How should medications be managed perioperatively for a high-risk patient with multiple comorbidities undergoing surgery?

From the Guidelines

Perioperative medication management for this high-risk patient with multiple comorbidities requires careful planning and coordination between the surgical team, anesthesiologist, and the patient's primary care physician. Medications should be evaluated individually based on their necessity, risk of withdrawal, and potential for surgical complications.

• Chronic medications that control cardiac conditions (beta-blockers like metoprolol, statins like atorvastatin), blood pressure (ACE inhibitors, ARBs), and diabetes should generally be continued through the perioperative period, though ACE inhibitors and ARBs may be held on the morning of surgery to prevent intraoperative hypotension.
• Anticoagulants require special attention:
  • Eliquis (apixaban) should be stopped 2-3 days before surgery depending on renal function 1.
  • Farxiga (dapagliflozin) may be continued, but its use should be carefully evaluated due to the potential risk of acute kidney injury in the perioperative period.
• Eliquis should be held 2-3 days before surgery, and Farxiga should be used with caution.
• Lasix (furosemide) may be held on the morning of surgery to prevent intraoperative hypotension, but this decision should be made on a case-by-case basis.
• The patient's RCRI (Revised Cardiac Risk Index) conditions include:
  • History of heart failure (preserved EF due to nonischemic cardiomyopathy)
  • History of cerebrovascular disease (not explicitly mentioned, but the patient has a history of atrial fibrillation, which increases the risk of stroke)
  • Preoperative treatment with a statin (atorvastatin)
  • Preoperative serum creatinine >2.0 mg/dL (not mentioned, but the patient's renal function should be carefully evaluated)
  • Diabetes (not explicitly mentioned, but the patient is taking Farxiga, which is used to treat type 2 diabetes)
  • High-risk type of surgery (robotic-assisted right anterior hip replacement is considered an intermediate-risk surgery) The patient's overall RCRI score should be carefully calculated to determine the risk of cardiac complications during the perioperative period 1.

From the FDA Drug Label

In ARISTOTLE, the results for major bleeding were generally consistent across most major subgroups including age, weight, CHADS2 score The safety of apixaban tablets has been evaluated in 1 Phase II and 3 Phase III studies including 5924 patients exposed to apixaban tablets 2. 5 mg twice daily undergoing major orthopedic surgery of the lower limbs Table 3: Bleeding During the Treatment Period in Patients Undergoing Elective Hip or Knee Replacement Surgery The efficacy profile of apixaban was generally consistent across subgroups of interest for this indication (e.g., age, gender, race, body weight, renal impairment).

The patient has atrial fibrillation, hypertension, heart failure with preserved EF due to nonischemic cardiomyopathy, history of mitral clip, severe tricuspid regurgitation, and hypothyroidism. The patient is taking Eliquis (apixaban), atorvastatin, Farxiga, levothyroxine, metoprolol XL, and Entresto.

Eliquis (apixaban) should be held before surgery due to the risk of bleeding. Farxiga may need to be held before surgery due to the risk of acute kidney injury. Lasix may need to be held before surgery due to the risk of dehydration and electrolyte imbalance.

The RCRI (Revised Cardiac Risk Index) conditions in this patient are:

• High-risk surgery (hip replacement)
• History of heart failure
• History of cerebrovascular disease (not explicitly mentioned, but the patient has atrial fibrillation, which increases the risk of stroke)
• Preoperative treatment with a sema (e.g. theophylline) or a beta-blocker (the patient is taking metoprolol XL)
• Preoperative serum creatinine >2.0 mg/dL (not mentioned, but the patient has nonischemic cardiomyopathy, which may affect kidney function) 2 2

From the Research

Medication Management

• The patient is taking Eliquis, atorvastatin, Farxiga, levothyroxine, metoprolol XL, and Entresto, and is undergoing robotic-assisted right anterior hip replacement surgery.
• The decision to hold Eliquis and Farxiga should be based on the patient's individual risk factors and the surgery type, as there is no direct evidence in the provided studies to support holding these medications specifically for this surgery type.
• The use of Lasix (furosemide) is not mentioned in the patient's current medication list, but it may be considered for patients with heart failure, as seen in the patient's medical history.

RCRI Conditions

• The Revised Cardiac Risk Index (RCRI) is a tool used to predict cardiac risk in patients undergoing non-cardiac surgery.
• The patient has several comorbidities, including atrial fibrillation, hypertension, heart failure with preserved ejection fraction due to non-ischemic cardiomyopathy, history of mitral clip, severe tricuspid regurgitation, and hypothyroidism, which may increase the cardiac risk.
• According to the RCRI, the patient's conditions that contribute to the risk score include:
  • History of heart failure
  • History of cerebrovascular disease (not mentioned in the patient's history)
  • High-risk type of surgery (e.g., thoracic, abdominal, or vascular surgery), but hip replacement surgery is considered intermediate-risk
  • Preoperative treatment with insulin (not mentioned in the patient's history)
  • Preoperative serum creatinine >2.0 mg/dL (not mentioned in the patient's history)

Study Findings

• The provided studies discuss the use of sacubitril/valsartan and dapagliflozin in patients with heart failure with reduced ejection fraction (HFrEF) 3, 4, 5, 6, 7.
• These studies suggest that both sacubitril/valsartan and dapagliflozin can improve outcomes in patients with HFrEF, and that the combination of these medications may offer additional benefits 7.
• However, these studies do not directly address the management of medications in the perioperative period for patients undergoing robotic-assisted hip replacement surgery.