Preoperative medication management

2023-08-19T18:34:50Z

Cdseger: Increased details on GLP-1 agonists

Patients often have a long list of medications they take, and decisions must be made about whether to continue or hold them prior to surgery.

== Cardiovascular ==

=== Beta blockers ===
''Continue if taking chronically''

* Reduces coronary ischemia
* Acute withdrawal of chronic beta blocker associated with increased morbidity/mortality

=== ACE inhibitors/Angiotensin receptor blockers (ARB) ===
''Discontinue morning of surgery. However, could consider continuing for certain cardiac procedures on patient-by-patient basis''

* Inhibition of RAAS leads to refractory intraoperative hypotension
* For most surgeries, appears to be no increase in mortality or cardiovascular events from holding ACE/ARB
** However, some studies suggest myocardial protection in CABG

=== Diuretics ===
''Discontinue morning of surgery if taking for hypertension and euvolemic''

''Continue if unstable volume status or history of poorly controlled heart failure''
* Theoretical risk of worsened hypotension due to intravascular depletion, though limited studies showing this in practice
* Theoretical risk of hypokalemia, though this has not been observed in practice

=== Calcium channel blockers ===
''Continue''

* Limited data showing neither benefit nor harm with continuation

=== Alpha 2 agonists (e.g. clonidine) ===
''Continue if taking chronically''

* Prevent rebound hypertension

=== Digoxin ===
''Continue''

* Limited data, though no evidence of adverse effects from continuation

=== Statins ===
''Continue''

* Shown to prevent vascular events perioperatively

== Hematologic ==

=== Anticoagulation (e.g. warfarin, DOAC) ===
''Case-by-case basis balancing increased risk of intraoperative blood loss with prevention of thromboembolic complication''

* AC should be continued if:
** risk factors of recent stroke, MI, atrial fibrillation, or prosthetic heart valve are present
* AC should be discontinued if:
** anticipated high surgical blood loss (e.g. CABG)
** procedure lasting longer than 45 min
** there is heavy consequence of bleeding (e.g. neurosurgical procedure)
* Timing of discontinuation:
** Discontinue warfarin 5 days before surgery (with PT/INR day of surgery) with consideration for heparin bridging
** Discontinue DOAC 1-2 days before surgery depending on bleeding risk

=== Antiplatelet (e.g. aspirin, clopidogrel) ===
''Case-by-case basis balancing increased risk of intraoperative blood loss with prevention of thromboembolic complication''

* DAPT should be continued if:
** recent stent or bypass procedures, given high likelihood of stenosis
** non-cardiac procedure
* DAPT should be discontinued if:
** there is heavy consequence of bleeding (e.g. neurosurgical procedure)

Ideally, a decision is facilitated by surgeon and cardiologist discussion.

=== Nonsteroidal antiinflammatory drugs (NSAID) ===
Discontinue 24 hr prior to surgery

* Increased risk of perioperative bleeding
* Could consider continuing if patient's pain control outweighs risk of surgical bleeding

== Endocrine (Diabetes) ==

=== DPP-4 inhibitors (e.g. sitagliptin) ===
''Continue''

* No risk for hypoglycemia, though increased risk of gastric motility changes with continuation

=== Insulin ===
''Continue basal (long-acting) insulin and discontinue mealtime insulin, but assess on patient-by-patient basis''

* Discontinuing insulin increases risk of DKA, particularly in type 1 diabetics
* Continuing insulin increases risk for hypoglycemia, particularly when NPO
* Insulin pumps should remain on basal rate as well
* For long and/or complex surgeries, intraoperative glucose management may include IV insulin and dextrose infusions

=== Meglitinides (e.g. repaglinide) ===
''Discontinue day of surgery''

* Increased risk of hypoglycemia

=== Metformin ===
''Discontinue day of surgery''

* Increased risk of lactic acidosis

=== GLP-1 agonists (e.g. Ozempic (semaglutide)) ===
''Regimen dependent (see below)''

* No risk for hypoglycemia, however this class has profound impacts on gastric motility. This is especially true for those who recently initiated therapy.
*June 2023 ASA guidelines by regimen<ref>{{Cite web|title=Patients Taking Popular Medications for Diabetes and Weight Loss Should Stop Before Elective Surgery, ASA Suggests|url=https://www.asahq.org/about-asa/newsroom/news-releases/2023/06/patients-taking-popular-medications-for-diabetes-and-weight-loss-should-stop-before-elective-surgery|access-date=2023-08-19|website=www.asahq.org}}</ref>:
**Dosed weekly: hold for one week prior to surgery.
**Dosed daily: hold for one day prior to surgery.
*Treat as full-stomach if unable to hold medication, in urgent/emergent situations, or if patient has GI symptoms suggestive of reflux or impaired motility.
*If taken weekly: Hold for one week.
*If taken daily: Hold dose on the day of surgery.

=== SGLT2 inhibitors ===
''Discontinue 3-4 days before surgery''

* Increased risk of hypovolemia, AKI, and postoperative euglycemic DKA (elevated ketones, normal glucose)

=== Sulfonylureas (e.g. glipizide) ===
''Discontinue day of surgery''

* Increased risk of hypoglycemia

=== Thiazolidinediones (e.g. rosiglitazone) ===
''Discontinue day of surgery''

* Increased risk of hypervolemia (CHF, peripheral edema)

== Endocrine (Non-diabetes) ==

=== Glucocorticoids ===
''Continue, but consider stress dosing for patients on high-dose steroids or surgeries of long duration:''

* Stress dosing is indicated if daily dose (>3 weeks) is at least:
** Dexamethasone 2 mg
** Hydrocortisone 80 mg
** Methylprednisolone 16 mg
** Prednisone 20 mg
* No stress dose is indicated if daily less less than:
** Any dose of steroid taken for less than 3 weeks
** Dexamethasone 0.5 mg
** Hydrocortisone 20 mg
** Methylprednisolone 4 mg
** Prednisone 5 mg
* For intermediate range, defer to patient history and HPA axis evaluation

If stress dose is indicated, hydrocortisone 300 mg/day (or equivalent) is common practice

'''Note:''' Avoid etomidate as an induction agent due to increased risk of adrenal crisis

=== Levothyroxine ===
''Continue''

* To maintain euthyroid state
* Can be given IM/IV at 80% dose if necessary

=== Methimazole/Propylthiouracil (PTU) ===
''Continue''

* To maintain euthryoid state

=== Oral contraceptives (OCP) ===
''Continue unless patient is has high risk of venous thromboembolism (VTE), in which case stop 4 weeks before surgery''

* If continued, requires perioperative VTE prophylaxis

=== Selective estrogen receptor modulators (SERM) ===
''Continue''

* Should be taken with VTE prophylaxis to offset increased VTE risk

=== Bisphosphonates ===
''Discontinue day of surgery''

* Unable to be taken as recommended (with >8 oz water) due to NPO status

== Pulmonary ==

=== Beta agonists ===
''Continue''

* Significant reduction in COPD/asthma complications

=== Anticholinergics ===
''Continue''

* Significant reduction in COPD/asthma complications

=== Glucocorticoids (inhaled) ===
''Continue''

* Avoids risk of adrenal insufficiency, particularly during stress of surgery
* Inhaled dosage relatively low and unlikely to cause adverse events

== Gastrointestinal (GI) ==

=== H2 blockers/Proton pump inhibitors (PPI) ===
''Continue''

* Very safe intraoperatively
* Prevents stress ulcers
* Prevents gastric aspiration/chemical pneumonitis

== Psych ==

=== Opioids ===
''Consider continuing buprenorphine/methadone therapy''

* For patients on opioid agonist therapy with buprenorphine or methadone, consider continuing home dosing in the perioperative period. May require dose reduction of buprenorphine pre-operatively if at doses >8 mg/day.
*Expect higher than usual/more frequent dosing requirements of full agonist mu-receptor agents (i.e. fentanyl, hydromorphone) for adequate pain control.
*Consider non-opioid adjuncts (Tylenol, NSAIDs, GABA agonists, regional techniques, ketamine infusions).

== Other ==

=== Herbal supplements ===

== References ==

[[Category:Surgical procedures]]

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Preoperative medication management