What is the perioperative management of NSAIDS?

Updated: Jan 09, 2018
  • Author: Nafisa K Kuwajerwala, MD; Chief Editor: William A Schwer, MD  more...
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NSAIDs are often prescribed for patients with rheumatic diseases. NSAIDs that inhibit platelet cyclooxygenase-1 (COX-1) block the formation of thromboxane A2, which impairs thromboxane-dependent platelet aggregation and variably prolongs the bleeding time. Because aspirin irreversibly blocks cyclooxygenase, the inhibition persists for the circulating lifetime of the platelet. Most nonaspirin NSAIDs inhibit cyclooxygenase reversibly; therefore, their duration of action depends on the specific drug, dose, serum level, and half-life. Those NSAIDs with limited activity against platelet COX-1 include nonacetylated salicylates and nabumetone. The highly selective cyclooxygenase-2 (COX-2) inhibitors (eg, celecoxib [Celebrex]) have no effect on platelet aggregation and bleeding time, even when given at supratherapeutic doses.

Conflicting data exist regarding the use of NSAIDs and perioperative bleeding. However, the general consensus is to withhold aspirin and platelet active–nonaspirin NSAIDs before surgery. Because the inhibitory effect of aspirin on platelet aggregation may persist for 7-10 days, discontinuing aspirin at least 1 week before surgery is prudent.

Because nonaspirin NSAIDs act in a reversible fashion, the function of cyclooxygenase returns as the drug clears from the circulation. Therefore, the rate of return of normal platelet function varies with the terminal drug half-life.

Withholding nonaspirin NSAIDs several days before surgery is reasonable, especially in surgical procedures in which bleeding complications could be catastrophic. In urgent cases, COX-2 selective NSAIDs can likely be used without increased risk of bleeding. Their effect on mucosal wound healing has not been studied in humans.

In those patients with inflammatory arthritis who are dependent on their NSAID therapy for control of their symptoms, withholding therapy in the perioperative period may result in increased pain and stiffness. This effect should be anticipated, and alternative therapy, such as analgesics or low-dose corticosteroids, should be considered to prevent pain, which may result in delayed postoperative rehabilitation.

Table 5. Perioperative Management of NSAIDs (Open Table in a new window)


Day Before Surgery

Day of Surgery

During Surgery

After Procedure

Substitute Drug if Needed

NSAIDs with long half-life

Discontinue 1 week before surgery



IM preparation until patient is on oral liquids


NSAIDs with short half-life

Discontinue 2-3 days before surgery



IM preparation until patient is on oral liquids


NSAIDs in patients with arthritis





Low-dose steroids

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