What preparations are needed for an adult patient with diabetes and/or on anticoagulant medications before arthroscopy?

Pre-Arthroscopy Preparation for Patients with Diabetes and/or Anticoagulation

For patients on anticoagulants undergoing arthroscopy, continue aspirin for all procedures, but discontinue P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) 7 days before surgery if at low thrombotic risk, and manage warfarin or DOACs based on thrombotic risk stratification with appropriate bridging when indicated. 1

Anticoagulation Management

Risk Stratification Framework

Arthroscopy should be considered a high-risk procedure for bleeding complications, similar to other invasive procedures requiring tissue manipulation. 1 This classification determines the anticoagulation management strategy.

Aspirin Management

• Continue aspirin through the perioperative period for all patients, regardless of whether it is for primary or secondary prevention 1
• Aspirin continuation does not significantly increase bleeding risk in most orthopedic procedures 1

P2Y12 Inhibitor Management (Clopidogrel, Prasugrel, Ticagrelor)

For patients at LOW thrombotic risk:

• Discontinue P2Y12 inhibitors 7 days before arthroscopy 1
• Continue aspirin if patient is on dual antiplatelet therapy 1
• Restart P2Y12 inhibitor 1-2 days after procedure depending on hemostasis 1

For patients at HIGH thrombotic risk (drug-eluting stent <12 months, bare metal stent <1 month, prosthetic heart valve):

• Continue aspirin and consult with interventional cardiologist before discontinuing P2Y12 inhibitors 1
• The decision requires balancing thrombotic versus bleeding risk 1

Warfarin Management

For patients at LOW thrombotic risk:

• Stop warfarin 5 days before arthroscopy 1
• Check INR prior to procedure to ensure <1.5 1
• Restart warfarin evening of procedure with usual daily dose 1
• Check INR 1 week later to ensure adequate anticoagulation 1

For patients at HIGH thrombotic risk (prosthetic metal heart valve, AF with mitral stenosis, recent VTE <3 months):

• Stop warfarin 5 days before procedure 1
• Start LMWH bridging 2 days after stopping warfarin 1
• Check INR prior to procedure to ensure <1.5 1
• Restart warfarin evening of procedure 1
• Continue LMWH until INR therapeutic 1

Direct Oral Anticoagulant (DOAC) Management

For patients at LOW thrombotic risk:

• Take last dose of DOAC 3 days (72 hours) before arthroscopy 1
• For dabigatran with CrCl 30-50 mL/min, extend to 72 hours before procedure 1
• Omit morning dose on day of procedure 1

For patients at HIGH thrombotic risk:

• Take last dose of DOAC at least 48-72 hours before procedure 1
• Consider hematology consultation for complex cases 1
• In patients with rapidly deteriorating renal function, consult hematologist 1

Diabetes Management

Pre-operative Assessment

• Optimize glycemic control before elective arthroscopy to minimize infection risk and improve wound healing 2
• Address modifiable risk factors including obesity, poor glycemic control, and malnutrition 2

Perioperative Considerations

• Patients with diabetes have increased risk of complications including infection and delayed healing 2
• Age >60 years increases complication risk (AOR 3.47) in arthroscopic procedures 3
• Surgical time >90 minutes increases complication risk (AOR 1.93) 3

Warfarin-Diabetes Interaction

• HSA glycation in diabetes affects warfarin binding and pharmacokinetics, potentially requiring closer INR monitoring 4
• Diabetic patients may have altered anticoagulant efficacy compared to non-diabetic patients on warfarin 4
• Consider more frequent INR checks in diabetic patients on warfarin perioperatively 4

Critical Timing Considerations

• Resume anticoagulation within 24-48 hours post-procedure depending on bleeding and thrombotic risk 1
• Earlier resumption (24 hours) for high thrombotic risk patients with adequate hemostasis 1
• Delayed resumption (48 hours) if ongoing bleeding concerns 1

Common Pitfalls to Avoid

• Do not routinely stop aspirin - this increases thrombotic risk without meaningful bleeding reduction 1
• Do not bridge DOACs with LMWH - bridging is only indicated for warfarin in high-risk patients 1
• Do not assume all arthroscopy is low-risk - procedures >90 minutes or with extensive tissue manipulation carry higher bleeding risk 3
• Ensure coordination between surgical and cardiology teams for patients with recent coronary stents 1

Patient Counseling

• Advise all patients of increased post-procedure bleeding risk compared to non-anticoagulated patients 1
• Discuss thrombotic risks of discontinuing anticoagulation as well as hemorrhagic risks of continuing therapy 1
• Ensure patients understand timing of medication cessation and resumption 1