What are the perioperative medication management recommendations for a patient with impaired renal function undergoing robotic-assisted right anterior hip replacement, taking Eliquis (apixaban), Farxiga (dapagliflozin), Lasix (furosemide), atorvastatin, levothyroxine, metoprolol XL (metoprolol succinate), and Entresto (sacubitril/valsartan)?

From the Guidelines

Perioperative medication management for an 87-year-old female with impaired renal function undergoing robotic-assisted right anterior hip replacement requires careful consideration of each medication, with the primary goal of minimizing morbidity, mortality, and optimizing quality of life. To achieve this, the following recommendations are made based on the most recent and highest quality evidence available:

• Eliquis (apixaban) should be discontinued 48-72 hours before surgery, depending on the degree of renal impairment, as it increases bleeding risk 1.
• Farxiga (dapagliflozin) should be stopped 24-48 hours preoperatively to prevent euglycemic diabetic ketoacidosis and resumed only after normal oral intake is established and renal function is stable.
• Lasix (furosemide) should be held the morning of surgery to prevent dehydration and electrolyte imbalances but may be restarted postoperatively based on fluid status.
• Atorvastatin can be continued throughout the perioperative period as it has cardiovascular protective effects, as supported by guidelines that recommend continuing statins in patients currently taking them 1.
• Levothyroxine should be taken the morning of surgery with a sip of water to maintain thyroid hormone levels.
• Metoprolol XL should be continued through the perioperative period to prevent rebound tachycardia and hypertension, in line with recommendations to continue beta blockers in patients who are on them chronically 1.
• Entresto (sacubitril/valsartan) should be held 24-48 hours before surgery to avoid hypotension and acute kidney injury, especially given the patient's baseline renal impairment. Key considerations include:
• Renal function should be closely monitored throughout the perioperative period with appropriate adjustment of medication dosages.
• Adequate hydration and avoidance of nephrotoxic agents are essential to prevent further renal deterioration. These recommendations prioritize minimizing risks associated with surgery and medication management, focusing on the patient's overall morbidity, mortality, and quality of life outcomes.

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 taking Eliquis (apixaban) for atrial fibrillation, and the decision to hold or continue this medication should be made in consultation with the patient's cardiologist or primary care physician, considering the risk of thromboembolic events versus the risk of bleeding during surgery 2, 3.
• Farxiga (dapagliflozin) is used to treat heart failure and hypertension, but there is limited evidence to guide its perioperative management in the context of robotic-assisted surgery. However, it is generally recommended to hold diuretics like Farxiga on the day of surgery to minimize the risk of hypotension and dehydration 4.
• Lasix (furosemide) is a diuretic used to manage heart failure and fluid overload. It is usually recommended to hold Lasix on the day of surgery to avoid dehydration and electrolyte imbalances, but this decision should be individualized based on the patient's volume status and renal function 5.
• Atorvastatin, levothyroxine, metoprolol XL, and Entresto should be continued as usual, as they are essential for managing the patient's underlying medical conditions, unless there are specific concerns or interactions that need to be addressed 6.

Renal Function Considerations

The patient's renal function should be carefully monitored perioperatively, especially when using medications like Farxiga and Lasix, which can affect kidney function.

• It is essential to assess the patient's renal function before surgery and adjust medication doses accordingly.
• Close monitoring of renal function and electrolyte levels is crucial during the perioperative period to minimize the risk of acute kidney injury or other complications.

Recommendations

Based on the available evidence, the following recommendations can be made:

• Consult with the patient's cardiologist or primary care physician to determine the best approach for managing Eliquis and other anticoagulant medications perioperatively.
• Hold Farxiga and Lasix on the day of surgery, unless otherwise indicated by the patient's clinical condition.
• Continue atorvastatin, levothyroxine, metoprolol XL, and Entresto as usual, unless there are specific concerns or interactions that need to be addressed.
• Closely monitor the patient's renal function and electrolyte levels perioperatively to minimize the risk of complications.