Drugs to Continue vs. Drugs to Stop

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Perioperative refers to the period before, during and after surgery. Preoperative refers to the time before surgery. Intraoperative refers to the time during surgery.

Many surgical patients are on regular medications. Some of these drugs can interact with anaesthetics or anaesthesia and/or surgical interventions. As a result, patients may experience complications such as bleeding, ischemia, infection or severe circulatory reactions.

Proper perioperative management helps to prevent or minimize complications, to reduce postoperative pain, and to accelerate recovery. Perioperative pharmacotherapy protocol should include:

• Accurate and complete medication history
• Established protocol for discontinuation and reinstitution of medications during the perioperative period
• Monitoring of relevant parameters to ensure accurate dosing of medications and help minimize adverse effects
• Appropriate management of pain
• Administration of adjunctive medications
• Use of appropriate formulations and alternative products when needed
• Review of discharge medications to ensure discontinuation of surgery-specific drugs (e.g., anticoagulants, analgesics) to avoid polypharmacy

It is extremely important to obtain a complete and accurate list of all the patient’s medications and this should occur at least 2 weeks before surgery. A thorough medication review should include:

• All prescription medications
• All over-the-counter (OTC) agents
• All vitamins & dietary supplements
• All herbal medications
• Substance use including alcohol, nicotine, etc.

Decisions about stopping or continuing medications perioperatively should be based on withdrawal potential, the potential for disease progression if therapy is interrupted, the potential for drug interactions with anaesthesia, and the patient’s short-term quality of life.

In the preoperative period, it is important to avoid the use of medications that may negatively interact with anaesthetic agents and to know whether the drug will negatively affect the procedure.

In the postoperative period, the concern is when to restart these agents in order to avoid the potential for withdrawal, a progression of the underlying disease state, and other adverse events.

KEY POINTS

Common drugs that have been associated with withdrawal symptoms when discontinued preoperatively include selective serotonin reuptake inhibitors (SSRIs), beta-blockers, clonidine, and corticosteroids.

In general, most nonsteroidal anti-inflammatory drugs should be stopped at least 3 days before surgery.

Although ACE inhibitors and angiotensin receptor blockers (ARBs) intensify the hypotensive effects of anaesthesia, it may be prudent to continue them perioperatively unless their only indication is for hypertension and the patient’s blood pressure is well controlled.

Herbal medications should be stopped at least 7 days before surgery, owing to the uncertainty over their actual contents.

Among psychotropics, SSRIs, tricyclic antidepressants, benzodiazepines, and antipsychotics are generally safe to continue perioperatively.

General principles of perioperative medication management

• Continue medications with withdrawal potential or taper where feasible. Substitute intravenous, transdermal, or transmucosal medicines when absorption will be impaired due to loss of gastrointestinal function or restrictions on oral intake.
• Discontinue medications that increase the risk of anaesthetic or surgical complications and are not essential for the short-term quality of life
• Use clinical judgment in other cases i.e., medications that do not meet either of the above principles. Note that:
  • Many other medications are given in the narrow perioperative time window increasing the potential for drug-drug interactions
  • Metabolism and elimination of medications and their metabolites may be altered during the perioperative period.

Medications contributing to the patient’s current state of medical homeostasis should be continued and generally, these include most prescription drugs. These drugs are not without risk and can potentially interact with anaesthesia agents.

Medications that do not contribute to the medical homeostasis of the patient should be discontinued in preparation for surgery (i.e., OTC medications, herbal or dietary supplements). Those that may increase the risk of adverse outcomes perioperatively should generally be discontinued based on pharmacokinetic principles. For example, NSAIDs and other anticoagulants increase bleed risk perioperatively. Some herbal supplements can prolong bleeding time, as well as increase blood pressure. The effects of many herbal supplements are unknown, as the actual composition of each product varies widely. Hormone replacement therapies and some osteoporosis agents may promote clot development perioperatively.

Optimal time frame for discontinuation before surgery depends on the pharmacokinetic profile of the medication, as well as individual patient factors. In general, it takes a drug approximately five half-lives to be completely eliminated from the system.

Quick reference tables

Click the links below to access the PDF Tables

Management of various classes of medications in the perioperative period (Table 1)

• Table 1a: – Perioperative management of cardiovascular medications
• Table 1b: – Perioperative management of gastrointestinal and pulmonary medications
• Table 1c: – Perioperative management of endocrine medications
• Table 1d: – Perioperative management of medications affecting hemostasis
• Table 1e: – Perioperative management of psychotropic medications
• Table 1f: – Perioperative management of rheumatologic medications

Perioperative management of diabetes mellitus (Table 2)

• Table 2: – Perioperative management of diabetes mellitus

Guidelines for perioperative corticosteroid management (Table 3)

• Table 3: – Guidelines for perioperative corticosteroid management

Overview of topical antiseptic used for preoperative skin preparation (Table 4)

• Table 4: – Overview of topical antiseptics used for preoperative skin preparation

Antibiotic selection guide (Table 5)

• Table 5a: – Antimicrobial prophylaxis for gastrointestinal surgery in adults
• Table 5b: – Antimicrobial prophylaxis for genitourinary surgery in adults
• Table 5c: – Antimicrobial prophylaxis for orthopaedic surgery in adults
• Table 5d: – Antimicrobial prophylaxis for gynecologic and obstetric surgery in adults

References:

1. Whinney C. Perioperative medication management: General principles and practical applications. CCJM 2009 Nov. Available from: http://www.ccjm.org/view-pdf.html?file=fileadmin/content_pdf/ccjm/content_68daa88_S126
2. Muluk V, Macpherson DS, Cohn SL, Whinney C.. Perioperative medication management. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2015.
3. Pass SE, Simpson RW. Discontinuation and reinstitution of medications during the perioperative period. Am J Health-Syst Pharm—Vol 61; 2004 May. Available from: http://goo.gl/DMgNgg (login required)
4. Card R, Sawyer M, Degnan B, Harder K, Kemper J, Marshall M, Matteson M, Roemer R, Schuller-Bebus G, Swanson C, Stultz J, Sypura W, Terrell C, Varela N. Perioperative protocol. Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2014 Mar. Available from: http://www.guideline.gov/content.aspx?id=48408