Summary Perioperative medical management is challenging due to the increasing complexity of patients presenting for surgical procedures. A key part of preoperative optimization is appropriate long-term medication management, however, guidelines and consensus statements for perioperative medication management are lacking. The available resources use recommendations derived from individual studies and do not include a multidisciplinary approach or formal consensus. The Society for Perioperative Assessment and Quality Improvement (SPAQI) identified the lack of authoritative clinical guidance as an opportunity to use its multidisciplinary membership to improve evidence-based perioperative care. SPAQI seeks to provide guidance on perioperative medication management that synthesizes the available literature with expert consensus. The purpose of this Consensus Statement is to provide practical guidance on the preoperative management of endocrine, hormonal, and urologic medications. A panel of experts with expertise in anesthesiology, perioperative medicine, hospital medicine, general internal medicine, and medical specialties was assembled and identified common medications in each of these categories. The authors then used a modified Delphi approach to critically review the literature and generate consensus recommendations. |
Background
The Society for Perioperative Assessment and Quality Improvement (SPAQI) is a multidisciplinary organization that has recently published several position papers on perioperative medication management. This statement, which addresses endocrine and urologic medications, was developed through a consensus process outlined by the authors.
Key Recommendations
Diabetes Medications:
- Basal insulins (intermediate- or long-acting) should generally be continued at 60% to 80% of the usual dose on the morning of surgery or the night before surgery, depending on the patient’s usual insulin schedule.
- Metformin, sulfonylureas, pioglitazone, and dipeptidyl peptidase (DPP)-4 inhibitors should not be administered the morning of surgery.
- Sodium-glucose cotransporter (SGLT)-2 inhibitors should be discontinued at least 3 days before surgery.
- Glucagon-like peptide (GLP)-1 agonists should be continued on the morning of surgery (for agents administered daily) or during the week prior to surgery (for agents administered weekly).
Other endocrine drugs:
- Thyroid hormone and antithyroid medications can be taken the morning of surgery.
- A patient’s usual dose of corticosteroids can be taken the morning of surgery (this paper did not address the perioperative administration of additional steroids at stress doses).
- Most other hormonal or endocrine-related medications can be continued the morning of surgery. However, bisphosphonates should be continued (given the risk of esophagitis when patients are supine after taking these medications).
Urological drugs:
- α-blockers and 5-α-reductase inhibitors can be taken the morning of surgery.
- Anticholinergic bladder medications should be taken the morning of surgery.
- Phosphodiesterase (PDE)-5 inhibitors, when prescribed for urological indications, should be held for 3 days before surgery, due to concern for intraoperative hypotension.
Comment
Most of these recommendations are based on common-sense inferences of the mechanisms of action and side effects of these drugs, not on direct perioperative studies. The authors encourage clinical judgment in certain scenarios (e.g., maintaining certain prothrombotic hormonal agents in patients at high risk for perioperative thrombosis). I urge physicians performing preoperative evaluations to read this report.
