Pre-Transplant Education
Pre-Transplant Medications (“Premeds”)
Before liver transplant surgery, your team will review every medication you take and decide what to continue, adjust, or temporarily stop so that anesthesia and surgery are as safe as possible.
Intravenous access and medications are carefully planned before major surgery.
Goals of Pre-Transplant Medication Planning
“Premeds” are not just the medications you take right before anesthesia; they include the entire plan for managing your usual drugs in the days leading up to transplant.
- Reduce bleeding, clotting, blood pressure swings, arrhythmias, and infections during and after surgery.
- Prevent withdrawal or rebound phenomena (for example, stopping beta blockers or benzodiazepines abruptly).
- Coordinate anesthesia, hepatology, cardiology, transplant surgery, and pharmacy so everyone agrees on which medications continue or are held.
- Make the medication plan easy to follow in case transplant occurs urgently (for example, a middle-of-the-night call for a donor organ).
What Your Team Needs to Know
Bring an up-to-date medication list to every transplant visit and keep a copy with you at home.
- All prescription medications, including exact doses and how many times a day you take them.
- Over-the-counter drugs (acid reducers, pain relievers, cold medicines, sleep aids, etc.).
- Herbal remedies and supplements (for example, milk thistle, St. John’s wort, ginkgo, turmeric), which can interact with anesthesia or liver function.
- Blood thinners, antiplatelet agents, and “heart medications” (aspirin, clopidogrel, warfarin, apixaban, beta blockers, ACE inhibitors, etc.).
- Insulin and diabetes pills, including how you adjust them on “sick days” or when you cannot eat.
- Any history of medication allergies or serious reactions to anesthesia.
Medications Commonly Continued
Many medications are continued right up to and including the morning of surgery, often with a sip of water, but decisions are individualized.
- Beta blockers (for example, propranolol, nadolol, carvedilol, metoprolol) are usually continued to avoid rebound hypertension or ischemia, especially when already prescribed for portal hypertension or coronary disease.[1,4,8,20]
- Most anti-seizure medications, antidepressants, and antipsychotics are continued to avoid withdrawal or relapse, with anesthesia adjusting doses or choices as needed.[0,4,20]
- Proton pump inhibitors or H2 blockers are often continued to limit stress ulcers and reflux; some centers give an IV dose pre-operatively.[0,4,20]
- Thyroid hormone replacement is usually continued, including on the morning of surgery, unless anesthesia advises otherwise.[0,4,20]
- Chronic pain medications (for example, long-acting opioids) are generally continued, but dosing and timing may be adjusted; the anesthesia team will plan intra-operative and post-operative pain management.[0,4,20]
Medications Often Held or Adjusted
Some drugs can worsen low blood pressure, bleeding, or kidney function during transplant and are therefore often held or changed.
- ACE inhibitors / ARBs (for example, lisinopril, losartan) may be held the night before and morning of surgery to reduce the risk of severe intra-operative hypotension.[4,8,20,24]
- Loop and thiazide diuretics are often held on the morning of surgery if there is concern for hypovolemia, electrolyte disturbance, or hypotension.[4,9,20]
- Non-steroidal anti-inflammatory drugs (NSAIDs) are usually stopped several days before transplant because of bleeding and kidney risks, especially in cirrhosis.[9,13]
- Some herbal supplements (for example, ginkgo, garlic, ginseng, St. John’s wort) are stopped days to weeks before surgery because of bleeding or drug-interaction concerns.[0,2,10]
- Weight-loss injectables and SGLT2 inhibitors may be adjusted or held because of nausea, delayed gastric emptying, or risk of ketoacidosis; your endocrinology and anesthesia teams will provide specific instructions.[7,16,20]
Anticoagulants and Antiplatelet Agents
Blood thinners require a carefully timed plan that balances bleeding risk during surgery with the risk of clotting if drugs are stopped.
- Aspirin may be continued or held depending on the indication (primary prevention versus coronary stent); transplant, cardiology, and anesthesia decide together.[0,8,16,20]
- P2Y12 inhibitors (for example, clopidogrel, prasugrel, ticagrelor) are often stopped several days before major surgery, but timing depends on stent type and thrombotic risk.[16,20]
- Warfarin is usually stopped several days pre-operatively with INR monitoring and, in some cases, short-acting “bridge” anticoagulation if thrombotic risk is high.[16,20,25]
- Direct oral anticoagulants (for example, apixaban, rivaroxaban, dabigatran) are typically held for 2–5 days depending on renal function and bleeding risk; reversal options may be considered for urgent cases.[7,16,20,25]
- In advanced cirrhosis, the clotting system is “rebalanced” and both bleeding and thrombosis are concerns; individualized planning using hematology and hepatology input is essential.[7,9,13,25]
Diabetes Medications and Steroids
Diabetes management before transplant is tailored to whether you use insulin, pills, or both, and to how long you will be fasting (NPO).
- Basal insulin is often continued at a reduced dose the night before and/or morning of surgery, with close intra-operative glucose monitoring.[4,8,20,24]
- Short-acting insulin doses are usually held once you are NPO, with IV insulin used in the operating room as needed.[4,8,20]
- Many oral diabetes agents (for example, metformin, SGLT2 inhibitors) are held before major surgery because of lactic acidosis or ketoacidosis risk; timing depends on kidney function and specific drug.[7,16,20]
- Patients on chronic steroids or with adrenal suppression may receive “stress-dose” steroids around the time of surgery; this is coordinated with endocrinology and anesthesia.[3,9,15]
Liver-Specific Medications Before Transplant
Many cirrhosis medications are continued right up to transplant to control portal hypertension, ascites, and encephalopathy.
- Non-selective beta blockers (for example, propranolol, nadolol, carvedilol) are often continued, especially if used for variceal bleed prophylaxis; dosing may be adjusted for blood pressure and kidney function.[1,9,17]
- Lactulose and rifaximin are usually continued until the patient goes NPO to maintain control of hepatic encephalopathy; some centers give doses via NG tube if needed.[1,9,23]
- Diuretics (spironolactone, furosemide) may be held on the morning of surgery if there is concern about intravascular volume or electrolytes, but this is individualized.[1,9,13]
- Antibiotic prophylaxis for spontaneous bacterial peritonitis is generally continued until surgery unless the team instructs otherwise.[1,9,23]
- For patients with a prior liver transplant coming for another procedure, chronic immunosuppressive therapy (tacrolimus, cyclosporine, mycophenolate, etc.) should be carefully reviewed; doses are rarely stopped without a transplant team plan.[3,15,23,27]
Day-of-Surgery Premeds Checklist
When you are called in for transplant, you will receive specific instructions from the transplant and anesthesia teams. A typical plan includes:
- Which medications to take with a small sip of water (often beta blockers, seizure meds, some cardiac drugs, thyroid pills).
- Which medications to hold (ACE inhibitors/ARBs, many diuretics, certain diabetes pills, some blood thinners, herbal supplements).
- When your last dose of anticoagulants or antiplatelets was taken, and whether bridging or reversal is needed.
- Verification of allergies, previous reactions to anesthesia, and any changes since your last pre-anesthesia evaluation.[2,6,10,18,22]
- A final review by anesthesia, hepatology, and surgery, with orders for antibiotic prophylaxis, stress-dose steroids if needed, and other IV “premeds” (for example, anti-nausea or anxiety medications).[3,6,10,15,23,27]
Selected References
- Froedtert Health. Guideline for Preoperative Medication Management. Institutional guideline PDF.
- Apfelbaum JL, et al. Practice advisory for preanesthesia evaluation: ASA Task Force. Anesthesiology. 2012.
- Nandhakumar A, et al. Liver transplantation: advances and perioperative care. World J Gastroenterol. 2012.
- Stanford Children’s Health. PARC Preoperative Medication Guidelines. Institutional guideline PDF.
- Abbas N, et al. Perioperative care of patients with liver cirrhosis. Clin Liver Dis. 2017.
- Apfelbaum JL, et al. Practice advisory for preanesthesia evaluation (update). ASA Standards & Advisories.
- Safi K, et al. Perioperative considerations in older kidney and liver transplant candidates. Transplant Rev. 2024.
- UCLA Health. What Medications Should Patients Take Before Surgery? UCLA Anesthesiology FAQ.
- Newman KL, et al. Risk assessment and surgical outcomes in cirrhosis. Ann Surg. 2020.
- VMFH. Perioperative Management of Medications guideline. Institutional guideline PDF. 2020.
- WakeMed. Outpatient Preoperative Medication Guidelines (2024). Institutional guideline PDF. 2024.
- AASLD. Practice guidelines and guidance documents for cirrhosis and portal hypertension. AASLD Practice Guidelines.
- Why do we use non-selective beta blockers in cirrhosis? AASLD Liver Fellow Network. 2021.
- Abbas N, et al. Perioperative management of cirrhosis. Clin Liver Dis. 2017.
- Rea A, et al. Preoperative medication management turnkey order set for cardiac surgery. Ann Thorac Surg. 2024.
- Velasco JAVR, et al. Position paper on perioperative management and surgical risk in cirrhosis. Ann Hepatol. 2024.
- NYSORA. Patient with a liver transplant: anesthesia considerations. NYSORA Review.
- Cutler J, et al. Adult liver transplantation: anesthetic considerations. OpenAnesthesia Summary.
- ASA Standards and Practice Parameters. American Society of Anesthesiologists.
Medical Disclaimer
This page provides general information about pre-transplant medication planning (“premeds”) and is not a substitute for individual medical advice. Never start, stop, or change any medication before transplant without specific instructions from your transplant team, hepatologist, anesthesiologist, and other treating clinicians.