Dominate perioperative medication management with tips from Kashlak’s newly minted Chief of Perioperative Medicine, @aoglasser, Avital O’Glasser MD, FACP, FHM (OHSU). We cover perioperative anticoagulation, why “bridging is dead”, aspirin, dual antiplatelet therapy, DMARDS, diabetic medications, buprenorphine, and much more! Be sure to check out Dr. O’Glasser’s previous episode #135 Perioperative Medicine: Assess and Optimize Risk to get a full overview of perioperative medicine.
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Written and Produced by: Avital O’Glasser MD, FACP, FHM and Matthew Watto MD, FACP
CME Questions: Matthew Watto MD, FACP
Infographic: Matthew Watto MD, FACP
Cover Art: Kate Grant MBChB DipGUMed
Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP
Editor: Matthew Watto MD, FACP
Guest: Avital O’Glasser MD, FACP, FHM
“Our role in pre-op is to quantify and qualify the known comorbid conditions…help me understand their risk and how I can optimize…”Dr. O’Glasser
The perioperative plan must be tailored to “this patient, for this surgery, for this indication, with this surgeon, at this time, and at this venue”Dr. O’Glasser
Kashlak Pearls (KP) are highlighted in the text below
The 2017 ACC guidelines for anticoagulation in patients with nonvalvular atrial fibrillation remind us that procedures with low bleeding risk often DO NOT require an interruption of anticoagulation (Doherty, 2017). Low risk procedures include: cataract surgery, dental cleaning, most tooth extractions, small distal limb procedures, and pacemaker implantation.
See The Consult Guys video on Dental Procedures -referenced by Dr. O’Glasser.
Anticoagulation is usually held prior to procedures with moderate to high bleeding risk. Historically, these patients were “bridged” with short acting heparin products with hopes of decreasing perioperative thromboembolic events. This practice was essentially debunked by the BRIDGE trial, which found that bridging warfarin with heparin in patients with afib DOES NOT improve arterial thromboembolic risk, AND increases bleeding risk (Douketis, 2015). Dr. O’Glasser notes that one caveat might be patients with a very high CHA2DS2Vasc score, or recent embolic event (e.g. stroke within 3 months). That said, such patients are likely to have a high perioperative risk and are probably poor candidates for an elective procedure anyway –expert opinion.
NOTE: Mechanical valves still warrant bridging outside of very specific low risk aortic valves per the 2014 ACC/AHA valvular heart disease guidelines (Nishimura, 2014).
In the BRUISE trial (Birnie, 2013), patients on therapeutic warfarin at the time of pacemaker implantation had a markedly reduced the incidence of clinically significant device-pocket hematoma compared to those bridged with heparin.
DOACs have a very short half life. Douketis et al 2018 (PAUSE) confirmed that a short hold of DOACs is safe and effective.
KP: Remember that the hold period for dabigatran is up to 4 days in patients with impaired renal function.
Not all patients with a history of VTE require periprocedural bridging. One recent retrospective analysis found that periprocedural bridging had no significant benefit for VTE prevention, but higher risk of bleeding events in patients with a history of VTE who were currently taking a VKA (Baumgartner, 2019). NOTE: Rookie of the Year (film) featured Henry Rowengartner, not Baumgartner as misremembered by Dr. Watto on the show.
Dr. O’Glasser sometimes bridges patients with a recent VTE, active malignancy, or severe thrombophilia (e.g. antiphospholipid Ab syndrome) –expert opinion. Admittedly, she is often working with a hematologist in these cases to help determine need for bridging.
KP: Placing a catheter in the neuraxial space is a risk factor for spinal hematoma. Thus, the hold period for DOACs is extended by 1 day (i.e. from 2 days to 3 days).
The following agents should be continued during the perioperative period: hydroxychloroquine, methotrexate, leflunomide, sulfasalazine —2017 ACR and AAHKS Guidelines for Perioperative Management of Antirheumatic Medication.
There is a theoretical concern for prosthetic joint or other perioperative infections. Current guidelines recommend timing surgery when patient has trough levels (Goodman 2017). For example, in a patient who receives monthly injections with the next injection due on January 1st, schedule their elective surgery near January 1st and skip that dose. The patient would resume therapy on February 1st.
KP: Hold any biologic DMARD for one cycle prior to surgery then resume agent at the start of the next cycle. Most nonbiologic DMARDS should be continued perioperatively (Goodman 2017).
Dr. O’Glasser recommends holding most supplements. A clearly defined time period for holding supplements and herbal does not exist, but directions are often to hold for 1 week to 1 month. Insights gained from the OPERA trial suggest that fish oil can be safely continued and might even have lower rates of bleeding (Akintoye, 2018). Stop supplements like Vitamin E and herbals one week (or so) before surgery –expert opinion.
Check out The Consult Guys riffing on fish oil.
KP: MSKCC has a nice tool to look up herbals and supplements used in integrative medicine.
This large randomized trial found no difference in CV outcomes, but higher bleeding risk (Devereaux, 2014).
This was NOT a pre-planned analysis. BUT, this subgroup analysis of patients from POISE-2 with a prior percutaneous intervention (PCI) suggested that continuing perioperative aspirin (ASA) decreased major adverse cardiac events without increased bleeding (Graham, 2018). The 2014 ACC/AHA, 2016 ACC/AHA Dual Antiplatelet Therapy (DAPT) and European guidelines all support continuing ASA post-PCI if surgical bleeding risk is acceptable.
NOTE: Dr. O’Glasser recommends holding ASA for central nervous system (brain and spinal cord) surgeries.
NOTE: The following paragraph assumes a newer generation stent placed for stable CAD. At this time, 6 months of DAPT is recommended after placement of a DES. Surgery should be avoided from 0 to 3 months after DES. The time period from 3-6 months post-DES is a gray area where risk, benefit and the need for surgery should be carefully weighed. In the event that surgery cannot be delayed beyond 6 months, patients should continue on ASA monotherapy perioperatively (if possible) with P2Y12 inhibitor therapy resumed as soon as possible after surgery (Levine, 2016).
Patients can be switched to aspirin monotherapy after 6 months of DAPT (Levine, 2016).
One month of DAPT is still recommended for bare metal stents (Levine, 2016).
Hotcakes: Two recent trials from Asia found that 1-3 months of DAPT followed by P2Y12 inhibitor monotherapy (e.g. clopidogrel) for the remainder of 12 months was noninferior for prevention of cardiovascular events and superior for bleeding risk —Watanabe, 2019 ; Hahn, 2019. Stay tuned as these shorter time frames are likely to change future guidelines and clinical practice!
Patients who receive a DES for an acute coronary syndrome (ACS) should continue DAPT for 12 months before elective surgery…or as long as possible (Levine, 2016).
KP: When necessary, the hold period for aspirin and other antiplatelets agents is typically 5-7 days –expert opinion.
Statins should be continued perioperatively. Dr. O’Glasser points out that the old package insert for statins recommending they be held is just wrong!
KP: Continue beta blockers for patients already taking them. Do not start beta blockers within a week of surgery, but if starting for some reason, “start low and go slow” —Dr. O’Glasser’s expert opinion.
ACEI and ARBs have been linked with perioperative hypotension —(see this blogpost by Dr. O’Glasser from NephMadness 2019).
KP: Dr. O’Glasser’s practice is to ACEI/ARBs on the day of surgery, assess the patient on post-op day #1, and then decide when it’s safe to resume —expert opinion.
Hold them on the day of surgery.
Dr O’Glasser holds these agents (including metformin) on the morning of surgery. For now, the convention is to hold metformin preoperatively, but this practice seems to be in flux — expert opinion.
SGLT2 inhibitors have been linked to euglycemic DKA (Diaz-Ramos, 2019) and experts worry that this might be heightened in the perioperative period. Dr O’Glasser and other experts (Bardia, 2019) recommend holding these agents for 2-3 days pre-op and resuming once oral intake normalizes.
KP: Hold SGLT2 inhibitors for 2-3 days pre-op and resume once oral intake normalizes.
Dr. O’Glasser has patients hold daily them the morning of surgery if taking daily injections. Patients on weekly injections should continue them perioperatively —expert opinion.
It’s convention to dose reduce insulin by 50%, though Dr. O’Glasser notes this percentage can be adjusted up or down based on baseline glucose control and risk for hypoglycemia (or hyperglycemia). Consider switching premixed 70/30 insulin to either plain NPH insulin (or a basal insulin) and omit the short acting component –expert opinion.
Follow your hospital’s protocol or consult endocrinology for patients with an insulin pump undergoing surgery.
A brief report in the Annals of Internal Medicine found that platelet function returned to normal within 24 hours after use of ibuprofen (Goldenberg, 2005).
Recent studies reassure us that it should be continued (Harrison, 2018).
KP: Don’t stop the buprenorphine! Dr. O’Glasser keeps patients on buprenorphine and supplements with the short term use of hydromorphone or fentanyl for pain control –expert opinion.
Dr O’Glasser recommends patients hold lithium for a few days before surgery. Perioperative volume shifts put patients at high risk for lithium toxicity. Lithium can be resumed once the patient has adequate oral intake and clinical stability –expert opinion.
SSRIs and SNRIs can be continued. MAOIs should be held.
Medical marijuana’s safety is to be determined. Dr. O’Glasser recommends avoiding it the night before and day of surgery —expert opinion.
NPO does not apply to pills. Dr. O’Glasser gives the instructions, “take this pill with a small sip of water” on the morning of your surgery. The Consult Guys have a great online module about NPO and what constitutes clear liquids (Merli and Weitz, 2017). Technically, the guidelines allow clear liquids until two hour before surgery (Maltby, 2006).
Listeners will develop a practical approach to perioperative medication management and review special considerations for the various drug classes.
After listening to this episode listeners will…
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Dr O’Glasser reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
O’Glasser A, Williams PN, Watto MF. “#174 Perioperative Medication Management”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. September 23, 2019.
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I feel like I learn so much from every episode, but I think this one will be practice-changing for many -- certainly for me.
Thanks for the awesome feedback!