Olivia C. Welter, PharmD
The ever-rising complexity of patient health has prompted the Society for Perioperative Assessment and Quality Improvement (SPAQI) to address the lack of resources for perioperative medication management through publication of their own guidance.
SPAQI has released articles in Mayo Clinic Proceedings since December 2021 with recommendations for holding medications preoperatively specific to distinct disease categories: gastrointestinal and pulmonary; psychiatric; rheumatologic and HIV; and neurologic.
The full guidance articles include notes with more information about each recommendation. Some common medications and drug classes need to be held at certain time points prior to surgical procedures.
SPAQI generally recommends some classes of medications to be continued as usual prior to any surgery. Anti-retrovirals, anti-anxiety medications, antidepressants, mood stabilizers, anti-psychotics, glucocorticoids, interferons, acetylcholinesterase inhibitors, methotrexate, proton pump inhibitors, most inhaled medications, anticonvulsants, and medications used in management of Alzheimer disease are all included in this category.
Patients taking immunosuppressants to treat severe lupus erythematosus (SLE) can typically continue on these medications, including on the day of surgery. It’s recommended that medications used to manage Parkinson disease are to be continued preoperatively, unless the patient is undergoing placement of deep brain stimulators under monitored anesthesia, in which case they should be held on the day of surgery.
Hold for entire dosing cycle
SPAQI recommends that most biologic medications used to treat rheumatologic disease be held for a full dosing cycle before surgery. Biologics are known to cause increased risk of infection for patients, and some biologics impair or delay wound healing. For belimumab and rituximab specifically, these medications should only be held in patients who have non-severe SLE. Janus kinase (JAK) inhibitors are the main exception for preoperative discontinuation, as SPAQI recommends they be held only for 3 days prior to the operation rather than an entire dosing cycle. Anifrolumab can be continued uninterrupted in all patients, regardless of surgical status.
In addition to biologics, SPAQI also includes several gastrointestinal immunomodulators, such as tumor necrosis factor inhibitors, on its list of recommended drugs to hold for an entire dosing cycle preoperatively.
Hold 4 weeks to 3 days prior
Medications that are not on specific, extended dosing cycles may need to be held for 4 weeks, 7 days, or 3 days before surgery. At the 4-week mark, cyclophosphamide is the main medication SPAQI recommends being held.
At 7 days, the guidance suggests that immunosuppressants used for patients with non-severe SLE, such as azathioprine, cyclosporine, tacrolimus, and mycophenolate can be held. Pegylated interferons used to treat viral hepatitis are also recommended to be held at 7 days.
Due to bleeding complications, SPAQI recommends that all NSAIDs except celecoxib be held for 7 days before surgery. The guidance includes additional notes to consider for each individual medication within the class, as the amount of time they’re required to be held differs based on several variables.
Three days before a surgery, lithium can be held for major procedures. If the patient is only undergoing a mild operation, SPAQI recommends continuing lithium as usual.
Hold on day of surgery only
Many common medications that patients take regularly are on the list of drugs that SPAQI says can be continued as usual up until the day of the surgery. This includes allergy medicine, antacids, laxatives, antidiarrheals, antiemetics, weight loss drugs, and medicine like pseudoephedrine.
Other medications that appear in these recommendations are theophylline, pegylated interferons, and drug combinations used to treat hepatitis infections. SPAQI also recommends that adults using ADHD medication do not take their dose on the day of surgery, except for guanfacine which does not need to be held.
The full guidance released by SPAQI should be consulted for additional details to better inform clinical decision-making for surgical teams when identifying which medications should be held prior to an operation. ■