Medication Management

Preoperative Medication Review - Pill Patrol Plan

• Comprehensive review: All current medications (prescribed, OTC, herbal supplements).
• Aim: Identify potential risks, prevent adverse drug interactions, optimize perioperative care.
• Decision framework: Continue, Hold, Modify (📌 CHM) based on drug, surgery, patient factors.
• Document: Drug name, dose, frequency, last dose time.
• Focus areas: Anticoagulants, antiplatelets, antidiabetics, antihypertensives, psychotropics, MAOIs.

⭐ A thorough preoperative medication reconciliation, including over-the-counter drugs and herbal supplements, is paramount to prevent adverse drug interactions and surgical complications.

Cardiac & Coagulation Conundrums - Heartbeat & Bleed Brief

• Cardiac Meds:
  • β-blockers: Continue.

    ⭐ Beta-blockers should generally be continued perioperatively in patients chronically taking them to prevent rebound tachycardia and ischemia, especially in those with known coronary artery disease.

  • ACEi/ARBs, Diuretics: Hold AM surgery (↓BP/volume).
  • Statins, Digoxin, Amiodarone: Continue.
• Antiplatelets:
  • ASA: Primary prev: Stop 7d. Secondary: Usually continue.
  • P2Y12 inh (Clopi, Tica): Stop 5d. Prasugrel: Stop 7d.
• Anticoagulants:
  • Warfarin: Stop 5d (INR < 1.5). Bridge if high VTE risk.
  • DOACs: Stop 1-5d (drug/renal/surgery specific).
  • LMWH (therap.): Stop 24h. UFH IV: Stop 4-6h.

Endocrine & CNS Agents - Hormone & Head Harmony

• Thyroid Meds:
  • Levothyroxine: Continue.
  • Antithyroid (PTU, Methimazole): Continue; ensure euthyroid.
• Diabetes Agents:
  • Metformin: Hold 24-48h pre-op.
  • Sulfonylureas: Hold AM of surgery.
  • SGLT2-i: Hold 3 days pre-op.
  • Insulin: Basal: 50-75% dose; Prandial: Hold AM. Target BG 140-180 mg/dL.
• Corticosteroids:

  ⭐ Patients on long-term corticosteroids (e.g., >5 mg prednisone equivalent daily for >3 weeks within the past year) require perioperative stress-dose steroids to prevent adrenal insufficiency.

  • Stress dose: Hydrocortisone 100 mg IV q8h.
• OCP/HRT: ↑ VTE risk. May hold 4-6 weeks pre-op (high-risk surgery).
• CNS Agents:
  • AEDs, Antiparkinsonian: Continue (critical).
  • SSRIs/SNRIs/TCAs: Continue.
  • MAOIs: Hold 2 wks pre-op (traditionally); consult.
  • Lithium: Hold 24-72h pre-op; monitor.

Analgesics & Herbals - Ache & Plant Alert

• Analgesics:
  • NSAIDs (Aspirin, Ibuprofen):
    • Effect: ↑ Bleeding risk.
    • Stop: Aspirin 7-10 days; others 1-3 days.
  • COX-2 Inhibitors (Celecoxib):
    • Effect: Less platelet impact.
    • Stop: 24-48 hours.
  • Opioids:
    • Effect: Respiratory depression, PONV.
    • Manage: Continue chronic use, adjust dose.
• Herbal Supplements: 📌 The 4 G's (Garlic, Ginger, Ginkgo, Ginseng) ↑ bleeding.

  ⭐ Herbal medications like Ginkgo, Garlic, Ginseng, and Ginger (the 4 G's) significantly increase bleeding risk and should typically be discontinued 1-2 weeks before surgery.

  • General rule: Stop most herbals 1-2 weeks pre-op.
  • Common Herbals & Stoppage:

    Herbal	Key Effect(s)	Stop (Pre-op)
    Garlic, Ginger	↑ Bleeding	7 days
    Ginkgo Biloba	↑ Bleeding	7 days
    Ginseng	↑ Bleeding, hypoglycemia	7 days
    St. John's Wort	Enzyme induction (↓ drug effect)	5-7 days
    Ephedra	↑ BP/HR, arrhythmias	24-48 hours
    Kava Kava	Sedation, ↑ anesthetic effect	24-48 hours
    Valerian	Sedation, withdrawal risk	7-14 days

High‑Yield Points - ⚡ Biggest Takeaways

• Aspirin/Clopidogrel: Stop 5-7 days pre-op if high bleed risk; continue if high cardiac risk.
• Warfarin: Stop 5 days (target INR <1.5); bridge if high TE risk. DOACs: stop 24-72h.
• Beta-blockers: Continue in chronic users. Avoid new initiation on surgery day.
• ACEi/ARBs: Hold on surgery morning to prevent hypotension.
• Oral Hypoglycemics: Hold most on surgery day. Insulin: adjust to half dose long-acting.
• Herbal Meds: Stop 1-2 weeks pre-surgery (interactions/bleeding).