For an open cholecystectomy, which preoperative medications need to be stopped—should furosemide (Lasix) be held and can ursodeoxycholic acid be continued?

Preoperative Medication Management for Open Cholecystectomy

You can continue ursodeoxycholic acid but should hold furosemide on the morning of surgery.

Ursodeoxycholic Acid (UDCA) - Continue

UDCA does not need to be stopped before cholecystectomy. The FDA label indicates that ursodeoxycholic acid is specifically used for patients with gallbladder stones who are undergoing elective cholecystectomy, particularly when there are increased surgical risks 1. The medication is designed to dissolve radiolucent gallstones and prevent new stone formation, making it complementary rather than contradictory to surgical intervention.

There is no evidence that UDCA interferes with surgical outcomes or increases perioperative complications. The bariatric surgery guidelines extensively discuss UDCA use in the context of cholecystectomy, noting its role in preventing gallstone formation after gastric surgery, with no mention of needing to discontinue it before the procedure 2. Research confirms UDCA's safety profile, with gastrointestinal side effects being the most common adverse events, none requiring hospitalization 3.

Key Points on UDCA:

• No documented surgical contraindications
• Does not affect bleeding, anesthesia, or wound healing
• Can be safely continued through the perioperative period
• May actually be beneficial in preventing postoperative biliary complications

Furosemide (Lasix) - Hold on Day of Surgery

Furosemide should be held on the morning of surgery to prevent intraoperative hypotension and electrolyte disturbances. While the ACC/AHA perioperative guidelines emphasize continuing most chronic medications including antihypertensives through the perioperative period 4, diuretics are a notable exception.

Rationale for Holding Furosemide:

• Volume depletion risk: Diuretics combined with preoperative fasting can lead to significant intravascular volume depletion
• Hypotension during anesthesia: Reduced intravascular volume increases risk of hemodynamic instability during induction and maintenance of anesthesia
• Electrolyte abnormalities: Hypokalemia and hypomagnesemia from chronic diuretic use can precipitate cardiac arrhythmias under anesthesia
• Impaired renal perfusion: Volume depletion combined with surgical stress can compromise renal function

Clinical Algorithm:

1. Check preoperative electrolytes (potassium, magnesium) - correct any abnormalities before surgery
2. Hold furosemide on the morning of surgery
3. Ensure adequate IV hydration in the perioperative period
4. Resume furosemide postoperatively once the patient is hemodynamically stable, taking oral intake, and has adequate urine output

Common Pitfalls to Avoid

• Do not stop UDCA unnecessarily: There is no indication to discontinue bile acid therapy before cholecystectomy
• Do not continue diuretics through surgery: This increases risk of hypotension and electrolyte-related complications
• Do not forget to check electrolytes: Chronic furosemide use often causes hypokalemia that must be corrected preoperatively
• Do not withhold furosemide for extended periods postoperatively: Resume once clinically appropriate to avoid fluid overload, especially in patients with heart failure or renal disease

The evidence base for antibiotic prophylaxis in cholecystectomy is well-established 5, 6, 7, but neither UDCA nor furosemide management affects antibiotic decision-making. Focus your perioperative planning on appropriate volume management given the held diuretic and ensuring electrolyte optimization.