Several medications are reviewed for use & disuse perioperatively.
Choose agent(s) for management
Antiplatelet (aspirin, clopidogrel, etc)
Direct oral anticoagulant (DOAC)
General principles of periop mgmt
General principles (students, residents)
External links to web & app resources
iPRO's MAPPP
MAQI2 Anticoag Toolkit U-Mich
ASRA's Coags (reg-neuraxial)
Two independent apps have offered more comprehensive mgmt guidance on these medications for years.
- iPRO's MAPPP (managing anticoag in the periprocedure period), includes antiplatelet
- Univ. Michigan's MAQ12 Anticoagulation Toolkit, anticoag-only
ASRA Coags (American Society Regional Anesthesia) covers the unique risks involved in neuraxial and regional anesthesia, and ASRA has no web version.
The ACC 2024, ADA 2024, and ICSI 2020 guidelines offer the following recommendations for the management of insulins and diabetic medications around surgery:
Oral meds:
- metformin continuation is reasonable to maintain glycemic control (ACC 2a, C)
- do not administer oral hypoglycemics preoperatively (ICSI strong, low) except for metformin (ACC above)
- DPP-4 inhibitors (e.g. sitagliptin) can be continued perioperatively, if patient desires (ICSI strong, low). But ICSI adds that since they work on glucose for absorption in the GI tract, the agents are safe but unnecessary since surgical patients are NPO
- SGLT-2 inhibitors (per FDA March 2020, not addressed by ICSI) are associated in case reports with euglycemic DKA. FDA recommends stopping dapagliflozin, empagliflozin, and canagliflozin 3 days before surgery, ertugliflozin 4 days before surgery, managing sugars in the interim, and not resuming until patient is tolerating full diet and patient no longer has risks for ketoacidosis, ACC agrees (ACC 1, C)
Insulins:
- long-acting insulins (e.g. glargine) may be decreased to 75-80% of usual dose the night before and/or day of surgery (ADA)
- intermediate-acting insulins (NPH) used BID can be decreased to 50% usual dose the night before and/or day of surgery (ADA)
- adjust insulin pump basal rates based upon type of diabetes and clinical judgement, ADA does offer that cutting basal pump rates down by 25% starting the evening before surgery achieves glycemic goals while reducing hypoglycemia (ADA)
- short-acting, sliding scale insulin should be used to treat high blood glucose values in patients holding their normal diabetic medications (ICSI strong, low; ADA)
Injectables non-insulin (GLP-1's):
- GLP-I agonists (semaglutide, liraglutide) should be held perioperatively (ICSI strong, low) as these agents slow GI motility and may further delay GI recovery after surgery. ACC sites recent ASA (anesthesiology) recommendation to hold daily GLP-1's > 1 day and weekly GLP-1's > 1 week prior to surgery
General guidance:
- individualized diabetes mgmt plans should be formulated prior to surgery so as to avoid glycemic extremes (ICSI strong, low)
- glycemic control should be directed at achieving blood glucose levels between 140-180 mg/dL and not be directed at more intensive goal targets (80-110 mg/dL) (ICSI strong, high)
- ACC notes that no evidence supports an Alc goal before surgery or delaying surgery to achieve one. ACC does support attention to perioperative glucose control.
Further ICSI pointers:
- mild hyperglycemia is preferable to hypoglycemia
- details of insulin recommendations influenced by insulin sensitivity of patient, timing of procedure, length of procedure, and how long patient will need to be NPO following procedure
ACE's and ARB's can cause transient hypotension but there has long been controversy in absence of optimal RCT evidence regarding whether clinical outcomes are worsened. The POISE-3 RCT has settled this showing no difference in outcomes continuing or withholding ACE's & ARB's, see below.
Thus ACC takes a permissive approach with level 2 recommendations, leaning towards discontinuation in most patients but leaning towards continuation in those with a compelling special indication for ACE-ARB like HFrEF:
- withholding ACE's and ARBs used for HTN mgmt 24 hours before elevated risk surgery may be beneficial to limit intraoperative hypotension (2b, B)
- continuing chronic ACE's and ARBs used for stability of HFrEF is reasonable (2a, B)
The POISE-3 RCT (Annals Int Med '23) randomized 7,490 patients to withholding or continuing an ACE-ARB perioperatively. Among a wide range of primary and secondary 30-day outcomes, there were no differences in outcomes with a hypertension- avoidance strategy (continue ACE-ARB) vs. a hypotension-avoidance strategy (withhold ACE-ARB).
Note that the anesthesiology concern about intraoperative hypotension is very old while the evidence on equal outcomes is quite new, so there may be strong opinions about perioperative ACE's and ARB's in your community.
Guidance on handling buprenorphine (and buprenorphine/naloxone a.k.a Suboxone) peri- and post-operatively is evolving. Guidelines suggest several options:
1) Continue buprenorphine at the patient's maintenance dose, but break the total daily dose into 3-4 smaller more frequent doses. Although used mainly for its craving/ withdrawal-suppression effect of 24+ hours duration, Buprenorphine also has a shorter pain-relieving effect on the order of 6-8 hours duration. Thus for mild-to-moderate pain, buprenorphine itself can be used when dosed more frequently.
2) Continue use of buprenorphine but at doses elevated above the patient's maintenance dose, divided every 6 hours, and then tapered post-operatively in both frequency and quantity back down to the original maintenance dose.
3) Continue buprenorphine at the patient's maintenance dose but add strong full opioid agonists (fentanyl, morphine, hydromorphone) at higher than usual doses to overcome buprenorphine binding and provide necessary post-op pain relief. Patients treated with high dose opioids should have closer monitoring and narcan available. Post-operative doses should be tapered until discontinued, leaving the patient once again on just the buprenorphine maintenance dose.
Earlier guidelines offered additional options of discontinuing buprenorphine altogether in favor of peri & post-op exclusive use of strong opiate agonists. The latest guideline (Kohan, 2021) recommends against such options due to evidence on risks of withdrawal and precipitated withdrawal.
Ideally, management would be coordinated with the patient's opiate use disorder prescriber and/or hospital pain management experts.
ACC says:
- patients chronically on beta-blockers should stay on beta-blockers perioperatively (I, B)
- for patients with a new indication for beta- blocker therapy, it may be reasonable to begin beta-blockers long enough in advance to assess safety and tolerability and respond with dose titrations, optimally > 7 days before surgery (11b, B)
- in patients without a need for beta-blocker therapy, beta-blockers should not be started on the day of surgery due to increased stroke and mortality harm (3, B)
What happened to the enthusiasm for perioperative beta-blockade? Several RCTIs initially created excitement that periop beta- blockade could protect patients from the risk of myocardial ischemia. But ACC reviews that some of those early trials included stopping chronic beta-blockers rather than initiating them anew, thus making beta-blockade look artificially favorable. Then the POISE trial gave untitrated fairly high-dose beta-blockade on the day of surgery, yielding cardiac benefit but stroke harm, which dampened overall enthusiasm. Furthermore, the scientific integrity of some work in this field has been called into question. Thus the ACC recommendations above which were once strongly favorable are now more tempered.
ACC says:
- patients on statins should continue (l, B)
- perioperative initiation of statin for those not on one is recommended for those with standard hyperlipidemia and cardiac risk guideline-based clinical indications (1, B)
The safety (if not outright benefit) of periop statins is important to note because in the early days of statins even up to the early 2000's, statin package inserts raised concerns about perioperative use.
ESA offers the following guidance.
- Patients chronically treated with TCAs should undergo cardiac eval [details unstated] (D).
- Antidepressant for chronically depressed patients should not be discontinued (B).
- Discontinuation of SSRI perioperatively is not recommended (D).
- Irreversible MAOIs should be discontinued at least 2 weeks prior to anaesthesia. In order to avoid relapse of underlying disease, medication should be changed to reversible MAOIs (D).
- The incidence of postoperative confusion is significantly higher in schizophrenic patients if medication was discontinued prior to surgery. Thus, antipsychotic medication should be continued in patients with chronic schizophrenia perioperatively (B).
- Lithium should be discontinued 72 h prior to surgery. It can be restarted if the patient has normal ranges of electrolytes, is haemodynamically stable and able to eat and drink. Blood levels of lithium should be controlled within 1 week (D).
- For minor surgery under local anaesthesia, continuation of lithium therapy can be considered (D).
When to stop (per ICSI 2014):
Non-COX selective
- shorter half-life agents (ibuprofen, indomethacin, etc.): stop 1 day before surgery
- longer half-life agents (naproxen, sulindac, etc.): stop 3 days before surgery
COX-2 selective agents (celecoxib): stop 2 days before surgery, mainly due to concern for renal effects
With NSAIDs primarily cleared by the kidneys, recommendations above might be adjusted (lengthened) in CKD patients. But CKD patients should not be taking NSAIDs, so perhaps this proviso won't arise often.
It is commonly advised that NSAIDs be stopped 7-14 days before surgery. But this is due to the misconception that NSAIDs inhibit platelets like aspirin. Aspirin irreversibly inhibits platelets, thus aspirin needs to be stopped long enough prior to surgery for the lifecycle of platelet production to replace old inhibited platelets with new ones. However, NSAIDs inhibit platelet function reversibly, and thus they only need to be discontinued long enough for roughly 5 half-lives of the agent so that it and its platelet inhibitory impact are cleared. It may not be worth arguing with physicians who demand a lengthy discontinuation period for NSAIDs, but patients should rest assured that inadvertent NSAID use closer to surgery is not an indication to postpone their procedure.
Systemic QI -antagonists are typically used for BPH and HTN. However, they can complicate cataract surgery by causing intraoperative floppy iris syndrome (IFIS), characterized by sudden intraoperative iris prolapse and pupil constriction. IFIS increases both the difficulty and the risk of cataract surgery. Tamsulosin is associated with higher rates of IFIS than other a-blockers. Few outside of ophthalmology know of this condition.
Stopping the a-blocker does not reduce the risk of IFIS. But having cataract surgery before starting a-blocker, avoiding Tamsulosin, and certainly alerting eye surgeons to a-blocker use before surgery are all recommended (ASCRS & AAO).
ACC reviews the evidence and concludes that perioperative alpha-2 agonists (i.e. clonidine) for prevention of cardiac events are not recommended (3, B)
Use of perioperative CCBIs fall into two general questions: (1) for those not on one, should CCBIs be initiated perioperatively; and (2) for those already on one, should CCBIs be withheld perioperatively.
Regarding initiation, ACC reports:
- no clear support for perioperative initiation of CCBIs
Regarding withholding, ACC reports:
- no clear support for perioperative withholding of CCB's, noting potential for hypotension for the dihydropyridine agents and for bradycardia for the non- dihydropyridine agents
Anticoagulant & antiplatelet guidance has become so complicated over the years that in previous versions of this app (through 4.0) I had given up on trying to master it, instead offering general principles and directing you to other excellent apps. However, now the guidance seems more clear and unified by ACCP in 2022 and ACC in 2024, so I'm adding that guidance back into this app as of version 4.1. I'm still not pleased with clarity on antiplatelet agent mgmt, so send feedback and ideas if you have any.