The Curbsiders' 'Hot Takes'

Hold This Drug? Perioperative Medication Management

Matthew F. Watto, MD; Paul N. Williams, MD; Stuart K. Brigham, MD


December 27, 2019

This transcript has been edited for clarity.

Matthew F. Watto, MD: Gentlemen, we're back. This is The Curbsiders. I'm Matt Watto, here with my two faithful cohosts, Dr Paul Williams and Dr Stuart Brigham.

What are some of our favorite things that we learned from our talk with Dr Avital O'Glasser, "Dominate Perioperative Medication Management"? Paul, can you start us off?

Paul N. Williams, MD: I liked the point she made about the management of diabetes medications perioperatively. Some of it is old standard, but with the newer agents coming down the pike and becoming more and more popular, I thought it was worth reviewing. Sulfonylureas we still obviously hold perioperatively. Even with metformin, the standard is still to hold it for about 1 day prior to the procedure, so I don't think that has changed. But the question that comes up is, what do we do with the SGLT2 inhibitors and the GLP-1 agonists?

With the SGLT2s, there is a concern for euglycemic diabetic ketoacidosis in patients who are about to undergo long procedures that might involve fluid shifts, so Dr O'Glasser recommends holding them for 2-3 days prior to the procedure and then resuming them when the patient's intake is stable.

For the GLP-1s, the recommendation, if they are being given weekly, is that they can just be continued throughout the procedure. However, if they are due on the day of the procedure, you should probably hold them at that time and then resume them when the surgery is over.

Stuart K. Brigham, MD: Is this expert opinion or based on evidence?

Williams: This is primarily based on expert opinion.

Watto: There just isn't enough experience. One thing we talked about was the fact that the GLP-1s, at least, are probably coming to the hospital in the near future. I'm a little bit bullish on metformin. We're probably going to be holding metformin less often, but for now, at least, holding it on the day of the procedure is perfectly acceptable. I think that's what most people are doing.

We spent a lot of time talking about anticoagulation and how bridging—meaning, taking them off warfarin and putting them on some sort of short-acting agent perioperatively—for atrial fibrillation is dead. The vast majority of patients will not need bridging. Unless someone had a stroke within the past 3 months or has a CHA2DS2-VASc score of 7, you are probably not going to need to bridge them. Bridging will increase the risk of bleeding and you won't be preventing any major events.

The direct-acting oral anticoagulants (DOACs) are so short-acting that you can hold them perioperatively—usually for 2-3 days before the day of surgery. A recent trial, PAUSE , showed that this is pretty safe. You don't have to check levels or anything; you just stop them 2-3 days before surgery.

Brigham: That was a question brought up by the ROCKET AF trial, which looked at rivaroxaban for atrial fibrillation. In the supplementary material they showed an increased risk for thrombosis 3-30 days after a transition period back to [warfarin]. The concern was that abrupt cessation of factor Xa inhibitors would increase the risk for thrombosis, at least within that time period.

In the PAUSE trial, they stopped the drug 2 days before and restarted it 1 day after the surgery, finding no increased risk during that short time period. I am unaware of any other trials that have looked beyond that 3-day period at the risk for hypercoagulability after abrupt cessation of factor Xa inhibitors. The question of whether the risk of bleeding is increased beyond day 3 is still unanswered by the literature.

Watto: The other point that I liked was that for patients with deep vein thrombosis, the risk for recurrence of thromboembolism was highest in the first 3 months. So during that period, it's recommended that the patient just postpone surgery. Beyond the 3-month point, most patients are not being bridged; it's done on a case-by-case basis. If it's an unusual case—for example, someone being actively treated for cancer or with a major thrombophilia—Dr O'Glasser often works with a hematologist to determine the need.

We got way into the weeds on anticoagulation and antiplatelet stuff. We also talked about the rheumatologic drugs (the DMARDs), so definitely check out the episode if this interests you. It's a pretty comprehensive look at perioperative medication management. If you want to hear more about this talk or continue the conversation, click on the link below to hear the full episode and our discussion with Dr O'Glasser.

Hear the full episode of Dominate Perioperative Medication Management or check out The Curbsiders on iTunes.

The Curbsiders are a national network of students, residents, and clinician educators from across the country, representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about their contributors and follow them on Twitter.

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