What is the appropriate use of chronic medications in the perioperative setting?

Case

A 72-year-old female with multiple medical problems is admitted with a hip fracture. Surgery is scheduled in 48 hours. The patient’s home medications include aspirin, carbidopa/levodopa, celecoxib, clonidine, estradiol, ginkgo, lisinopril, NPH insulin, sulfasalazine, and prednisone 10 mg a day, which she has been taking for years. How should these and other medications be managed in the perioperative period?

Cessation of medications can result in decompensation of disease or withdrawal.

PHOTODISC
Cessation of medications can result in decompensation of disease or withdrawal.

Background

Perioperative management of chronic medications is a complex issue, as physicians are required to balance the beneficial and harmful effects of the individual drugs prescribed to their patients. On one hand, cessation of medications can result in decompensation of disease or withdrawal. On the other hand, continuation of drugs can alter metabolism of anesthetic agents, cause perioperative hemodynamic instability, or result in such post-operative complications as acute renal failure, bleeding, infection, and impaired wound healing.

Certain traits make it reasonable to continue medications during the perioperative period. A long elimination half-life or duration of action makes stopping some medications impractical as it takes four to five half-lives to completely clear the drug from the body; holding the drug for a few days around surgery will not appreciably affect its concentration. Stopping drugs that carry severe withdrawal symptoms can be impractical because of the need for lengthy tapers, which can delay surgery and result in decompensation of underlying disease.

Drugs with no significant interactions with anesthesia or risk of perioperative complications should be continued in order to avoid deterioration of the underlying disease. Conversely, drugs that interact with anesthesia or increase risk for complications should be stopped if this can be accomplished safely. Patient-specific factors should receive consideration, as the risk of complications has to be balanced against the danger of exacerbating the underlying disease.

KEY Points

  • Perioperative medication use should be tailored for each patient.
  • Medications should be continued to avoid perioperative disease decompensation and withdrawal.
  • Medications that interact with anesthesia or increase the risk of perioperative complications might need to be stopped.
  • Continue antiplatelet drugs, if possible.
  • Stop ACEI/ARB 24 hours before surgery.
  • Stop diuretics once NPO.
  • Continue CNS-active drugs.
  • Insulin may require adjustment.
  • Stop metformin 24 hours before surgery.
  • Stop sulfonylureas the night before surgery.
  • Stop OCPs and HRT four weeks before surgery, if possible.
  • Stop nonselective NSAIDs two to three days before surgery, but continue COX-2 inhibitors.
  • Continue outpatient dosing of corticosteroids and add a stress dose.
  • Stop DMARDs and biologics one week before surgery.
  • Stop herbal medicines one to two weeks before surgery.

Additional Reading

  • Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA. 2001;286(2):208-216.
  • Axelrod L. Perioperative management of patients treated with glucocorticoids. Endocrinol Metab Clin North Am. 2003;32(2):367-383.
  • Kohl BA, Schwartz S. Surgery in the patient with endocrine dysfunction. Med Clin North Am. 2009;93(5):1031-1047.
  • Pass SE, Simpson RW. Discontinuation and reinstitution of medications during the perioperative period. Am J Health Syst Pharm. 2004;61(9):899-914.
  • Rosandich PA, Kelley JT III, Conn DL. Perioperative management of patients with rheumatoid arthritis in the era of biologic response modifiers. Curr Opin Rheumatol. 2004;16(3):192-198.

Overview of the Data

The challenge in providing recommendations on perioperative medication management lies in a dearth of high-quality clinical trials. Thus, much of the information comes from case reports, expert opinion, and sound application of pharmacology.

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