Perioperative Medication Management

General Principles & Risk Assessment - Setting the Stage

• Goal: Minimize perioperative risk; optimize patient status.
• Preoperative Evaluation: H&P, targeted investigations.
• Risk Stratification:
  • ASA Physical Status (I-VI).
  • RCRI for MACE: 6 predictors (IHD, CHF, CVD, DM, Cr >2 mg/dL, high-risk surgery).
    • Score 0-1 (low/intermediate), ≥2 (elevated risk).
• Medication Management: Continue, hold, or modify based on risk/benefit.

⭐ Beta-blockers & statins are typically continued perioperatively to reduce cardiac events.

Cardiovascular Medications - Heartfelt Decisions

• Beta-blockers: Continue if chronic. Start if RCRI ≥2 (not on surgery day).
• ACEi/ARBs: Hold AM of surgery. Restart post-op (euvolemic).
• Statins: Continue.
• Aspirin:
  • Secondary prevention: Continue (unless high bleed risk).
  • Primary prevention: Stop 7 days prior.
• P2Y12 Inhibitors (e.g., Clopidogrel):
  • Stent recent? (BMS <1m, DES <6-12m): Defer surgery. Urgent? Cardiology consult.
• Anticoagulants (Warfarin/DOACs):
  • Warfarin: Stop 5 days (target INR <1.5).
  • DOACs: Stop 24-72h. Bridge if high VTE risk.

⭐ Premature DAPT cessation post-stent ↑ risk of fatal stent thrombosis.

Endocrine Medications - Hormonal Harmony

• Diabetes Management:
  • Oral Hypoglycemics (OHAs): Hold Metformin, Sulfonylureas (SUs), SGLT2 inhibitors 24-72h pre-op. DPP4 inhibitors often continued.
  • Insulin: Continue basal (may ↓ dose by 20-50%). Hold bolus/short-acting. Perioperative target BG: 140-180 mg/dL.
• Thyroid Medications:
  • Levothyroxine: Continue throughout perioperative period.
  • Antithyroid drugs (e.g., Methimazole, PTU): Continue.
• Adrenal Steroids (Chronic Use: >5mg prednisone/day for >3 weeks):
  • Administer stress-dose steroids to prevent adrenal insufficiency.
• Oral Contraceptives (OCPs) / Hormone Replacement Therapy (HRT):
  • Stop 4-6 weeks before major surgery (↑ VTE risk).

⭐ For patients on chronic steroids, abrupt cessation or major stress without supplementation can precipitate an adrenal crisis, a life-threatening emergency. Always assess HPA axis suppression risk!

CNS & Respiratory Medications - Mind & Breath Matters

• General Principle: Most vital CNS & respiratory meds continued perioperatively.
• Anticonvulsants: Continue; monitor levels (e.g., phenytoin, valproate).
• Antidepressants:
  • SSRIs/SNRIs: Generally continue. ⚠️ Caution: ↑ bleeding risk with NSAIDs.
  • TCAs: Continue cautiously; monitor for cardiac effects (QT prolongation, orthostasis).

  • ⭐ MAOIs: Discontinue 2 weeks prior to elective surgery. High risk of hypertensive crisis or serotonin syndrome with anaesthetic agents.

• Antipsychotics: Continue; monitor for NMS, EPS, QT prolongation.
• Parkinson's Medications (Levodopa): Crucial to continue uninterrupted to prevent Parkinsonism-hyperpyrexia syndrome.
• Respiratory Inhalers (β-agonists, anticholinergics, steroids): Continue, including on the day of surgery. Optimize lung function pre-op.
• Systemic Corticosteroids: Continue. Consider stress dose if on >5mg prednisone equivalent daily for >3 weeks in the past year.

Analgesics, DMARDs & Herbals - Pain & Assorted Pills

• Analgesics (Perioperative):
  • NSAIDs: Continue if chronic use, but ⚠️ risk of bleeding, renal injury. Stop 5 half-lives before major surgery if possible (e.g., Ibuprofen 1-2 days, Naproxen 4-5 days, Piroxicam 10-12 days). COX-2 inhibitors (Celecoxib) generally safer for GI, less platelet effect.
  • Opioids: Continue chronic therapy to avoid withdrawal. Plan multimodal analgesia.
  • Paracetamol: Safe, continue.
• DMARDs:
  • Methotrexate: Hold 1-2 weeks pre-op (controversial, discuss with rheumatologist). Restart post-op once healing evident.
  • Biologics (e.g., TNF-α inhibitors): Hold for 1-5 half-lives before surgery (varies by drug); restart post-op with good healing, no infection.
  • Hydroxychloroquine, Sulfasalazine: Generally safe to continue.
• Herbals (⚠️ Stop 2 weeks pre-op):
  • Ginseng, Garlic, Ginkgo Biloba: ↑ Bleeding risk.
  • St. John's Wort: Induces CYP450, alters drug metabolism.
  • Ephedra (Ma Huang): ↑ Cardiovascular risk.

⭐ Aspirin for secondary prevention: Generally continue low-dose aspirin (75-100 mg) perioperatively unless bleeding risk is very high (e.g., neurosurgery, posterior eye surgery).

High‑Yield Points - ⚡ Biggest Takeaways

• Beta-blockers: Continue if chronic use. Consider for RCRI ≥2 (not on surgery day).
• Statins: Continue perioperatively. ACEi/ARBs: Hold on day of surgery.
• Aspirin: Continue for secondary prevention. Clopidogrel: Stop 5-7 days pre-op if safe.
• Warfarin: Stop 5 days prior (bridge if high risk; target INR <1.5).
• DOACs: Hold 24-96h based on drug, renal function, and bleed risk.
• Oral Hypoglycemics: Hold on surgery day. Adjust insulin (e.g., 50% basal dose).