When is it safe to pause a dose of medication?

When to Safely Pause Medication Doses

Medication doses should be paused based on specific clinical circumstances, with decisions guided by the medication type, patient condition, and procedure requirements, rather than arbitrarily stopping medications.

General Principles for Medication Pausing

Medication Categories and Pausing Guidelines

1. Disease-Modifying Antirheumatic Drugs (DMARDs):

   • For patients with rheumatic diseases exposed to SARS-CoV-2 or with mild COVID-19: EULAR recommends not pausing DMARDs 1
   • For severe COVID-19 requiring hospitalization: Decision to pause should be made by the treating physician in consultation with the rheumatologist 1
   • This differs from ACR guidelines which recommend pausing most DMARDs with COVID-19 exposure or infection 1

2. Glucocorticoids (GCs):

   • Should be continued in patients with rheumatic diseases who develop COVID-19 symptoms 1
   • Cannot be stopped abruptly due to risk of adrenal insufficiency
   • May require stress-dosing during severe illness 1

3. Non-Vitamin K Antagonist Oral Anticoagulants (NOACs):

   • For low bleeding risk procedures: Last dose 24 hours before procedure if normal kidney function 1
   • For high bleeding risk procedures: Last dose 48 hours before procedure if normal kidney function 1
   • Longer pausing periods needed with impaired renal function (see table below) 1
   • No bridging with LMWH/UFH recommended 1

Renal Function	Low Bleeding Risk	High Bleeding Risk
CrCl ≥80 mL/min	≥24h	≥48h
CrCl 50-79 mL/min	≥36h	≥72h
CrCl 30-49 mL/min	≥48h	≥96h
CrCl 15-29 mL/min	≥36h (dabigatran not indicated)	≥48h (dabigatran not indicated)

1. Proton Pump Inhibitors (PPIs):

   • Can be either tapered or abruptly discontinued when de-prescribing 1
   • Decision to discontinue should be based on lack of indication, not concerns about adverse effects 1

2. Preventive Migraine Medications:

   • Can be paused after 6-12 months of successful treatment 1
   • Purpose is to determine if preventive treatment can be stopped 1
   • Decision should be made on case-by-case basis 1

3. Potentially Nephrotoxic Medications:

   • Should be withdrawn before and after procedures involving iodinated contrast media in patients with GFR <60 mL/min/1.73m² 1
   • NSAIDs should be avoided in patients with GFR <30 mL/min/1.73m² 1

Medication Tapering vs. Abrupt Discontinuation

Some medications require gradual tapering rather than abrupt discontinuation:

1. Medications requiring tapering:

   • Glucocorticoids (risk of adrenal insufficiency)
   • Antidepressants (withdrawal symptoms)
   • Antiseizure medications (seizure risk)
   • Opioids (withdrawal syndrome)
   • Beta-blockers (rebound hypertension/tachycardia)

2. Tapering recommendations:

   • For most medications: Initial taper rate of 10-15% every 7 days 2
   • Slow to 5-10% reductions for final stages 2
   • For patients with history of severe withdrawal, long-term use, or anxiety disorders: 5-10% reduction every 2 weeks 2

Special Circumstances for Medication Pausing

1. Perioperative management:

   • Individualized based on bleeding risk of procedure and thrombotic risk of patient
   • For dental procedures with minor bleeding risk: No need to suspend NOACs 1

2. Interleukin-2 (IL-2) therapy:

   • Should be held if toxicity occurs and does not rapidly resolve with supportive measures 1
   • If one dose is held, can resume at next scheduled dose if patient recovers 1
   • If two consecutive doses are held, IL-2 should be permanently discontinued 1

3. Contrast studies:

   • Nephrotoxic agents should be withdrawn before and after procedures with contrast media in patients with reduced renal function 1

Common Pitfalls to Avoid

1. Abrupt discontinuation of medications requiring tapering (glucocorticoids, antidepressants, antiseizure medications)
2. Unnecessary pausing of DMARDs during mild COVID-19 infection
3. Inadequate pausing time for anticoagulants before high bleeding risk procedures
4. Failure to resume medications appropriately after procedures
5. Bridging anticoagulation when not indicated (increases bleeding risk without benefit)

Monitoring During Medication Pauses

1. Monitor for disease flares when DMARDs are paused
2. Watch for withdrawal symptoms when tapering medications
3. Assess for thrombotic risk when anticoagulants are paused
4. Monitor renal function after contrast procedures

Remember that medication pausing decisions should balance the risks of continuing medication against the risks of pausing it, with the ultimate goal of optimizing patient outcomes in terms of morbidity, mortality, and quality of life.