Withdrawal due to preoperative medication stoppage refers to the physiological and psychological disturbances that occur when chronic medications are abruptly stopped before surgery. While the cessation of certain drugs before surgery is necessary to reduce risks such as bleeding or intraoperative hemodynamic instability, abrupt stoppage can result in rebound syndromes, physiological dysregulation, and poorer surgical outcomes. Balancing the competing risks of medication continuation versus stoppage is an ongoing challenge for anesthesiologists.
Preoperative medication management involves evaluating each patient’s chronic therapy for potential interactions with anesthetic agents, the surgical stress response, and hemodynamic stability and implementing a stoppage plan when necessary, ideally one that minimizes withdrawal. However, this is often difficult in practice, whether due to the urgency of the procedure, variation in how individual patients respond to medication, or other factors.
Beta-adrenergic antagonists (β-blockers) are among the most well-documented examples of adverse symptoms upon cessation; stopping them preoperatively can cause rebound hypertension, tachycardia, and ischemia due to the upregulation of adrenergic receptors during chronic therapy (1). Multiple studies have demonstrated that continuing β-blockers throughout the perioperative period reduces cardiovascular morbidity and mortality in high-risk patients (2). Consequently, current anesthesia guidelines strongly recommend maintaining β-blockade throughout the perioperative period, except in cases of severe bradycardia or hypotension.
Similar concerns apply to centrally acting antihypertensives, such as clonidine. Abruptly stopping them may cause rebound hypertension and sympathetic overactivity, which can lead to myocardial ischemia during induction or emergence from anesthesia (3). For this reason, clonidine is usually continued until the day of surgery, and if oral administration is not possible, intravenous administration becomes an available option.
Psychotropic medications, particularly selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), introduce another layer of complexity. Stoppage of these agents in the preoperative period may cause withdrawal symptoms such as dizziness, insomnia, sensory disturbances, agitation, or anxiety for 24 to 72 hours. These symptoms can mimic or exacerbate postoperative delirium and complicate anesthetic emergence. Evidence from perioperative reviews indicates that antidepressant withdrawal syndromes are clinically relevant and that these medications are best continued through the surgical period, unless there are specific contraindications, such as the potential for serotonin syndrome with monoamine oxidase inhibitors (4).
Benzodiazepine withdrawal syndromes also present significant perioperative risks. Sudden discontinuation may cause tremors, agitation, autonomic instability, or seizures. The aforementioned symptoms can overlap with postoperative delirium and complicate anesthetic recovery. Current perioperative guidelines recommend continuing benzodiazepine therapy for dependent patients or gradually tapering off if discontinuation is unavoidable. Cross-tolerant substitutes (e.g., long-acting benzodiazepines) may be used when necessary to prevent withdrawal during the perioperative period (5).
The broader issue beyond individual drug classes lies in polypharmacy and communication failures among care teams. Patients often don’t know which medications to continue or withhold before surgery, and perioperative teams may not have full medication histories. Studies show that up to 60% of surgical inpatients have at least one medication discrepancy upon admission, which increases the likelihood of inappropriate withdrawal and drug duplication (5). Therefore, medication reconciliation, multidisciplinary coordination, and patient education are crucial components of preoperative safety.
For anesthesiologists, awareness of withdrawal phenomena related to preoperative medication stoppage has practical implications for intraoperative management. Patients in withdrawal states may exhibit elevated catecholamine levels, resistance to anesthetic agents, or altered responses to opioids and sedatives. Inadequately recognized withdrawal can also confound hemodynamic monitoring and lead to misattribution of symptoms (e.g., tachycardia from β-blocker withdrawal mistakenly attributed to inadequate anesthesia). Anticipating and mitigating these effects through preoperative planning and postoperative vigilance can significantly improve surgical safety.
References
1. Pass SE, Simpson RW. Discontinuation and reinstitution of medications during the perioperative period. Am J Health Syst Pharm. 2004 May 1;61(9):899-912; quiz 913-4. PMID: 15156966.
2. Doak GJ. Discontinuing drugs before surgery. Can J Anaesth. 1997 May;44(5 Pt 2):R112-23. English, French. doi: 10.1007/BF03022270. PMID: 9196845.
3. Spell NO 3rd. Stopping and restarting medications in the perioperative period. Med Clin North Am. 2001 Sep;85(5):1117-28. doi: 10.1016/s0025-7125(05)70367-9. PMID: 11565489.
4. Zafirova Z, Vázquez-Narváez KG, Borunda D. Preoperative Management of Medications. Anesthesiol Clin. 2018;36(4):663-675. doi:10.1016/j.anclin.2018.07.012
5. Mercado DL, Petty BG. Perioperative medication management. Med Clin North Am. 2003;87(1):41-57. doi:10.1016/s0025-7125(02)00146-3
