Official Journal of the Italian Society of Orthopaedics and Traumatology
Table 1 Perioperative management of medications
Class | Benefits in continuing therapy | Risks in continuing therapy | Considerations | Recommendation |
|---|---|---|---|---|
A: Alimentary tract and metabolism | ||||
A02B: Drugs for peptic ulcer and gastro-oesophageal reflux disease (GORD) | Prevents stress-related mucosal damage caused by surgery, decreases gastric volume and raises gastric fluid pH, reducing the risk of chemical pneumonitis from aspiration | PPIs increase the risk of Clostridium difficile infection | Essential prior to anesthesia | Continue as usual |
A03A: Drugs for functional gastrointestinal disorders | Promotes gastric emptying | No known perioperative adverse effects | Baseline ECG required to document QT interval | Continue as usual |
A06: Drugs for constipation | No known perioperative adverse effects | Continue as usual | ||
A07E: Intestinal antiinflammatory agents | Increased bleeding risk due to antiplatelet effects | Discontinue | ||
A10A: Insulins and analogues | Hyperglycemia increases the risk of perioperative infections | Induces hypoglycemia | Basal insulin therapy is necessary in all insulin-treated diabetic patients | Continue with adjustments |
A10B: Blood-glucose-lowering drugs excl. insulins | Avoids perioperative hyperglycemia | Significant risk of hypoglycemia Metformin: contraindicated in conditions that increase the risk of renal hypoperfusion, lactate accumulation, and tissue hypoxia Thiazolidinediones: could precipitate congestive heart failure due to fluid retention and peripheral edema DPP4 inhibitors and GLP-1 analogs: alter gastrointestinal motility | Monitor blood glucose frequently | Should be taken until the day before the operation but discontinued the day of the operation |
A12: Mineral supplements | Ensure that electrolyte balance is controlled | Discontinue | ||
B: Blood and blood-forming organs | ||||
B01: Antithrombotic agents | Increased bleeding risk | Refer to perioperative management of antiplatelet therapy guide | ||
B03A: Iron preparations | Constipation risk in bedridden patients, which is increased with opioid therapy | Severe iron-deficiency anemia may require a blood transfusion | Discontinue | |
B03B: Vitamin B12 and folic acid | Discontinue | |||
C: Cardiovascular system | ||||
C01AA: Digitalis glycosides | Management of underlying atrial fibrillation or congestive heart failure | Narrow therapeutic window. Check digoxin levels | Continue as usual | |
C01BD: Antiarrhythmics, class III | Possibility of recurrence of arrhythmias if stopped | Bradycardia, electrolyte imbalances may exacerbate risk of QT prolongation with amiodarone | Amiodarone: long half-life | Should be continued until and including the day of the operation |
C01DA: Organic nitrates | May precipitate chest pain if withheld | Hypotension | Should be continued until and including the day of the operation | |
C02CA: Alpha-adrenoreceptor antagonists | Risk of intraoperative floppy iris syndrome (IFIS) with cataract surgery. Hypotension | Continue | ||
C03: Diuretics | Prevent decompensation of congestive heart failure (CHF) | Tissue damage and reduced kidney perfusion immediately postoperatively may contribute to the development of hyperkalemia, which may be additive with concurrent potassium-sparing diuretics | Should be taken until the day before the operation but discontinued the day of the operation, except in patients with CHF | |
C04: Peripheral vasodilators | Increased bleeding risk | Discontinue | ||
C07: Beta-blocking agents | Reduce ischemia by decreasing myocardial oxygen demand due to increased catecholamine. Help to prevent or control arrhythmias | Bradycardia and hypotension Interacts with epinephrine | Rebound hypertension can occur if stopped abruptly Monitor blood pressure closely postoperatively Only some drugs are available as injections; it may be necessary to change to an alternative drug if an oral route is not available | Should be continued until and including the day of operation |
C08: Calcium channel blockers | May precipitate chest pain if withheld | Rebound hypertension can occur if stopped abruptly | Monitor blood pressure closely postoperatively Only some drugs are available as injections; it may be necessary to change to an alternative drug if an oral route is not available | Should be continued until and including the day of the operation |
C09: Agents acting on the renin–angiotensin system | Management of postoperative hypertension | Can decrease blood pressure at induction of anesthesia, and many drugs within this class have differing half-lives | Should be continued until the day before the operation but discontinued on the day of the operation. Last dose should be given 10 h before induction of anesthesia | |
C10: Lipid-modifying agents (non-statin) | Niacin and fibric acid derivatives: may increase risk of myopathy and rhabdomyolysis, especially when used in combination with statins Bile acid sequestrants: interfere with the absorption of other medications | Discontinue | ||
C10AA: HMG-CoA reductase inhibitors | Provide cardiovascular protection | May increase the risk of myopathy and rhabdomyolysis | Continue as usual | |
G: Genitourinary system and sex hormones | ||||
G03A: Hormonal contraceptives for systemic use | Increased risk of postoperative venous thromboembolism (VTE) | Estrogen-containing oral contraceptives: discontinue 4–6 weeks prior to surgery in patients with a high risk of VTE | ||
G04BD: Drugs for urinary frequency and incontinence | Risk of arrhythmias | Continue as usual | ||
H: Systemic hormonal preparations, excl. sex hormones and insulins | ||||
H02AB: Glucocorticoids | Increased risk of Addisonian crisis if stopped | Impaired wound healing, increased superficial blood vessels, risk of fractures, infections, and gastrointestinal ulcer | Continue—add stress dosing if > 5 mg prednisone per day (or equivalent) in six months prior to surgery, or on chronic therapy | |
H03: Thyroid therapy | No known perioperative adverse events | Thyroid function should ideally be checked preoperatively to ensure euthyroid state | Should be continued until and including the day of the operation | |
J: Antiinfectives for systemic use | ||||
J05A: Direct-acting antivirals | Incidence of postoperative bacterial complications and sepsis is increased in patients with lower CD4 cell counts if antiretroviral agents are discontinued | Most data regarding surgical morbidity and mortality in the HIV-infected patient predate the availability of effective antiretroviral therapy | Continue as usual | |
L: Antineoplastic and immunomodulating agents | ||||
L01AB: Alkyl sulfonates | No studies suggest that stopping preoperatively reduces the incidence of infection or improves wound healing | The use of lower doses may permit safer use. Monitor renal function and blood count postoperatively | Continue as usual | |
L01XX: Other antineoplastic agents | Discontinue 3–4 days prior to surgery | |||
L02BA: Anti-estrogens | If used for cancer treatment, disease progression may be of concern once treatment interrupted | Increased risk of venous thromboembolism | Discontinue 4–6 weeks prior to surgery in hip and knee surgery | |
L02BG: Aromatase inhibitors | If used for cancer treatment, disease progression may be of concern once treatment interrupted | Unknown perioperative effects | Continue as usual | |
L04AA: Selective immunosuppressants | Controlling rheumatoid response | Increased risk of myelosuppression and wound-healing complications postoperatively | Abatacept: discontinue prior to surgery at 2 months | |
L04AB: Tumor necrosis factor alpha (TNF-Α) inhibitors | Controlling rheumatoid response | Increased risk of myelosuppression and wound-healing complications postoperatively | Discontinue prior to surgery at a timing equal to 2–5 half-lives of the respective drug Mean half-life (days): infliximab (8–9, 5), etanercept (4–5), adalimumab (15–19) | |
M: Musculoskeletal system | ||||
M03BX: Other centrally acting agents | Abrupt withdrawal of intrathecal baclofen may result in severe sequelae (hyperpyrexia, rebound/exaggerated spasticity, muscle rigidity, and rhabdomyolysis), leading to organ failure and fatality | Continue as usual | ||
M04A: Antigout preparations | Surgery could precipitate acute gouty arthropathy | Continue as usual. Held on the morning of surgery | ||
M05BA: Bisphosphonates | Esophagitis in bedridden patients | Discontinue | ||
N: Nervous system | ||||
N02A: Opioids | Abrupt withdrawal can cause yawning, abdominal cramps, nausea, vomiting, insomnia, anxiety, and salivation | Should be continued until and including the day of the operation without exception | ||
N02B: Other analgesics and antipyretics | Aspirin (ASA) withdrawal linked to cardiovascular events | Continuation may cause perioperative hemorrhage | Continue ASA for secondary cardiovascular prevention Discontinue ASA for primary cardiovascular prevention | |
N03: Antiepileptics | Possibility of precipitating convulsions if stopped | Phenytoin: levels may fluctuate in response to perioperative situations Carbamazepine: interactions with medications administered in the perioperative period Valproic acid: thrombocytopenia | Check serum drug level | Should be continued until and including the day of the operation |
N04: Antiparkinson drugs | Avoid symptoms of Parkinson’s disease (agitation, rigidity) | Metabolite of levodopa, dopamine can cause arrhythmias, hypotension or hypertension | Should be continued until and including the day of the operation | |
N05A: Antipsychotics | Withdrawal symptoms can occur if stopped abruptly plus severe agitation | Some agents are associated with QT prolongation, and occasionally cause hypotension or arrhythmias | A routine ECG should be performed on all patients preoperatively | Continue as usual |
N05AN: Lithium | Decreases the release of neurotransmitters and may prolong the effect of neuromuscular blockers | Close monitoring of fluid and electrolytes is essential due to the narrow therapeutic index of lithium and the usual changes in electrolyte levels postoperatively | Should be continued until and including the day of the operation | |
N05B: Anxiolytics | Continue these agents to avoid withdrawal; however, the patient will likely have decreased anesthesia requirements | Risk of pharmacokinetic and pharmacodynamic interactions with drugs used in the perioperative setting | If a benzodiazepine becomes necessary, consider using short–medium half-lives | Continue if indicated |
N06AA: Nonselective monoamine reuptake inhibitors | Withdrawal symptoms can occur if stopped abruptly | Arrhythmias with anesthetics | Continue as usual. Discontinue if arrythmia occurs | |
N06AB: Selective serotonin reuptake inhibitors | Withdrawal symptoms can occur if stopped abruptly | Bleeding risk, drug interactions | Continue as usual | |
N06AG: Monoamine oxidase A inhibitors | Risk of withdrawal symptoms | Interactions with medications used in the perioperative setting (hypertension) | Avoid administration of meperidine/dextromethorphan/ephedrine and monitor closely while on narcotics (potential for reactions consisting of rigidity, hallucinating, fever, confusion, coma, and death) | Discontinue |
N06D: Antidementia drugs | Through their effects on acetylcholinesterase, these agents are likely to exaggerate muscle relaxation during anaesthesia produced by suxamethonium, hence prolonging neuromuscular blockade | The relevant pharmaceutical manufacturers recommend discontinuation of both of these agents preoperatively to avoid these effects | ||
N07C: Antivertigo preparations | Continue as usual | |||
R: Respiratory system | ||||
R03: Drugs for obstructive airway diseases | Inhaled bronchodilators: may precipitate bronchospasm if withheld | Theophylline: risk of arrhythmias and neurotoxicity | Theophylline: narrow therapeutic range | Continue as usual Theophylline: discontinue evening before surgery |
S: Sensory organs | ||||
S01: Ophthalmologicals | No known perioperative adverse effects | Continue as usual | ||
S02: Otologicals | No known perioperative adverse effects | Continue as usual | ||
V: Various | ||||
V03AE: Drugs for treatment of hyperkalemia and hyperphosphatemia | No known perioperative adverse effects | Continue as usual | ||
V03AF: Detoxifying agents for antineoplastic treatment | No known perioperative adverse effects | Continue as usual | ||
Phytotherapy | No evidence that phytotherapy improves surgical outcomes | Ephedra: increases the risk of heart attack and stroke Garlic: increases the risk of bleeding Ginkgo: increases the risk of bleeding Ginseng: lowers blood sugar and increases the risk of bleeding Valerian: increases the sedative effects of anesthetics and is associated with benzodiazepine-like withdrawal Echinacea: allergic reactions and immune stimulation | Should be discontinued at least one full week prior to the planned surgical procedure | |