#174 Dominate Perioperative Medication Management

September 23, 2019 | By Matthew Watto, MD

Avital O’Glasser MD talks periop anticoagulation, antiplatelets, diabetes drugs, DMARDS, and more!

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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Credits

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

Time Stamps

• 00:00 Intro, disclaimer, guest bio
• 03:20 Guest one-liner
• 04:46 Picks of the Week*: A Moment of Lift (book) by Melinda Gates; Crawl (film); Rich Roll (podcast) episodes w/Valter Longo and David Sinclair
• 09:35 Avi’s mantras for perioperative management and other core tenants
• 14:40 NPO and The Consult Guys
• 17:23 Medical cannabis (marijuana) in perioperative medicine
• 19:24 Case #1 Ms. Bridge – perioperative anticoagulation: to bridge or not to bridge
• 25:00 Low bleeding risk surgeries and anticoagulation
• 27:25 Moderate to high bleeding risk surgeries and anticoagulation; What about the CHA2DS2 Vasc of 7?
• 28:42 Bridging for venous thromboembolism (VTE)
• 31:30 How to give instructions for holding warfarin
• 32:30 Bridging a DOAC
• 36:16 Recap on bridging VKAs and use of DOACs
• 37:48 Neuraxial anesthesia and anticoagulation
• 39:49 Biologic DMARDS; Nonbiologic DMARDS
• 43:48 Supplements and herbals
• 48:40 Case #1 wrap up
• 50:16 Case #2 -Mr. DAPT; Perioperative Aspirin; DAPT -dual antiplatelet therapy
• 57:20 Summary of perioperative antiplatelet therapy
• 63:18 Statins
• 64:45 Beta blockers
• 67:21 ACEI and ARB; Diuretics
• 69:17 Oral hypoglycemics and newer diabetes agents (SGLT2 inhibitors, GLP1 agonists); What about metformin?
• 72:04 Insulin
• 74:40 Case #2 wrap up
• 75:35 Case #3 Ms. GB Stone who takes lithium and buprenorphine
• 77:30 NSAIDS, Buprenorphine
• 81:45 ART, transplant meds, Lithium, MAOIs, Levothyroxine; Watch out for lithium
• 86:34 Case #3 wrap up
• 87:25 Take Home Points
• 88:45 Outro
• 90:15 Avi and Mr. Rogers

Perioperative Mantras and Take Home Points from Dr. O’Glasser

“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

1. Don’t underestimate the value of a thorough preoperative medication reconciliation. This is a chance to educate and reassure patients that you are providing safe, individualized care. 
2. Be systematic and go through each medication one at a time.

Kashlak Pearls (KP) are highlighted in the text below

Perioperative Medication Management Show Notes

Perioperative Anticoagulation

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.

“Bridging is dead”

Bridging for Atrial fibrillation

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.

Mechanical valves

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).

Pacemaker implantation

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. 

Don’t bridge the Direct Oral Anticoagulants (DOACs)!

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.

Bridging for a history of venous thromboembolism (VTE)

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.

Neuraxial anesthesia

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).

Disease Modifying Antirheumatic Drugs (DMARDS)

Nonbiologic DMARDS

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.  

Biologic DMARDS

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).

Supplements and Herbals

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.

Perioperative Aspirin (ASA)

POISE-2

This large randomized trial found no difference in CV outcomes, but higher bleeding risk (Devereaux, 2014).

POISE-2 PCI Subgroup Analysis

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.  

Perioperative Dual Antiplatelet Therapy (DAPT)

Drug Eluting Stent (DES) for stable Coronary Artery Disease (CAD)

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!

DES for Acute Coronary Syndrome

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.  

Other Cardiac Medications

Statins

Statins should be continued perioperatively. Dr. O’Glasser points out that the old package insert for statins recommending they be held is just wrong!

Beta Blockers

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.

ACE inhibitors (ACEI) and ARBs

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.

Diuretics

Hold them on the day of surgery.

Perioperative Management of Diabetes Medications

Oral hypoglycemics

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

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.

GLP-1 agonists

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.

Insulin

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.

Insulin Pumps

Follow your hospital’s protocol or consult endocrinology for patients with an insulin pump undergoing surgery.

Miscellaneous Perioperative Medication Management

NSAIDS

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).

Buprenorphine

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.

Lithium

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.

Antidepressants

SSRIs and SNRIs can be continued. MAOIs should be held.

Cannabinoids

Medical marijuana’s safety is to be determined. Dr. O’Glasser recommends avoiding it the night before and day of surgery —expert opinion.

NPO

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).

Goals

Listeners will develop a practical approach to perioperative medication management and review special considerations for the various drug classes.

Learning objectives

After listening to this episode listeners will…

1. Frame perioperative medication management decisions as another type of patient-centered, surgery-specific perioperative “risk/benefit” decision
2. Discuss guideline recommendations for the perioperative management of multiple classes of medications
3. Examine more nuanced or challenging medications to manage in the perioperative setting
4. Explore professional, patient-centered and multidisciplinary communication techniques when disagreements arise regarding best medication management recommendations

Links*

Any articles mentioned on the show are linked in the text above (hyperlinks contain PubMed ID).

References are included in the test above as PubMed links. NOTE: The 8 digit PMID or 7 digit PMC ID is included in each link.

1. The Moment of Lift (book) by Melinda Gates
2. Crawl (film)
3. Rich Roll (podcast) episodes w/Valter Longo and David Sinclair
4. Dear Mr Rogers Does It Ever Rain In Your Neighborhood? (book) by Fred Rogers

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on my Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Disclosures

Dr O’Glasser reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

O’Glasser A, Williams PN, Watto MF. “#174 Perioperative Medication Management”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. September 23, 2019.