Perioperative medication decisions need individualized risk-benefit approach

Editor's Note

Medication management in the perioperative period is often made without robust evidence, requiring clinicians to balance surgical safety with the risks of interrupting treatment, according to expert guidance presented at the annual Perioperative Medicine Summit. Paul Grant, MD, of the University of Michigan Medical School, noted most medications do not interfere with anesthesia or surgery, but understanding why a patient is taking a drug is central to deciding whether to continue or hold it.

Per the OR Management News June 16 article covering the presentation, stopping a medication may worsen the underlying condition or cause withdrawal, while continuing it can affect wound healing or raise cardiovascular, hematologic, neurologic, or infection risks. Experts recommended evaluating a drug’s mechanism, half-life, side effects, and potential alternatives if the patient will be NPO after surgery. Kurt Pfeifer, MD, of the Medical College of Wisconsin, advised discontinuing supplements without clear indications but continuing those with defined therapeutic purposes, such as vitamin D for osteoporosis.

The outlet reports hormonal therapies require careful weighing of benefits and risks. Discontinuation can disrupt contraception, cancer treatment, gender-affirming care, or bone health, while continuation—particularly with certain estrogens and SERMs—can raise venous thromboembolism (VTE) risk. Because stopping these agents requires a month-long washout, often incompatible with surgical timelines, aggressive VTE prophylaxis may be a safer alternative. Recommendations include continuing testosterone, continuing SERMs for breast cancer but stopping them 7 days prior for other indications, and maintaining transdermal estrogen use, with VTE prophylaxis in high-risk situations.

Regarding nonsteroidal anti-inflammatory drugs, the traditional approach of stopping COX-1 and COX-2 inhibitors before surgery may not always be necessary. Evidence suggests COX-1 inhibitors likely do not increase perioperative bleeding risk and can aid postoperative pain control. COX-2 inhibitors may be continued unless the patient has high acute kidney injury risk, and topical diclofenac is considered safe due to minimal systemic absorption.

For immunomodulators, the article explains, interruption can trigger disease flares, but continuation can increase infection or wound healing risk. Organ transplant patients should not have these medications stopped. For others, the decision should be made collaboratively, considering disease severity and procedure type. Nonbiologics are generally safe to continue, while biologics are often held for one dosing cycle, Janus kinase inhibitors for three days, and certain immunosuppressants may be paused or maintained depending on disease severity, such as severe lupus.