolerated, ketorolac chlortetracycline or ibuprofen can be administered by sedation to control pain and fever, and the patient does not have renal impairment-like disease. For patients with renal impairment, acetaminophen may be administered sedately. The preoperative management of these drugs varies depending on the type of drug and the patient's mental status. Guidelines for these drugs are lacking, and some experiments and data reported in the literature are limited. The preoperative management of these drugs weighs three main points: side effects of psychotropic drugs; potential interactions of psychotropic drugs with narcotics; and withdrawal syndrome. In general, medications used to control severe and unstable psychiatric disorders may be continued preoperatively to avoid psychiatric discomfort. However, the most appropriate anesthetics and analgesics for use in combination with psychotropic medications are unknown. Tricyclic and tetracyclic antidepressants 1. Pros and cons: These drugs inhibit the uptake of norepinephrine and 5-hydroxytryptamine in the synaptic gap. These drugs have low seizure threshold and have anticholinergic, antihistamine and α₁ receptor antagonistic effects, which can delay gastric emptying and prolong QT interval, and can increase the risk of arrhythmia when combined with volatile narcotics and sympathomimetic drugs. Abrupt discontinuation of such drugs can lead to insomnia, nausea, headache, salivation, sweating, etc. Avoid abrupt discontinuation. These drugs potentiate the systemic effects of norepinephrine and epinephrine and are generally safe when combined with local anesthetics that inhibit epinephrine. When combined with atropine and scopolamine, there is an increased risk of postoperative complications. Because the combination with tramadol and pethidine can lead to a large activation of serotonin, it is not recommended to combine them. 2. Continue OR discontinue: ① Most of the literature recommends continuing preoperative dosing. However, the FDA and the following experts recommend preoperative discontinuation for elective surgery, when the patient's condition permits. ②This literature recommends that for those patients using high doses and no cardiac abnormalities, continue preoperatively; ③For those patients using low doses or at high risk of arrhythmias, taper the dose over 7-14 days preoperatively. 3. Agents/replaceable drugs: parenteral administration of amitriptyline or clomipramine is sufficient. Selective 5-hydroxytryptamine reuptake inhibitors SSRIs 1. Pros and cons: It may increase the risk of bleeding due to its effect on platelet aggregation and causes different consequences depending on the type of surgery. This is also mainly related to the antiplatelet function and the application of NSAIDs as previously mentioned. Avoid sudden discontinuation of short-acting SSRIs because it can cause a series of withdrawal syndromes, such as vertigo, cold, myalgia, anxiety, etc. 2. continue OR discontinue: For most patients, it is recommended to continue SSRIs preoperatively. whether to discontinue is critically assessed by the trade-off between bleeding and psychiatric disorders. If the patient is at risk for life-threatening postoperative blood loss, or if the patient requires continuous antiplatelet therapy as secondary prevention, taper the dose in the weeks before surgery and replace it with another antidepressant. (ii) If the patient is at relatively low risk of blood loss, continue preoperatively. ③If SSRIs are continued, other antiplatelet agents should be discontinued. ④If aspirin or thienopyridine is required for secondary prevention, discontinue SSRIs and replace them with other antidepressants. Bupropion This drug is administered preoperatively as SSRIs. Monoamine oxidase inhibitors (MAO inhibitors) 1. Pros and cons: Non-selective MAO inhibitors (e.g., isocarbohydrazide, pagyline, phenelzine, antiphenobarbital) can cause accumulation of biogenic amines in the central and autonomic nervous systems. During anesthesia, the use of sympathomimetic drugs, such as ephedrine, can cause the release of accumulated norepinephrine, causing an increase in blood pressure. In addition, the central nervous system can produce two reactions related to surgery and anesthesia. First, when anticholinergics (e.g., dextromethorphan) and pethidine are combined with MAO inhibitors, 5-hydroxytryptamine syndrome (agitation, headache, fever, seizures, and even coma and death) is produced; second, because MAO inhibitors inhibit hepatic microsomal oxidase, free anesthetic and sedative drugs accumulate, resulting in respiratory and circulatory depression. In patients who continue to take MAO inhibitors, the application of morphine and fentanyl can effectively avoid the first reaction, but the suppressive effect of CSN should be closely monitored. Phenelzine will enhance the effect of succinylcholine. 2.Continuation OR discontinuation: Whether to discontinue the drug is discussed by the anesthesiologist and psychiatrist. ①The following two conditions can be met: Ⅰ, the anesthesiologist is familiar with the mastery of the safe operation of MAO; Ⅱ, the psychiatrist believes that the sudden discontinuation of the drug may aggravate the patient's condition. MAO inhibitors are irreversible antagonists, and it takes two weeks for MAO function to recover after discontinuation. Therefore, it is recommended to gradually reduce the dosage of MAO inhibitors until they are discontinued, and surgery is feasible after two weeks. During this period, other medications may be used to treat depression instead. (iii) For those who continue to take them, the patient's diet should be set by the doctor, without tyramine-rich foods and without acute fluctuations in blood pressure. Pay close attention to the drugs interacting with MAO inhibitors preoperatively and intraoperatively. XIII. Anticonvulsants (lithium carbonate, sodium valproate) 1. Pros and cons: ① Lithium carbonate will reduce the release of neurotransmitters and will prolong the duration of action of muscarinic drugs. It has a small efficacy index and is mainly cleared by the kidneys; and interacts with a variety of drugs (such as diuretics, NSAIDs, ACEI, pethidine, tramadol, etc.). Long-term use of this drug will also produce multiple effects on the thyroid gland. In addition, up to 20% of patients taking this drug have nephrogenic uremia, and these patients who already have renal impairment maintain normal serum sodium by drinking more. Preoperative release of large amounts of water can have adverse effects, leading to fluid loss and hypernatremia. ② Sodium valproate is mainly used in patients with bipolar psychiatric disorders, and it can interact with NSAIDs and some antibiotics. There are no reports of problems caused by the continued use of this drug before surgery. 2.Continuation OR discontinuation: This drug is generally used to treat more severe psychiatric disorders. It is recommended to continue taking it before surgery, but pay close attention to fluid and serum sodium, and check nail function before surgery. 3.Preparation/replaceable drugs: Lithium carbonate can be temporarily discontinued for patients who cannot tolerate oral administration because there is no parenteral preparation, to be reintroduced within 24h after surgery. Sodium valproate can be given parenterally. And when patients can not tolerate oral lithium carbonate, it and second-generation anticonvulsants (risperidone, olanzapine, ziprasidone) can replace lithium carbonate. XIV. Antipsychotics 1. Pros and cons: Relevant studies have pointed out that antipsychotics, whether typical or atypical, increase the risk of sudden death and all prolong the QT interval and cause arrhythmias, especially when combined with volatile narcotics and other drugs (erythromycin, quinolone, amiodarone, sotalol). They enhance the analgesic and hypotensive effects of narcotics and opioids. It will cause vertebral fasciculus side effects for different reasons, as well as rare malignant syndrome of nerve blockers. 2. Continue OR discontinue: If the psychiatric disorder is severe, the drug should be continued. If the patient has a prolonged QT interval, discontinue the drug. After discussion with the psychiatrist, short-acting, low-dose application until complete discontinuation can also be considered. Abrupt discontinuation of the drug is rarely associated with withdrawal syndrome. 3. Preparations/replaceable drugs: Classic drugs can be administered subcutaneously. Haloperidol decanoate and fluphenazine decanoate are both long-acting preparations lasting one month and two weeks, respectively. Short-acting olanzapine and ziprasidone, as well as long-acting risperidone, can also be administered subcutaneously. Olanzapine and risperidone are also available in chemical formulations. XV. Anti-anxiety drugs 1. Pros and cons: ① Abrupt discontinuation of long-acting benzodiazepines can lead to a series of euphoric states, such as hypertension, impatience, delirium, psychotic episodes, etc. Because the metabolites of these drugs are active, the withdrawal syndrome can last from a few days to several weeks after discontinuing the drug. ② It is also safer to continue taking buspirone preoperatively. This drug has been reported to lower the myofibrillation threshold when combined with dexmedetomidine intraoperatively. Because of its serotonin-activating effect, it is not recommended to be combined with pethidine and tramadol. 2.Continuation OR discontinuation: Benzodiazepines and buspirone used for long-term anxiety control can be continued preoperatively. 3. Agents/replaceable drugs: Benzodiazepines can be administered parenterally, such as diazepam and lorazepam. Since only oral preparations of buspirone are available, parenteral benzodiazepine preparations can be used instead. Intravenous injection is also not recommended because it may lead to unstable blood pressure. XVI. Psychostimulants 1. Pros and cons: Psychostimulants used to treat attention deficit disorder may have an increased risk of hypertension, arrhythmias, low threshold for psychotic episodes, and may interact with other drugs used preoperatively. When haloperidol is combined with methylphenidate, there is an increased risk of acute fluctuations in blood pressure. 2.Continue OR discontinue: There are limited relevant data, and there is no withdrawal syndrome with sudden discontinuation. If the patient is stable, it is recommended to discontinue the drug before surgery. Naltrexone 1. Pros and cons: Naltrexone is derived from hydromorphone and can be used as an antagonist of opioids due to its high affinity with μ receptors. It can help patients who are addicted to opioids to reduce their desire and reach the purpose of detoxification. When combined with buprenorphine, it increases the concentration of opioid receptors in the CNS, which leads to a temporary aggravation of the response to receptor agonists in acute pain. 2, continue OR discontinue: It is recommended to discontinue before surgery. The first two drugs are described in the previous article. DMARDs include traditional drugs (methotrexate MTX, hydroxychloroquine, lorazepam, azathioprine, and leflunomide) and biological agents such as tumor necrosis factor TNF-α inhibitors (etanercept, indiximab, adalimumab, certolizumab, golimumab), T-cell inhibitors (abciximab), IL-6 and IL-1 receptor antagonists, and anti-CD20 monoclonal antibodies (rituximab).1 Studies have found that continued preoperative administration of MTX does not increase the chance of infection. There is less data from studies of other drugs in the DMARDs class. Most DMARDs are nephrotoxic and can lead to drug accumulation in patients with renal impairment, and their metabolites can also have myelosuppressive effects. ② TNF-α inhibitors increase the chance of skin soft tissue infections in non-surgical patients, and the three TNF-α inhibitors do not differ in this adverse effect. However, there are no reports on the relationship between TNF-α inhibitors and surgical site infections. (iii) There is a lack of reports regarding the continuation OR discontinuation of preoperative abciximab, rituximab, IL-6 and IL-1 receptor antagonists. However, sudden discontinuation may lead to acute compensatory dysregulation of the immune system, so whether to discontinue them should be considered from all aspects. 2. Continue OR discontinue: For patients with normal renal function, continue to take MTX before surgery; for patients with renal insufficiency, discontinue the drug two weeks before surgery. For lenazodipine and azathioprine, discontinue one week before surgery. Long-acting leflunomide, discontinue two months before surgery. Hydroxychloroquine can be continued. TNF-α inhibitors are discontinued two weeks before surgery. XVIII. Gout medications 1. Pros and cons: Surgery itself can aggravate gouty arthritis. Gout patients take long-term gout medications to maintain a low uric acid status or use colchicine. The best preoperative management strategy for these drugs is unknown. Colchicine has a low therapeutic index and can cause muscle weakness and polyneuropathy in cases of renal insufficiency or drug interactions. 2. Continuation OR discontinuation: Colchicine and allopurinol and propiodol are recommended to be discontinued on the morning of the day of surgery. Nineteen, prostatic hypertrophy drugs 1.Pros and cons: Some patients with prostatic hypertrophy taking α₁ receptor antagonists (terazosin, dorazosin, tamsulosin, etc.) may lead to intraoperative iris relaxation syndrome. 2.Continue OR discontinue: It is unknown whether discontinuing α₁ receptor antagonists before surgery will reduce the incidence of IFIS. Based on clinical experience, these drugs have a long duration of action, and most ophthalmologists do not believe that the drug should be discontinued preoperatively. Many intraoperative options are available to reduce the incidence of IFIS. It is important for the surgeon to confirm that the patient is taking this medication. XX. Herbal Drugs Herbal drugs are widely used and their continued use preoperatively can have many adverse effects, including abnormal blood pressure coagulation and interactions with anesthetic drugs. Physicians should be careful to ask patients before surgery. There is also no evidence that herbs improve the postoperative period, and some theories suggest that herbs also increase preoperative mortality. Therefore, it is recommended to stop using them 2 weeks before surgery.