Medications & the Perioperative Balance

Part of The Joint Replacement Guide — Phase 5: Recovery and Rehabilitation · Article 37 of 44 · Hip & Knee

Key Points

  • Joint replacement temporarily increases the risk of a blood clot, while medication used to reduce that risk can also increase bleeding.
  • Your team assesses both risks before selecting a prevention plan; there is no single medicine or duration suitable for everyone.
  • Do not stop or change regular medicines, prescribed blood-clot prevention or pain relief without instructions from your clinical team.
  • Provide a complete list of prescription medicines, over-the-counter products, vitamins and herbal supplements before surgery.
  • Persistent or increasing wound leakage needs prompt surgical advice, but you should not stop blood-thinning medication yourself.

Two Different Medication Questions

Medication planning around joint replacement involves two related but distinct questions:

  1. What should happen to medicines you already take?
  2. What treatment should be prescribed after surgery to reduce the risk of a blood clot?

The answers depend on the operation, anaesthetic, kidney and liver function, other health conditions, and the reasons for which your existing medicines were prescribed. They should therefore be recorded in an individual perioperative medication plan.

Your Regular Medicines

Before surgery, give the pre-assessment team an accurate list of everything you take, including doses and timing. This includes:

  • prescription medicines
  • anticoagulants such as warfarin, apixaban, rivaroxaban, edoxaban or dabigatran
  • antiplatelet medicines such as aspirin or clopidogrel
  • insulin and other diabetes medicines
  • steroid tablets
  • immune-suppressing medicines and biological treatments
  • hormone replacement therapy or oestrogen-containing contraception
  • anti-inflammatory painkillers
  • vitamins, herbal remedies and dietary supplements.

Some medicines are continued, some require temporary adjustment and others may need to be stopped and restarted at carefully selected times. The plan may also be affected by whether you are having a spinal anaesthetic.

Stopping an anticoagulant or antiplatelet medicine too early can increase the risk of a stroke, clot or another serious event. Continuing it too close to surgery may increase bleeding or make a spinal anaesthetic unsafe. Never make this decision yourself.

Diabetes medicines also require an individual plan because fasting and surgical stress affect blood glucose. Different instructions apply to insulin, sodium-glucose cotransporter-2 inhibitors—usually called SGLT2 inhibitors—and medicines such as GLP-1 receptor agonists. Guidance in this area continues to evolve, so follow the specific instructions from your current pre-assessment and anaesthetic team rather than generic online stopping rules.[1–3]

Steroid medication should not be stopped abruptly unless a clinician has expressly instructed you to do so. Immune-suppressing and biological medicines should be planned with the specialist who prescribes them as well as the surgical team.

Why Joint Replacement Increases Clot Risk

Surgery activates the body’s clotting response, while reduced mobility can slow blood flow through the veins. Together, these temporarily increase the risk of venous thromboembolism (VTE).

VTE includes:

  • deep vein thrombosis (DVT)—a clot, usually in a deep vein of the leg
  • pulmonary embolism (PE)—when part of a clot travels to the lungs.

Everyone should have their VTE and bleeding risks assessed. NICE recommends drug prophylaxis after elective hip or knee replacement when the person’s risk of VTE outweighs their risk of bleeding.[4]

Prevention may combine medication with early mobilisation, hydration and, where appropriate, mechanical measures such as anti-embolism stockings or intermittent pneumatic compression.

Medicines Used to Prevent Blood Clots

Several acceptable regimens are available. The choice depends on your individual assessment and local protocol.

For elective hip replacement, NICE lists the following principal options:

  • low-molecular-weight heparin (LMWH) for 10 days followed by aspirin for a further 28 days
  • LMWH for 28 days, combined with anti-embolism stockings until discharge
  • rivaroxaban.

If these options cannot be used, apixaban or dabigatran may be considered.[4]

For elective knee replacement, NICE lists:

  • aspirin for 14 days
  • LMWH for 14 days, combined with anti-embolism stockings until discharge
  • rivaroxaban.

Apixaban or dabigatran may be considered when the principal options cannot be used.[4]

These are national guideline options rather than a single compulsory regimen. Hospitals may use locally agreed protocols with different medicines, combinations or treatment durations, and your team may adapt these further according to your individual clotting and bleeding risks. Follow the specific prescription and discharge instructions provided by your hospital, and do not change the medicine or duration without clinical advice.

These are guideline options, not instructions for an individual patient. Your hospital may use a particular evidence-based local pathway, modified where necessary for factors such as:

  • a previous DVT or PE
  • cancer
  • limited mobility
  • a known bleeding disorder
  • previous significant bleeding
  • kidney or liver impairment
  • other anticoagulant or antiplatelet treatment
  • body weight and other health conditions.

If you already take an anticoagulant, your long-term treatment and your postoperative prophylaxis must be coordinated as one plan. You should not assume that both are taken together.

Balancing Clotting and Bleeding

Medicines that reduce clot formation can increase bleeding, bruising or wound leakage. However, it is misleading to arrange available medicines on a simple scale from “weak” to “strong.”

Different medicines have different effects, dosing schedules, elimination pathways and supporting evidence. In a systematic review of randomised trials, apixaban was associated with fewer overall wound complications than LMWH, while dabigatran and rivaroxaban did not significantly increase overall wound complications; rivaroxaban was, however, associated with more major or clinically relevant non-major bleeding in that analysis.[5]

This illustrates why the decision is more complicated than assuming that a more effective clot-prevention medicine will necessarily cause a wound infection. Bleeding and persistent drainage may contribute to wound problems, but infection has multiple potential causes and cannot be attributed to the prophylaxis medicine alone.

Wound Leakage

A small spot of blood on a new dressing can occur after surgery. What matters is whether the wound is becoming dry or continues to release fluid.

Seek prompt advice from your surgical team if:

  • the dressing is repeatedly becoming wet or saturated
  • leakage continues or increases rather than settling
  • fluid continues to escape from the wound beyond approximately 72 hours
  • the wound begins leaking again after becoming dry
  • leakage is accompanied by increasing redness, warmth, swelling or pain
  • you develop pus, fever, chills or feel generally unwell.

Persistent wound drainage is associated with an increased risk of infection around a joint replacement and should be assessed rather than simply covered with repeated dressings.[6]

Do not stop aspirin, LMWH or another prescribed clot-prevention medicine yourself because the wound is leaking. Contact the surgical team promptly; they will assess the wound and decide whether the dressing, activity, medication or another part of the treatment plan needs changing.

Do not take leftover antibiotics without assessment, as this can interfere with investigation and may not treat the underlying problem appropriately.

Pain Relief and Over-the-Counter Medicines

Postoperative pain relief commonly combines medicines with different actions. This may include paracetamol, an anti-inflammatory medicine where appropriate, and a short course of stronger medication.

Follow the discharge prescription carefully:

  • do not take more than the prescribed dose
  • check before combining products, as some over-the-counter remedies also contain paracetamol
  • do not add ibuprofen, naproxen, aspirin or another anti-inflammatory without checking with your team, particularly if you are taking clot-prevention medication or have kidney, stomach or heart problems
  • do not drive or drink alcohol if an opioid or another medicine is making you drowsy
  • ask what to do about constipation or nausea if an opioid has been prescribed
  • obtain advice if pain remains uncontrolled despite taking the medicines correctly.

NICE recommends that postoperative pain management consider age, frailty, kidney and liver function, other medicines, allergies and the need to regain function.[7]

Nutrition

Poor nutritional status can reduce physiological resilience and is associated with poorer surgical outcomes. For this reason, NICE recommends nutritional screening before major or complex surgery, including total joint replacement.[7]

Albumin is sometimes included in a clinical assessment, but a low albumin result is not simply a measurement of dietary protein. It can also be affected by inflammation, illness, liver or kidney disease and fluid balance.

For most patients, the appropriate advice is to eat a varied, balanced diet with adequate energy and protein rather than begin high-dose supplements independently. Tell your team if you:

  • have unintentionally lost weight
  • have a poor appetite
  • have difficulty swallowing or preparing food
  • follow a restricted diet
  • have a condition affecting absorption
  • are concerned that you may be undernourished.

Individual advice from a dietitian may be helpful. Protein or nutritional supplements are not automatically suitable for everyone, particularly people with certain kidney, liver or metabolic conditions.

Mobilisation and Hydration

Early movement helps restore function and contributes to reducing venous stasis. NICE advises patients to mobilise as soon as possible and to avoid dehydration unless there is a clinical reason for fluid restriction.[4]

Mobilisation works alongside—not instead of—prescribed medication and mechanical prevention. Walking more does not make it safe to stop prophylaxis early, and taking prophylaxis does not remove the need to move as advised.

Follow your physiotherapy plan and seek help rather than walking unsupported if weakness, dizziness or the effects of an anaesthetic make you unsafe.

Before You Leave Hospital

Make sure you know:

  • the name and dose of every medicine you should take
  • which regular medicines have been stopped or altered
  • when altered medicines should be restarted
  • the name and duration of your clot-prevention treatment
  • whether you need stockings and how to use them
  • what to do if you miss a dose
  • which painkillers can be taken together
  • whom to contact about bleeding, wound leakage or side effects.

Ask for written instructions if anything is unclear. Advice from the current discharge prescription should take priority over an older medication list.

When to Seek Help

Contact your surgical team or NHS 111 promptly about continuing wound leakage, increasing wound redness, unexplained calf pain or swelling, significant medication side effects or bleeding.

Call 999 for severe breathlessness, chest pain, collapse, uncontrolled major bleeding or a severe allergic reaction.

This article provides general information and does not replace an individual medication plan. Do not stop or alter prescribed medication without advice from the clinician responsible for your perioperative care.

References

  1. NHS. Having an operation—before surgery. Available at: https://www.nhs.uk/tests-and-treatments/having-surgery/preparation/
  2. Centre for Perioperative Care. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Updated October 2023. Available at: https://cpoc.org.uk/guidelines-and-resources/guidelines/guideline-diabetes
  3. El-Boghdadly K, Dhesi J, Fabb P, et al. Elective perioperative management of adults taking glucagon-like peptide-1 receptor agonists, glucose-dependent insulinotropic peptide agonists and sodium-glucose cotransporter-2 inhibitors: a multidisciplinary consensus statement. Anaesthesia. 2025. Available at: https://cpoc.org.uk/sites/cpoc/files/documents/2025-01/Anaesthesia%202025%20elective%20periop%20management%20of%20adults%20taking%20glucagon%20article.pdf
  4. National Institute for Health and Care Excellence. Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. NICE guideline NG89, recommendations 1.3.14–1.3.15 and 1.11.5–1.11.9. Available at: https://www.nice.org.uk/guidance/ng89/chapter/Recommendations
  5. Wang M, Xie J, Zheng H, et al. Wound complications and bleeding with new oral anticoagulants in patients undergoing total joint arthroplasty: a systematic review and meta-analysis of randomized controlled trials. British Journal of Clinical Pharmacology. 2022;88(2):500–513. doi: 10.1111/bcp.15005
  6. Almeida RP, Mokete L. The draining surgical wound post total hip and knee arthroplasty: what are my options? A narrative review. EFORT Open Reviews. 2021;6(10):872–880. doi: 10.1302/2058-5241.6.200054
  7. National Institute for Health and Care Excellence. Perioperative care in adults. NICE guideline NG180, recommendations 1.3.10–1.3.11 and 1.6.1–1.6.13. Available at: https://www.nice.org.uk/guidance/ng180/chapter/Recommendations

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