Perioperative Medications - Which Medications to Hold or Continue? Aspirin - Continue • Aspirin should be continued in patients with coronary stents unless the surgery has a very high bleeding risk (many neurosurgical procedures) Metoprolol - Continue • Evidence reveals multiple potential benefits (reduces O2 demand, controls arrhythmias) - Even some scenarios in which b-blockers should be initiated preoperatively to reduce cardiac mortality • Abrupt withdrawal may result in angina, MI (box warning) as well as tachycardia and hypertension. Risks of withdrawal are not as important in patients taking beta blockers for reasons other than HF, CAD, or arrhythmias such as hypertension or migraine prophylaxis. Lisinopril - Hold morning of surgery • Data Is inconsistent with some studies revealing risk for prolonged postop hypotension (interestingly, not much mention of AKI) • When indication is for HF or poorly controlled hypertension, may want to continue → Need to discuss with anesthesiology/surgical team to notify them of your reasoning Atorvastatin - Continue • There is evidence that statins may prevent vascular events in the perioperative period Lasix - Hold morning of surgery • Again, no consensus, but most recommend holding morning of. • May consider continuing in patients with HF and difficult to control volume status. Metformin - Hold morning of surgery Empagliflozin (SGLT2 Inhibitors) - Hold 3-4 days before surgery • Risk of UTI and hypovolemia. Also reports of AKI and euglycemic ketoacidosis. Glargine - Continue • Consider reducing by 15-20%, especially if patient has a history of low blood glucoses Apixaban - Hold 2 days before surgery • General approach is to estimate thromboembolic risk and bleeding risk Of surgery/procedure. Knee/hip surgeries are high bleeding risk. • Most patients don't require bridging anticoagulation. May be necessary in patients on warfarin at high thromboembolic risk (mechanical heart valve, recent stroke). Amlodipine - Continue • Limited data re risks/benefits, but overall they appear to be safe and may even have some benefit on hemodynamic stability Dr. Lizzy Hastie @LizzyHastie #Perioperative #Medications #Hold #Continue #preop #preoperative
