What are the perioperative medication management recommendations for an 87-year-old female with atrial fibrillation, hypertension, heart failure, severe tricuspid regurgitation, and hypothyroidism undergoing robotic-assisted right anterior hip replacement?

From the Guidelines

Perioperative medication management for this 87-year-old female with multiple cardiac comorbidities undergoing robotic-assisted right anterior hip replacement should prioritize continuation of essential medications while minimizing bleeding risks.

Key Considerations:

• Continue antihypertensive medications, except for ACE inhibitors and ARBs, which should be held 24 hours before surgery to prevent intraoperative hypotension, as recommended by 1.
• For atrial fibrillation, if she's on Eliquis, stop it 48-72 hours before surgery, depending on her renal function, and consider bridging with therapeutic-dose low molecular weight heparin until 24 hours before surgery, as suggested by 1.
• Heart failure medications, including beta-blockers (e.g., metoprolol XL) and diuretics, should be continued, though diuretic dosing may need adjustment based on volume status, in line with recommendations from 1.
• For severe tricuspid regurgitation, maintain euvolemia and avoid excessive fluid administration.
• Continue levothyroxine on the morning of surgery with a sip of water to prevent hypothyroidism exacerbation.
• Postoperatively, resume anticoagulation 24-72 hours after surgery when hemostasis is assured, with possible initial prophylactic dosing of heparin or LMWH.
• Early mobilization, compression devices, and adequate pain control are essential components of care.
• Close monitoring of cardiac function, fluid status, and electrolytes is crucial given her cardiac comorbidities and age.

Medication-Specific Recommendations:

• Eliquis: Hold 48-72 hours before surgery, depending on renal function, as per 1.
• Farxiga: Continue, as there is no clear indication to hold this medication perioperatively, but monitor renal function and adjust as necessary.
• Lasix: Continue, but adjust dosing based on volume status to avoid excessive fluid administration, in line with recommendations for managing heart failure patients perioperatively from 1.
• Levothyroxine: Continue on the morning of surgery with a sip of water.
• Metoprolol XL: Continue, as beta-blockers are recommended for patients with heart failure and atrial fibrillation, as suggested by 1 and 1.
• Entresto: Continue, as this medication is essential for heart failure management, and there is no clear indication to hold it perioperatively, consistent with recommendations from 1.

From the Research

Perioperative Medication Management

The patient's medical history and current medications should be carefully considered when planning for robotic-assisted right anterior hip replacement.

• The patient is currently taking Eliquis, atorvastatin, Farxiga, levothyroxine, metoprolol XL, and Entresto.
• The decision to hold or continue these medications perioperatively should be based on the patient's individual risk factors and the potential benefits and risks of each medication.

Anticoagulation Management

• Eliquis is an anticoagulant medication used to prevent stroke and systemic embolism in patients with atrial fibrillation.
• The decision to hold or continue Eliquis perioperatively should be based on the patient's risk of thromboembolic events and the risk of bleeding associated with the surgery 2, 3.
• It is generally recommended to hold anticoagulant medications, including Eliquis, for a certain period before elective surgery to minimize the risk of bleeding.

Diuretic Management

• Lasix (furosemide) is a diuretic medication used to treat fluid overload and edema in patients with heart failure.
• The decision to hold or continue Lasix perioperatively should be based on the patient's volume status and the potential risks and benefits of diuretic therapy in the perioperative period.
• Patients with severe tricuspid regurgitation, like this patient, may be at increased risk for fluid overload and may require careful management of diuretic therapy to avoid dehydration and electrolyte imbalances 4, 5.

Other Medications

• Farxiga (dapagliflozin) is a sodium-glucose cotransporter 2 inhibitor used to treat type 2 diabetes and heart failure.
• The decision to hold or continue Farxiga perioperatively should be based on the patient's individual risk factors and the potential benefits and risks of the medication.
• It is generally recommended to hold Farxiga for a certain period before elective surgery to minimize the risk of acute kidney injury and other complications 6.

Recommendations

• Eliquis and Farxiga should be held before surgery, as recommended by the patient's healthcare provider, to minimize the risk of bleeding and other complications.
• Lasix should be used with caution in the perioperative period, as patients with severe tricuspid regurgitation may be at increased risk for fluid overload and electrolyte imbalances.
• The patient's other medications, including atorvastatin, levothyroxine, metoprolol XL, and Entresto, should be continued as prescribed by the patient's healthcare provider, unless otherwise indicated.