Should beta blockers, indomethacin (Inderal), diuretics, and lisinopril be initiated on the morning of surgery?

From the Guidelines

Beta blockers should be continued on the morning of surgery, while ACE inhibitors like lisinopril and diuretics may be held or continued based on individual patient factors and surgery type. The decision to continue or hold these medications should be made on a case-by-case basis, taking into account the patient's cardiovascular risk, type of surgery, and overall health status 1.

Key Considerations

• Beta blockers should not be started on the day of surgery in beta blocker-naive patients, as this can be harmful 1.
• Continuing beta blockers in patients who have been on them chronically is recommended to prevent withdrawal and potential rebound hypertension or tachycardia 1.
• For ACE inhibitors like lisinopril, the recommendation depends on the specific surgery and patient factors - they may be held on the morning of major surgeries due to risk of intraoperative hypotension, but continued for minor procedures 1.
• Diuretics are typically held on the morning of surgery to prevent dehydration and electrolyte imbalances during the perioperative period.

Individualized Approach

The decision to continue or hold these medications should be individualized based on the patient's specific situation, and patients should always follow their surgeon's or anesthesiologist's specific instructions, as they may differ based on individual circumstances 1.

Prioritizing Patient Safety

Ultimately, the goal is to balance the risks of medication discontinuation against potential surgical complications, prioritizing patient safety and minimizing morbidity, mortality, and impact on quality of life 1.

From the FDA Drug Label

Chronically administered beta-blocking therapy should not be routinely withdrawn prior to major surgery, however the impaired ability of the heart to respond to reflex adrenergic stimuli may augment the risks of general anesthesia and surgical procedures Surgery/Anesthesia In patients undergoing major surgery or during anesthesia with agents that produce hypotension, lisinopril may block angiotensin II formation secondary to compensatory renin release If hypotension occurs and is considered to be due to this mechanism, it can be corrected by volume expansion.

Medication Management on the Day of Surgery

• Beta blockers: should not be routinely withdrawn prior to major surgery 2
• Lisinopril: may block angiotensin II formation secondary to compensatory renin release during surgery or anesthesia, and hypotension can be corrected by volume expansion 3
• No direct information is available in the provided drug labels regarding the administration of Inder, diuretics on the day of surgery. The FDA drug label does not answer the question.

From the Research

Medication Management on the Day of Surgery

• The decision to start or continue beta blockers, Inderal (propranolol), diuretics, and lisinopril on the morning of surgery should be based on the individual patient's medical condition and the type of surgery being performed 4, 5.
• For patients with hypertension, beta blockers may be used in combination with other anti-hypertensive drugs to achieve maximal blood pressure control, but their use as first-line therapy for hypertension without compelling indications is controversial 6, 7.
• Diuretics, such as thiazide diuretics, are commonly used in combination therapy for the treatment of hypertension, but their use should be carefully considered in patients with certain medical conditions, such as renal failure or hyperthyroidism 6, 8.
• Lisinopril, an angiotensin-converting enzyme inhibitor (ACEI), is often used in combination with other medications, such as beta blockers and diuretics, to treat hypertension and heart failure 8.
• The American Family Physician recommends that patients with heart failure with reduced ejection fraction should be treated initially with a beta blocker and an ACEI or ARB, followed by add-on therapy with a mineralocorticoid receptor antagonist and a diuretic based on volume status 8.

Considerations for Perioperative Medication Management

• The use of beta blockers to reduce perioperative myocardial ischemia and cardiovascular complications may not benefit as many patients as once hoped and may actually cause harm in some individuals 4.
• The decision to start or continue medications on the morning of surgery should be based on the individual patient's medical condition, the type of surgery being performed, and the potential risks and benefits of continuing or withholding medication 5.
• Patients who are already receiving beta blockers for known cardiovascular conditions should continue to take their medication as directed, unless otherwise instructed by their healthcare provider 4, 5.