Perioperative Medication Management Controversies
The session began with Alana Sigmund, MD, SFHM, medical director for arthroplasty at the Hospital for Special Surgery in New York, addressing the complex issue of perioperative medication management, specifically regarding the continuation or cessation of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs).
Dr. Sigmund examined the discordant findings presented in recent literature. The POISE trial demonstrated a significant elevation in intraoperative hypotension among patients who maintained ACEi and ARB therapy. Conversely, the SPACE trial indicated that discontinuation of these medications did not mitigate myocardial injury but potentially increased clinically significant hypertension. To reconcile these discrepancies, the Stop or Not trial was conducted, which reported no statistically significant difference in adverse outcomes between patients who continued or discontinued ACEi and ARBs.
Dr. Sigmund emphasized that, aligning with the anticipated findings of the Stop or Not trial, the 2024 American Heart Association/American College of Cardiology guidelines for non-cardiac surgery do not advocate for the routine discontinuation of ACEi and ARBs. This may represent a resolution to the clinical uncertainty surrounding this practice.
Dr. Sigmund further addressed the management of glucagon-like peptide-1 (GLP-1) agonists, a class of medications with evolving perioperative guidelines due to their relatively recent introduction and expanding indications. A primary concern is the potential for delayed gastric emptying and the subsequent risk of aspiration during anesthesia. Optimal timing for withholding these medications perioperatively is still under investigation. In 2021, the Society for Perioperative Assessment and Quality Improvement issued a consensus statement advising that weekly doses of GLP-1 agonists could be administered as scheduled, unless the administration day coincided with the day of surgery. In such instances, the dose should be postponed until after surgery. An exception was made for GI surgeries or cases with anticipated postoperative nausea, vomiting, or GI dysfunction, where withholding the medication for seven days prior to surgery was recommended. Reviewing subsequent studies published since the 2021 Society for Perioperative Assessment and Quality Improvement statement, Dr. Sigmund advocated for a patient-specific risk assessment approach.
For example, patients undergoing GLP-1 agonist dose escalation are more likely to experience delayed gastric emptying. Therefore, delaying elective surgery in this patient population until dose stabilization and improvement of GI side effects may be prudent.
Next, Paul Grant, MD, SFHM, hospitalist and associate chief medical information officer for the University of Michigan Health System in Ann Arbor, addressed the perioperative management of sodium-glucose cotransporter-2 (SGLT-2) inhibitors.
These agents, like GLP-1 agonists, are a relatively recent class of medications experiencing increasing utilization, which necessitates ongoing refinement of perioperative guidelines. The primary concern associated with SGLT-2 inhibitors is euglycemic diabetic ketoacidosis (EDKA). SGLT-2 inhibitors induce glucosuria, which lowers serum glucose, thereby decreasing insulin levels and increasing glucagon levels. The physiological stress of surgery further elevates glucagon, potentially resulting in ketogenesis, particularly when combined with preoperative fasting. Due to this risk, it is generally recommended that SGLT-2 inhibitors be discontinued three to four days prior to elective surgical procedures.
However, Dr. Grant discussed the management of urgent or emergent surgeries, citing studies demonstrating the rarity of postoperative EDKA in patients taking SGLT-2 inhibitors. He emphasized that delaying urgent procedures, such as those for hip fracture, to allow for medication discontinuation is generally not warranted. Rather, in such instances, patients should proceed to surgery with heightened vigilance for the potential development of postoperative EDKA.
Dr. Grant proceeded with a discussion of immunomodulators. The perioperative management of these medications presents a delicate balance between the risks of continued use, such as infection and impaired wound healing, and the risks associated with discontinuation, notably exacerbation of the underlying disease.
Dr. Grant emphasized that decisions regarding these medications are typically made by an interdisciplinary team, including the surgeon and the prescriber, often a rheumatologist or other subspecialist. However, he highlighted the crucial role of hospitalists as care coordinators and therefore the importance of their understanding of these management principles.
While medication management is ultimately patient-specific, several general principles were discussed. For immunomodulatory agents used in organ transplant recipients, these agents are continued without interruption throughout the perioperative period. For non-transplant indications, biologic agents are generally held for one dosing cycle. Janus kinase inhibitors are typically held for three days prior to surgery. Other immunosuppressants, including methotrexate and hydroxychloroquine, are generally continued.
The session concluded with a discussion on the perioperative management of buprenorphine. Dr. Grant explained that, contrary to historical practice, which advocated for discontinuing buprenorphine perioperatively to facilitate the use of full mu-opioid agonists for postoperative pain management, the current recommendation is to continue buprenorphine therapy. This paradigm shift stems from the recognition that preoperatively tapering or discontinuing buprenorphine carries a substantial risk of relapse in patients with opioid use disorder. Consequently, the current recommendation is to maintain a patient’s home buprenorphine regimen and employ a multimodal approach to postoperative pain management, including the judicious use of full mu-opioid agonists. A specific consideration was addressed for patients on high baseline doses of buprenorphine (exceeding 16 mg). For this patient population, a suggested approach involves preoperative dose reduction to 16 mg. Patients should then be instructed to administer 8 mg on the morning of surgery, followed by 4 mg every eight hours. Postoperatively, the patient’s home buprenorphine dose should be resumed as soon as clinically feasible.
Dr. Caputo-Seidler is a hospitalist and assistant professor at the University of South Florida in Tampa, Fla.