Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
1 Preoperative Testing and Medication Management I. Preoperative Testing and Workup for Non-Cardiac Procedures a. Preoperative Management II. Preoperative Medication Management a. Medication Specific Recommendations by Class i. Anticoagulants/Antithrombotics Medications ii. Antidepressants iii. Cancer Medications iv. Cardiovascular and Antihypertensives v. Corticosteroids and Glucocorticoids vi. Diabetes Medications vii. Disease Modifying Antirheumatic Drugs (DMARD) viii. Gastrointestinal Medications ix. Genitourinary Medications x. Herbal Agents xi. Hormonal Medications xii. Investigational Medications xiii. Pulmonary Medications xiv. Substance Abuse xv. TNF alpha Inhibitors xvi. Miscellaneous Other Medications III. Additional Perioperative Recommendations, Considerations, and Guidelines a. b. c. d. e. f. g. h. i. j. k. Indications for Electrocardiography Based on Cardiac Risk OSU Preoperative Assessment Center/Preadmission Test (OPAC/PAT) Carotid Bruit Algorithm Preoperative Testing Grid Management of Obstructive Sleep Apnea (OSA) Management of Antiplatelet Therapy in Patients with Arterial Stents Perioperative / Periprocedure Glucose Management Blood Type and Cross with appropriate allocation per Surgical Blood Order Schedule (SBOS) Prevention of Surgical Site Infections (SSIs) with Antimicrobial Prophylaxis Antibiotic Prophylaxis for Infective Endocarditis Deep Venous Thrombosis (DVT) - Prevention Anticoagulation Reversal i. Dabigatran (Pradaxa) Reversal Treatment for Bleeding Events ii. Rivaroxaban, Apixaban: Factor Xa Inhibitors - Reversal Treatment for Bleeding iii. Warfarin - Management of Elevated INR and Reversal l. Inpatient Tobacco Cessation Clinical Protocol m. Contrast Induced Neuropathy Disclaimer Clinical practice guidelines and algorithms at The Ohio State University Wexner Medical Center (OSUWMC) are standards that are intended to provide general guidance to clinicians. Patient choice and clinician judgment must remain central to the selection of diagnostic tests and therapy. OSUWMC’s guidelines and algorithms are reviewed periodically for consistency with new evidence; however, new developments may not be represented. Copyright © 2017. The Ohio State University Wexner Medical Center. All rights reserved. No part of this document may be reproduced, displayed, modified, or distributed in any form without the express written permission of The Ohio State University Wexner Medical Center. 2 Preoperative Testing and Medication Management for Non-Cardiac Surgical Procedures Preoperative Evaluation • • • A preoperative evaluation must be done within 30 days before a surgical procedure. History and physical examination information must be reviewed and updated within 24 hours of admission or registration and prior to the planned surgical procedure. The preoperative evaluation is not a substitute for preventive health care but may be used as an opportunity to address preventive services. Medical History • Indication(s) for the surgical procedure o Allergies and adverse medication reactions o It is most helpful to specify the approximate date, the type of reaction, the treatment, the response, and if the agent was subsequently taken. • Current medications including prescriptions, over-the-counter, and herbal and dietary supplements o Specify the generic and brand name, specific preparation (tablet, capsule, liquid), dose in each unit, route by which the agent is taken (oral, feeding tube, transdermal), number of units taken, and time(s) of day taken. o Pay special attention to high-risk medications including opioids, diabetes medications, antihypertensives, anticoagulants (warfarin, heparins, antiplatelet medications), and oral cancer/chemotherapy medications. • • • Medical problems, including current status o Use the IHIS Problem List o Pay special attention to sleep apnea risk, abnormal airway, recent stroke or heart attack and intravascular stents Factors that increase infection risk o Skin disease (e.g., open lesions) o Diabetes mellitus o Malnutrition o Smoking Thorough evaluation of issues relevant to the planned procedure and anesthesia: o History of anesthesia complication, personal and family (e.g., obstructive sleep apnea, malignant hyperthermia) o Cardiac and pulmonary function o o o Functional capacity History of clotting or bleeding abnormality, personal and family History of tobacco, alcohol, drug use Physical Examination • • • • • • • Height, weight, and body mass index (BMI) Vital signs: o Blood pressure o Pulse (rate and rhythm) o Respiratory rate Airway assessment Pulmonary Cardiovascular Neurologic Other findings pertinent to the patient and the procedure Preoperative Risk Assessment • The American Society of Anesthesiology (ASA) classification is a global impression of the clinical state of a patient based upon all available history, physical examination findings, and laboratory data (Table 1 on page 3). • Document ASA class, as it is a robust predictor of perioperative complications. • Determine the perioperative cardiac risk based on the type of procedure planned (Table 2 on page 3). • See page 4 for a more detailed algorithm on cardiac risk. (The algorithm addresses ordering electrocardiography and scoring cardiac risk.) Preoperative Testing • Laboratory and diagnostic tests are not routinely necessary unless there is a specific patient or procedural indication. Nothing by Mouth (NPO)* Type Clear Liquid Light Meal Full Meal Infant Formula/Non-Human Milk Breast Milk Tube Feeds Duration 2 hours 6 hours (A light meal consists of dry toast and clear liquids) 8 hours 6 hours 4 hours 6 hours *Recommendations for generally healthy patients who undergo elective procedures. Not recommended for women in labor. Reference: Anesthesiology 3 2011, Vol.114, 495-511. doi:10.1097/ALN.0b013e3181fcbfd9 3 Preoperative Testing and Medication Management for Non-Cardiac Surgical Procedures Table 1: American Society of Anesthesiologists' (ASA) Physical Status Classification ASA ASA I Definition A normal healthy patient Table 2: Cardiac Risk by Surgical Procedure Examples, including, but not limited to: HIGH RISK >5% Healthy, non-smoking, no or minimal alcohol use Aortic and other major vascular surgical procedures Emergent major operations, particularly in older adults (especially those >75 years of age) Peripheral vascular surgical procedures ASA II A patient with mild systemic disease Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (30 < BMI < 40), well-controlled DM/HTN, mild lung disease Major cardiac and thoracic surgical procedures Anticipated prolonged surgical procedures associated with large fluid shift and/or blood loss INTERMEDIATE RISK 1-5% Carotid endarterectomy Non-major head and neck surgery / procedures ASA III A patient with severe systemic disease Substantive functional limitations; One or more moderate to severe diseases. Examples include (but not limited to): poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant PCA < 60 weeks, history (>3 months) of MI, CVA, TIA, or CAD/stents. ASA IV A patient with severe systemic disease that is a constant threat to life Examples include (but not limited to): recent ( < 3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis ASA V A moribund patient who is not expected to survive without the operation Examples include (but not limited to): ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction ASA VI A declared brain-dead patient whose organs are being removed for donor purposes Reference: American Society of Anesthesiologists' (ASA) Physical Status Classification/1991 is reprinted with permission of the American Society of Anesthesiologists, 1061 American Lane, Schaumburg, Illinois 60173-4973 Non-major intraperitoneal and intrathoracic surgery / procedures Orthopedic surgical procedures Prostate surgical procedures Urologic surgical procedures LOW RISK <1% Biopsies and superficial procedures (e.g., breast biopsy) Endoscopic procedures Cataract surgery / ophthalmologic procedures Breast surgery Minor prostate procedures (e.g., cystoscopy) 4 Indications for Electrocardiography Based on Cardiac Risk Preoperative history and physical examination Note: If the past medical history shows the patient has a medical issue which would indicate the appropriateness of an EKG (and this can be seen on the chart review before the provider does their own history and physical) consider obtaining an EKG Signs or symptoms of cardiovascular disease? Electrocardiography* YES NO Low risk surgery** (risk < 1%) Electrocardiography NOT Indicated Intermediate risk surgery** (risk 1-5%) At least one RCRI*** clinical risk factor? NO High-risk surgery** (risk > 5%) Electrocardiography* YES *ECG is valid for 6 months if patient is clinically stable **Please refer to Table 2 on page 3 for cardiac risk by procedure ***RCRI = Revised Cardiac Risk Index (see below) Risk Factor Points History of stroke or transient ischemic attack (TIA) 1 History of MI, CABG, or PTCA 1 Heart failure 1 Serum creatinine level > 2.0mg/dL 1 Diabetes mellitus requiring insulin Major vascular, intrathoracic, intra-abdominal, or intracranial procedure 1 1 Revised Cardiac Risk Index (RCRI)*** Points Risk % 0 0.4 1 0.9 2 6.6 >3 >11 RCRI Source: Lee, T.H. Lee, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery Circulation, 100 (1999), pp. 1043–1049 5 OPAC/PAT Carotid Bruit Algorithm This algorithm is for patients who have a carotid bruit discovered during preoperative examination. First, determine if the patient has had stroke/TIA symptoms in the previous 9 months. Examples of stoke/TIA symptoms include, but are not limited to: ○ Shade coming down over the eye or other sudden vision change ○ Sudden confusion or difficulty talking ○ Sudden loss of balance or difficulty walking ○ Sudden focal weakness or loss of dexterity If the patient has had stroke/TIA symptoms in the previous 9 months, and, if there is no contraindication, then ensure they are taking aspirin 81mg PO daily. Next, obtain carotid duplex ultrasound within the previous 6 months. ○ OSUWMC order “vasc duplex carotid bilateral” Result of carotid duplex ultrasound < 50% internal carotid stenosis 70-99% internal carotid stenosis (both sides) (either side) Asymptomatic OK for surgery/procedure Symptomatic Refer to Endovascular Neurosurgery OR Vascular Surgery at the preference of the referring physician. Consider atrial fibrillation as well as other causes and consult Cardiology, Stroke Neurology, or “Neurovascular/ Stroke Neurosurgery” as indicated. 50-69% internal carotid stenosis (one or both sides, but no more than 69% either side) Asymptomatic OK for surgery/procedure Refer to Endovascular Neurosurgery OR Vascular Surgery at the preference of the referring physician. Symptomatic Refer to Endovascular Neurosurgery OR Vascular Surgery at the preference of the referring physician. Preoperative Testing Grid Timing Prior to Procedure OPAC/ PAT¹ ECG 30 days 6 mos 2 CXR 1 yr CBC Ediff Plt 6 wks Coagulation Tests 6 4 T&C INR/PT PTT 30 days DOS DOS X Hgb A1c Chem 6 4 wks 6 wks K+ LFTs DOS² 6 wks UA Total MRSA/ TSH, with MSSA Free T4 Reflex to Screen7 Culture 6 wks 6 wks 6 wks HCG UCG DOS 3 Medical Condition or Current Treatment Anemia Anesthesia complications (history) Atrial fibrillation (current or paroxysmal) Bleeding dis order Chemotherapy ( recent < 6 months ) CNS disease Acute or symptomatic heart failure Coronary artery disease and planned intermediate- or highrisk surgery (see page 3 of guideline) Diabetes mellitus (DM) or DM risk ESRD (on dialysis) Factor deficiency Functional capacity (poor, < 4 mets ) Hepatic (liver) disease Hypertension (poorly controlled) Hyperthermia (malignant) Immigrant (recent, < 2 years) Intubation difficulty in the past or at high ris k for difficulty Cachexia (Malabsorption and/or malnutrition) Malignancy (current) Muscular dystrophy Nausea and vomiting (severe or active) Neck mobility poor or unable to open mouth (trismus) Obesity (morbid, BMI > 40 kg/m 2) Pacer/ICD Premenopausal unless S/P TAH and/or BSO Pulmonary disease-symptomatic Radiation therapy to chest (history) Radiation therapy to neck (history) and not taking thyroid replacement Renal Ins ufficiency (not on dialysis) Rheumatoid arthritis (receiving treatment) Scoliosis/Kyphosis (moderate to severe) Sickle cell anemia Sleep apnea or risk for sleep apnea 5 Stroke (CVA/TIA), History of Thrombocytopenia Upper airway or mediastinal les ion Venous thromboembolism (DVT, PE) (recent < 6 months) X X X X X X X X X X X X X X X X X X X X X X X X X X DOS DOS X X DOS X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X DOS X X X X X X X X X X X X X X X X X X X X X X X X X X X X ¹ Appropriate for OPAC/PAT visit if also has ASA score of 3-4 ² PA & Lateral CXR or equivalent radiologic examination 3 DOS = Day of Surgery 4 See Surgical Blood Order Schedule (SBOS) for maximum recommended blood volume per procedure 5 See OSUWMC Obstructive Sleep Apnea guideline 6 Also refer to surgeon’s preference list 7 If MRSA/MSSA Screen positive, order mupirocin/bactroban Preoperative screening and laboratory testing is unwarranted and may be harmful unless the patient has a specific clinical indication. DOS X 7 Preoperative Testing Grid OPAC/ PAT¹ Timing Prior to Procedure 2 ECG CXR 30 days 6 mos 1 yr CBC Coagulation Tests Ediff Plt T&C 6 wks INR/PT 30 days X DOS PTT 4 Hgb A1c Chem 6 4 wks 6 wks K+ LFTs DOS² 6 wks UA Total MRSA/ HCG TSH, with MSSA Free T4 Reflex to 7 UCG Screen Culture 6 wks 6 wks 6 wks X X X X X X X Medication History Coumadin/ Warfarin Digoxin Diuretic X X X X X Dabigatran X Rivaroxaban Apixaban/edoxaban Anticipated IV contrast for procedure X X DOS DOS PTT/TT DOS DOS X 6 Types of Procedures Major vascular, peripheral vascular-including carotid Craniotomy Head/Neck surgery-major Major cerebral vascular Open abdominal cases Orthopedic surgery-major Procedures with anticipated EBL > 500 mL Prolonged procedures with major fluid shifts and/or blood loss Spine surgery-major Thoractomy/lung resection/VATS X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X ¹ Appropriate for OPAC/PAT visit if also has ASA score of 3-4 ² PA & Lateral CXR or equivalent radiologic examination 3 DOS = Day of Surgery 4 See Surgical Blood Order Schedule (SBOS) for maximum recommended blood volume per procedure 5 See OSUWMC Obstructive Sleep Apnea guideline 6 Also refer to surgeon’s preference list 7 If MRSA/MSSA Screen positive, order mupirocin/bactroban Preoperative screening and laboratory testing is unwarranted and may be harmful unless the patient has a specific clinical indication. X DOS3 8 Perioperative Medication Management by Class Limited clinical trials data are available to guide medication management in the perioperative period. Therefore, perioperative medication management is largely based on estimating the risks and benefits of either continuing or discontinuing the medication and the urgency of the surgery or procedure being performed. Management must be tailored to the specific patient and procedure and should be based upon: • The patient’s medication allergies and prior adverse reactions • The patient’s medical problems/comorbidities • The specific procedure being performed including anesthesia/analgesia management (e.g. neuraxial anesthesia). • For specific recommendations on antiplatelets and anticoagulants with regional anesthesia while the catheter is in place and post-catheter removal see Appendix A. Anticoagulant/Antithrombotics Consider the procedure and need for neuraxial anesthesia when planning perioperative medication management. Oral Anticoagulant/Antithrombotic Medications • Restart time depends on the procedure and risk for bleeding Class aspirin Do not hold* clopidogrel (Plavix®)1,2 5 - 7 days * Prior to Procedure Minimum recommended time between last dose of antithrombotic and neuraxial catheter placement Patient- and procedurespecific decision should be made with patient and care team. 7 days prasugrel (Effient®)1,3 7 days* 10 days ticagrelor (Brilinta®)1,4 5 days* 5 days vorapaxar (Zontivity®) 40 - 50 days Elective procedures with a low bleeding risk CrCl > 80 mL/min: > 24 hours Contraindicated Examples 1 Antiplatelet medications Minimum Recommended Holding Time Additional Considerations Before holding any of these medications see OSUWMC Management of Antiplatelet Therapy in Patients with Arterial Stents Around the Time of Surgeries and Procedures guideline CrCl 50 – 79 mL/min: > 36 hours CrCl 30 – 49 mL/min: > 48 hours CrCl 15 – 29 mL/min: > 72 hours Direct Thrombin Inhibitor ® 5 dabigatran (Pradaxa ) CrCl <15 mL/min: > 96 hours and normal PTT and TT Procedures at moderate - high bleeding risk CrCl > 80 mL/min: > 48 hours CrCl > 15 mL/min: 5 days CrCl < 15 mL/min: 6 days Depending on indication for anticoagulation, risk of bleeding with the procedure and renal function patient may require longer holding time and/or bridging. Check PTT or TT to verify CrCl 50 – 79 mL/min: > 72 hours CrCl 30 – 49 mL/min: > 96 hours CrCl 15 – 29 mL/min: > 120 hours CrCl <15 mL/min: > 120 hours and normal PTT and TT *Patient- and procedure-specific decision should be made with patient and care team whether to hold medication. A Consider the procedure and need for neuraxial anesthesia prior to holding anticoagulation medications. 9 Oral Anticoagulant/Antithrombotic Medications (Continued) • Restart time depends on the procedure and risk for bleeding Class Minimum Recommended Holding Time Examples Elective procedures with a low bleeding risk CrCl > 30 mL/min: > 24 hours apixaban (Eliquis®)5 Prior to Procedure Minimum recommended time between last dose of antithrombotic and neuraxial catheter placement CrCl > 30 mL/min: 3 days CrCl < 30 mL/min: 5 days CrCl 15 – 29 mL/min: > 36 hours Factor Xa Inhibitors ® 5 rivaroxaban (Xarelto ) 5 edoxaban (Savaysa®) CrCl <15 mL/min: > 48 hours Procedures at moderate - high bleeding risk CrCl > 30 mL/min: > 48 hours Additional Considerations CrCl > 50 mL/min: 3 days CrCl < 50 mL/min: 5 days Depending on indication for anticoagulation, risk of bleeding with the procedure and renal function patient may require longer holding time and/or bridging. CrCl < 30 mL/min: > 72 hours celecoxib (Celebrex®) ibuprofen (Motrin®, Advil®) NSAIDs ® meloxicam (Mobic ) No need to hold dose If holding other antiplatelets or anticoagulants, hold NSAID concurrently naproxen (Aleve®, Naproxyn®) Phosphodiesterase Inhibitors Vitamin K Antagonist If the decision is made to hold, the time to hold should be based upon 5 halflives of specific NSAID. Contact Pharmacy for assistance. See Appendix A cilostazol (Pletal®) dipyridamole-aspirin (Aggrenox®) dipyridamole (Persantine®) Do not hold 48 hours* Do not hold* 7 days Do not hold 48 hours* pentoxifylline (Trental®) Do not hold Do not hold warfarin (Coumadin®, Jantoven®)*5,6 0 - 5 days* 5 days, normalization of INR Discontinue NSAID 5 days prior to surgical procedure if not on any other antiplatelet or anticoagulant. Depending on indication for anticoagulation and risk of bleeding with the procedure the holding time may vary and bridging may be required. Check INR to verify. Do not use Point-ofcare. *Patient- and procedure-specific decision should be made with patient and care team whether to hold medication. A Consider the procedure and need for neuraxial anesthesia prior to holding anticoagulation medications. 10 Intravenous or Subcutaneous Anticoagulant/Antithrombotic Medications • Restart time depends on the procedure and risk for bleeding Class Minimum Recommended Holding Time Examples unfractionated heparin (UFH) - subcutaneous 5000 units q12h 3 - 4 hours 3 - 4 hours 3 - 4 hours 5000 units q8h 7500 units q8h 24 hours ® dalteparin (Fragmin ) prophylaxis 12 hours ® Heparin and related medications6 enoxaparin (Lovenox ) therapeutic 24 hours enoxaparin (Lovenox®) prophylaxis 12 hours Outpatients: 8 hours CrCl ≤ 30mL/min: 48 hours CrCl > 30mL/min: 12 hours CrCl ≤ 30mL/min: 24 hours CrCl > 30 mL/min: 24 hours CrCl < 30 mL/min: 72 hours CrCl > 30 mL/min: 12 hours CrCl < 30 mL/min: 72 hours CrCl > 50 mL/min: 4 days ® fondaparinux (Arixtra ) therapeutic 3 days fondaparinux (Arixtra®) prophylaxis 48 hours unfractionated heparin (UFH) – infusion Additional Considerations 8 hours 8 hours CrCl > 30mL/min: 24 hours ® dalteparin (Fragmin ) therapeutic Prior to Procedure Minimum recommended time between last dose of antithrombotic and neuraxial catheter placement Inpatients: No time restriction. Consider the peak effect of subcutaneous heparin at 2 hours when placing catheter. Consider LMWH anti-Xa level to assess level of anticoagulation CrCl ≤ 50 mL/min: 5 days CrCl > 50 mL/min: 3 - 4 days CrCl < 50 mL/min: 4 days Hold 4-6 hours prior to procedures 4 hours if normal PTT Verify PTT is normal Heparin should be resumed at the discretion of the surgeon/ medical team when postoperative hemostasis deemed to be adequate Rate > 1.5 mcg/kg/min hold 6 hours and recheck PTT Argatroban7 Rate 0.5 - 1.5 mcg/kg/min - hold 8 hours and recheck PTT Rate < 0.5 mcg/kg/min hold for 12 hours and recheck PTT If neuroaxial anesthesia is needed, decision should be based upon discussion with the Anesthesiologist, surgical team, and pharmacy specialist *Hepatic and/or renal insufficiency may need to hold longer CrCl >60 mL/min: Hold for 2 - 4 hours and recheck PTT Direct Thrombin Inhibitor bivalirudin (Angiomax®)8 CrCl 10 – 60 mL/min: Hold for 4 - 6 hours and recheck PTT See Bivalirudin Dosing and Monitoring Guide See Argatroban Dosing and Monitoring Verify PTT is Normal If neuroaxial anesthesia is needed, decision should be based upon discussion with the Anesthesiologist, surgical team, and pharmacy specialist Intermittent HD offdialysis: (May need to hold longer) desirudin (Iprivask®) 24 hours 24 hours if normal PTT Depending on indication may require longer holding time and/or bridging. 11 Intravenous or Subcutaneous Anticoagulant/Antithrombotic Medications (Continued) Class 12 hours Prior to Procedure Minimum recommended time between last dose of antithrombotic and neuraxial catheter placement 5 days 4 hours 24 hours Minimum 48 hours for emergency procedures No need to hold dose Minimum 48 hours for emergency procedures No need to hold dose Minimum Recommended Holding Time Examples ® 9 abciximab (Reopro ) eptifibatide (Integrilin®)10 Antiplatelets tirofiban (Aggrastat®)11 Therapeutic Alteplase ® (TPA ) Catheter Clearance Thrombolytic Additional Considerations Platelet function may remain abnormal for up to 7 days post abciximab infusion due to irreversible platelet inhibition. *Patient- and procedure-specific decision should be made with patient and care team whether to hold medication. A Consider the procedure and need for neuraxial anesthesia prior to holding anticoagulation mediations. Antidepressants Class Monoamine Oxidase Inhibitors (MAOIs) Selective Serotonin Reuptake Inhibitors (SSRIs) Selective Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) Class Examples phenelzine (Nardil®) selegiline (Emsam®) sertraline (Zoloft®) paroxetine (Paxil®) citalopram (Celexa®) duloxetine (Cymbalta®) Milnacipran (Savella®) Venlafaxine (Effexor®) Examples amitriptyline (Elavil®) Tricyclic Antidepressants doxepin (Sinequan®) imipramine (Tolfranil®) Lithium Benefits of Continuation Maintain control of psychiatric symptoms Risks of Continuation Can cause hypertensive crisis when used with sympathomimetics. Continue Can cause neuroleptic malignant syndrome when used with meperidine. Maintain control of psychiatric symptoms Avoid withdrawal syndrome Increased bleeding risk due to inhibition of platelet aggregation Maintain control of psychiatric symptoms Avoid withdrawal syndrome Increased bleeding risk due to inhibition of platelet aggregation Benefits of Continuation Risks of Continuation Maintain control of psychiatric symptoms Avoid withdrawal syndrome Maintain control of psychiatric symptoms Avoid withdrawal syndrome Usual Management Continue Continue Additional Considerations Clearly document to avoid both drug and food interactions during the procedure and hospitalization. Requires low tyramine diet. SSRI need to be discontinued for up to 3 weeks to be out of the system and clinical benefit may not occur for several weeks after reinitiating. Use methylene blue with caution because of risk of serotonin syndrome SNRI need to be discontinued for up to 3 weeks to be out of the system and clinical benefit may not occur for several weeks after reinitiating. Use methylene blue with caution because of risk of serotonin syndrome May increase risk of arrhythmia in combination with some volatile anesthetics or sympathomimetics. May increase risk for prolongation of muscle relaxant effects. May increase risk for nephrogenic diabetes insipidus and thyroid dysfunction. Usual Management Additional Considerations Continue Continue Consider checking free T4 and TSH prior to the procedure. Monitor fluid balance and check electrolytes frequently. *Patient- and procedure-specific decision should be made with patient and care team whether to hold medication. 12 Cancer Medications * Class Examples Minimum Recommended Holding Times Additional Considerations At least 4 weeks prior to the procedure per the package insert, although based on pharmacokinetics, at least 6 weeks is desired in most cases Wait at least 4 weeks postoperatively or until wound is healed to start ® bevacizumab (Avastin ) ramucirumab (Cyramza®) VEGF Inhibitor ziv-Aflibercept (Zaltrap®) regorafenib (Stivarga®) 2 weeks ® axitinib (Inlyta ) 24 hours ® cabozantinib (Cometriq ) 28 days ® Tyrosine Kinase Inhibitors ibrutinib (Imbruvica ) 3 - 7 days olaratumab (Lartruvo®) No data Consult Clinical Pharmacy Specialist ® pazopanib (Votrient ) 7 days Hold ibrutinib 3 - 7 days after the procedure depending on the risk of bleeding with the procedure ® ponatinib (Iclusig ) 7 days sorafenib (Nexavar®) 6 days sunitinib (Sutent®) Asparaginase derivative Consider holding these medications based upon the indication for the medication, procedure, and risk for wound healing. 2 - 3 weeks Fibrinogen should be checked preoperatively if given within 4 weeks of the procedure. For fibrinogen < 100 mg/dL consider cryoprecipitate. pegaspargase (Oncaspar) Cancer/Immunomodulation Medications * Class Minimum Recommended Holding Time Minor Surgery: Stop 1 day before Examples Lenalidomide (Revlimid®) Immunomodulator (IMiDs) Pomalidomide (Pomalyst®) ® Thalidomide (Immunoprin ) Ortho, GI or GU Surgery: Stop 1 week before Risks of Continuation Wound healing, bleeding to secondary to thrombocytopenia/concurrent anticoagulation, increased risk of thrombosis if aspirin/anticoagulant Additional Considerations* Minor Surgery: Resume at least 7 days after surgery Ortho, GI or GU Surgery: Follow up with Multiple Myeloma physician before resuming *Discontinuation/continuation or holding times for procedures must be determined by the attending physician for each case 13 Cardiovascular and Antihypertensives Class Benefits of Continuation Examples Risks of Continuation Usual Management Additional Considerations* aliskiren ® (Tekturna ) candesartan cilexetil (Atacand®) enalapril (Vasotec®) irbesartan (Avapro®) ACE Inhibitors, ARBs, Neprilysin inhibitor/ARB, and Renin Inhibitors12 lisinopril (Zestril®, Prinivil®) Blood pressure control Intraoperative hypotension Hold 24 hours prior to surgical procedure Hypotension Continue Hypotension Continue losartan (Cozaar®) quinapril (Accupril®) ramipril (Altace®) valsartan (Diovan®) sacubitrilvalsartan ® (Entresto ) doxazosin (Cardura®) Alpha Blocker ® Blood pressure control terazosin (Hytrin ) tamsulosin (Flomax®) Less postoperative urinary retention clonidine ® (Catapress ) Blood pressure and heart rate control methyldopa (Aldomet®) Avoid withdrawal syndrome Alpha 2 Agonists amiodarone (Cordarone®) dronedarone (Multaq®) Antiarrhythmics dofetilide (Tikosyn®) Suppress arrhythmia Induce arrhythmia Continue QT prolongation sotalol (Betapace®, Betapace AF®) metoprolol (Lopressor®, Toprol XL®) Beta-Blockers13 carvedilol (Coreg®) atenolol (Tenormin®) bisoprolol (Zebeta®, Ziac®) Consider obtaining baseline preoperative 12-lead ECG in patients with changes in renal function (sotalol, dofetilide). Consider monitoring potassium and magnesium (sotalol and dofetilide). Minimize medications that prolong QT interval. * All patients receiving IV antiarrhythmic therapy must be continuously monitored on telemetry If beta-blocker is combined with thiazide diuretic, e.g. atenolol-chlorthalidone, then treat as a beta-blocker and usually continue. Less cardiac ischemia Blood pressure and heart rate control Avoid withdrawal syndrome Hypotension Continue Bradycardia Ideally, initiation of betablocker therapy should be long enough in advance to assess safety and tolerability before surgery. 14 Cardiovascular and Antihypertensives (continued) Class Benefits of Continuation Examples Risks of Continuation Usual Management Additional Considerations* Dihydropyridine: amlodipine (Norvasc®) Blood pressure nifedipine (Procardia®, Adalat®) Calcium Channel Blockers Heart rate control ® felodipine (Plendil ) Nondihydropyridine: diltiazem (Cardizem®) verapamil (Calan®, Isoptin®) Digoxin Ivabradine Hypotension – some of these drugs have a long half- life digoxin (Lanoxin®) ivabradine (Corlanor®) Blood pressure Hypotension Heart rate control Bradycardia Lower heart rate Induce arrhythmia Less heart failure Toxicity Lower heart rate Induce arrhythmia Continue If blood pressure or heart rate is too low, then hold 24 hours prior to surgical procedure. Continue Consider obtaining digoxin level prior to surgical procedure. Consider obtaining potassium and magnesium prior to surgical procedure. Continue chlorthalidone (Thalitone®) furosemide (Lasix®) torsemide (Demadex®) Hypotension bumetanide (Bumex®) Diuretics hydrochlorothiazide (Mircozide®) Hypokalemia Avoid fluid overload Hyperkalemia Do not take on day of procedure Hyponatremia metolazone (Zaroxolyn®) Hypernatremia Continue diuretics in diureticdependent heart failure patients. If a thiazide diuretic is combined with a betablocker, e.g. atenololchlorthalidone, then treat as a beta-blocker and usually continue. spironolactone (Aldactone®) triamterene/hydroc hlorothiazide (Dyazide®, Maxzide®) isosorbide dinitrate (Isordil®) Nitric Oxide Vasodilators isosorbide mononitrate (Imdur®) hydralazine (Apresoline®) Continue Blood pressure Hypotension Angina control Do not take on day of procedure minoxidil (Loniten®) Hyperkalemia Potassium potassium chloride ® ® (K-Dur , Klor-con ) Avoid hypokalemia Irritation of esophagus or stomach Do not take on day of procedure Consider risks of hypotension versus hypertension when making decisions to either give or hold antihypertensives If the patient will be receiving a diuretic, then continue potassium. 15 Cardiovascular and Antihypertensives (continued) Class Examples Benefits of Continuation Risks of Continuation Usual Management Additional Considerations* atorvastatin ® (Lipitor ) pravastatin (Pravachol®) Statin rosuvastatin (Crestor®) Lower risk of thrombotic stroke and myocardial infarction Rhabdomyolysis Continue simvastatin ® (Zocor ) Cholestyramine ® (Questran ) ezetimibe (Zetia®) Non-Statin LipidLowering Medications fenofibrate (Tricor®) gemfibrozil (Lopid®) Cholestyramine can sequester other medications Fibrate-induced rhabdomyolysis Niacin-induced vasodilation and itching Do not take on day of procedure niacin (Niaspan®) Fish oil (> 3 grams/day) Increased risk of bleeding Hold for 7 days prior to procedure May consider continuing in patients treated for very high triglycerides. *Patient- and procedure-specific decision should be made with patient and care team whether to hold medications Corticosteroids and Glucocorticoids • For relative potencies of corticosteroids please see the OSUWMC Pharmacy Intranet site ® ® ® • Examples: prednisone (Deltasone ), methylprednisolone (Medrol , Medrol Dosepak ), dexamethasone ® (Decadron ) o Plan for stress dose in patients who have been taking immunosuppressants or immunomodulators for an extended period of time. • If receiving steroids for transplant immunosuppression, consider consulting transplant team for specific recommendations This table applies to patients with adrenal suppression caused by exogenous steroids. For patients with endogenous adrenal failure consult the patient’s endocrinologist for steroid management. (Note: patients with primary adrenal insufficiency will require mineralocorticoids perioperatively with oral fludrocortisones, higher doses of hydrocortisone, or liberal use of saline solutions) Dose/Duration of Corticosteroid Less than 3 weeks duration Adrenal Reserves Usual Choice Additional Considerations* Likely has adequate cortisol reserves in adrenal glands Continue usual dose of corticosteroid on the morning of the procedure and afterwards For hypotension unresponsive to intravenous fluid boluses treat with hydrocortisone sodium succinate (Solu-Cortef®, A-Hydrocort®) 50-75 mg IV Q8H x3 during postoperative period or equivalent alternate corticosteroid Dose equivalent to 5 - 20 mg/day prednisone for more than 3 weeks May or may not be adequate reserve cortisol in adrenal glands Adrenal reserves testing is expensive, time consuming and unreliable in this setting. Most patients will not need “stress dose” corticosteroids and should continue usual doses of corticosteroids on the morning of the procedure and afterwards. However, for major procedures consider hydrocortisone sodium succinate (Solu-Cortef®, A-Hydrocort®) 5075mg IV Q8H x3 during postoperative period or equivalent alternate corticosteroid If patient has not received stress dose corticosteroids and develops hypotension unresponsive to intravenous fluid boluses treat with hydrocortisone sodium succinate (Solu-Cortef®, A-Hydrocort®) 50-75 mg IV Q8H x3 during postoperative period or equivalent alternate corticosteroid Dose greater than or equal to 20 mg/day prednisone for three weeks or more and patients with Cushingoid appearance Likely has minimal reserve cortisol available in adrenal glands Should usually receive “stress dose” corticosteroids, e.g. hydrocortisone sodium succinate (Solu-Cortef®, A-Hydrocort®) 50-75 mg IV Q8H x3 during postoperative period or equivalent alternate corticosteroid Dose equivalent to 5 mg/day or less or 10 mg every other day of prednisone *Patient- and procedure-specific decision should be made with patient and care team whether to hold medication. 16 Diabetes Medications • See OSUMC Perioperative / Periprocedure Glucose Management guideline Disease Modifying Antirheumatic Drugs (DMARD) Class Benefits of Continuation Examples Risks of Continuation methotrexate ® (Trexall ) DMARD hydroxychloroquine ® (Plaquenil ) sulfasalazine ® (Azulfidine ) azathioprine ® (Imuran ) Usual Management If normal renal function ok to continue in perioperative period Additional Considerations* Continue Avoid disease flares Myelo/ immunosuppression Continue Continue Stop 2 weeks prior to procedures, resume when wound fully healed ® leflunomide (Arava ) *Patient- and procedure-specific decision should be made with patient and care team whether to hold medication. Gastrointestinal Medications Class Examples Benefits of Continuation Risks of Continuation Usual Management Additional Considerations* calcium carbonate Antacids Anti-inflammatory aluminum hydroxide (AlternaGEL®, AluCap®, Alu-Tab®, Amphojel®) mesalamine (Pentasa®, Asacol®) balsalazide ® (Colazal ) cimetidine (Tagamet®) H2 Blockers famotidine (Pepcid®) ranitidine (Zantac®) esomeprazole (Nexium®) Proton Pump Inhibitors lansoprazole (Prevacid®) omeprazole (Prilosec®) Temporary neutralization of stomach acid Avoid flare of irritable bowel disease Reduction in stomach acid and GERD symptoms Additional matter in the stomach Do not take on day of procedure Continue Continue Avoid rebound hyperacidity Reduction in stomach acid and reflux symptoms May substitute H 2 blocker or PPI If on cimetidine, consider replacing with other H 2 blocker due to multiple drug interactions. Continue Avoid rebound hyperacidity pantoprazole (Protonix®) *Patient- and procedure-specific decision should be made with patient and care team whether to hold medication. 17 Genitourinary Medications Class Recommended Holding Time Examples Risk of Continuation Usual Management Additional Considerations* ® alfuzosin (Uroxatral ) ® doxazosin (Cardura ) dutasteride (Avodart®) BPH ® finasteride (Proscar ) Less postoperative urinary retention Hypotension Continue ® tamsulosin (Flomax ) ® terazosin (Hytrin ) *Patient- and procedure-specific decision should be made with patient and care team whether to hold medication Herbal Agents • There is no evidence herbal medications improve surgical outcomes and there are theoretical reasons these agents may increase perioperative morbidity and the exact purity of some herbal medications is unclear • Stop the following agents 7 days prior to procedures because of the potential increased risk of bleeding o Aloe, Burdock root, Chamomile, Chondroitin, Dong quai, Evening primrose, Flaxseed, Fish oil, Garlic, Ginger, Ginkgo, Ginseng, Glucosamine, Green tea, Hu zhang, Melatonin, Saw palmetto, Tumeric, Vitamin A and E • The above list in not all inclusive - Consult pharmacy if there are any concerns with additional herbal agent Hormonal Medications Class Benefits of Continuation Examples oral contraceptives Avoid unplanned pregnancy hormone replacement therapy Decrease postmenopausal symptoms Hormonal medications Risks of Continuation Additional Considerations* Advise the patient to use other forms of birth control if oral contraceptives are held Increased risk of Venous Thromboembolism anastrozole (Arimidex®) Usual Management Continue exemestane (Aromasin®) ® letrozole (Femara ) For specific very high DVT risk patients/ procedures it may be appropriate to discontinue their estrogen containing medications 4 – 6 weeks prior to the procedure. raloxifene (Evista®) Selective estrogen receptor modulator tamoxifen (Nolvadex®) toremifene (Fareston®) Stop 4 weeks prior to procedures for patients at moderate/high risk of VTE Investigational Medications 1. Summary protocol procedures are on the “Pharmacy Intranet” a. Provides study name and #, location of investigational medication, and protocol link. b. Procedures include drug preparation, dose, storage/stability parameters, randomization process, and more. 2. For Non-Oncology studies: a. A “Drug Order Form,” (customized paper Rx) will be faxed to the pharmacy executing the study. b. For additional protocol information such as inclusion/exclusion criteria the Investigational Drug Services (IDS) can provide this during business hours or the study coordinator can after IDS hours of operation. The study team is responsible for ensuring the patient meets all criteria before and during their enrollment. 3. For Oncology studies: a. Treatment plans including the pertinent investigational medications are available in Beacon (IHIS). b. The protocol can be found in OnCore 18 Pulmonary Medications Class Benefits of Continuation Examples ipratropium ® (Atrovent HFA) Beta-Agonists formoterol (Foradil®, Perforomist®) Usual Management Additional Considerations* Anti-cholinergic side effects Anti-Cholinergics tiotropium (Spiriva HandiHaler®) albuterol ® (Proventil or Ventolin® HFA) Risks of Continuation Reduced risk of postoperative pulmonary complications in patients with reactive airway disease Continue Tachycardia salmeterol (Serevent®) bosentan ® (Tracleer ) Endothelin receptor antagonists macitentan (Opsumit®) Avoid withdrawal, rebound pulmonary hypertension Hypotension Continue Improved control of reactive airway disease Thrush Continue Improved control of asthma No known perioperative adverse effects Continue ambrisentan (Letairis®) Inhaled Glucucorticoids fluticasone (Flovent®) montelukast (Singulair®) Leukotriene Inhibitors zafirlukast (Accolate®) ® Intravenous Prosta cyclin/ analogues Inhaled Prostacycli n/ analogues Oral Prostacyclin/ a nalogues zileuton (Zyflo ) epoprostenol (Flolan®, Veletri®) Consult to cardiovascular anesthesia is required. Hypotension treprostinil (Remodulin®) iloprost (Ventavis®) Hypotension treprostinil (Tyvaso®) treprostinil (Orenitram®) Hypotension Interruption for ≥ 3 days, will need to retitrate Hypotension Oral prostacyclin receptor (IP) agonist Phosphodiesterase (PDE5) inhibitors15 Selexipag (Uptravi®)14 sildenafil (Revatio®) Avoid withdrawal, rebound pulmonary hypertension Anemia Continue Concomitant use of riociguat or nitrates is contraindicated Hypotension ® Hemoglobin drops were seen in selexipag in clinical trials tadalafil (Adcirca ) Risk of anemia, hemorrhage, and hemoptysis Hypotension Soluble guanylate cyclase stimulator Interruption for ≥ 3 days, will need to retitrate Riociguat (Adempas®)16 Anemia Subcutaneous Pros tacyclin/ analogues treprostinil (Remodulin®) Theophylline theophylline (Theodur®) Contraindicated with nitrates, nitric oxide donors, or PDE5 inhibitors Hypotension No known perioperative benefits Arrhythmia Neurotoxicity Hold 24 hours before procedures *Patient- and procedure-specific decision should be made with patient and care team whether to hold medication. 19 Substance Abuse Class Examples Nicotine replacement products (gum, lozenge, patch, nasal spray, inhaler, etc.)17 Benefits of Continuation Maintain abstinence from smoking to reduce smokingrelated complications Risks of Continuation Vasospams Usual Management Per surgeon’s preference Additional Considerations* Likely safe for continuation: lack of evidence from human studies that NRT increases risk of post-op complications (healing or cardiovascular). NRT may yield positive cotinine test Smoking Cessation Varenicline (Chantix®)18,19 Maintain abstinence from smoking to reduce smokingrelated complications Bupropion (Zyban®)20 Maintain abstinence from smoking to reduce smokingrelated complications Decreased seizure threshold (doses > 450 mg/day) Continue Acamprosate (Campral®)21 Maintain abstinence from alcohol intake None Continue Naltrexone (Revia®, Vivitrol®)22,23 Maintain abstinence from alcohol intake or opioid use Continue Inadequate perioperative pain control with opioid analgesics (ex. Hydromorphone, fentanyl, remifentanil) Induction of opioid withdrawal upon administration of opioids Opioid/Alcohol Use Deterrents Buprenorphine (Subutex®) Buprenorphine/na loxone (Suboxone®) Buprenorphine patch (Butrans®)24-26 Maintain abstinence from opioid use; Control chronic pain Inadequate perioperative pain control with opioid analgesics (ex. Hydromorphone, fentanyl, remifentanil) Use methylene blue with caution because of risk of hypertensive reactions Consider regional analgesia or the use of non-opioid analgesics if clinically appropriate Oral: Hold 5 days IM: Contact prescribing physician Continue unless patient was otherwise instructed by the prescribing physician IM formulation may take at least 4 weeks to be eliminated from body Naltrexone should be restarted at the discretion of the prescribing chronic pain management/substanc e use physician Consider regional analgesia or the use of non-opioid analgesics if clinically appropriate If held, restarting may be deemed “re-initiation” depending on length of hold Recommend to alert surgeon For other products which contain any of the above ingredients but are not listed in the table, recommend following the perioperative management guidance for the agent which is most restrictive. 20 TNF alpha inhibitors Class Recommended Holding Time Examples Risk of Continuation Usual Management Additional Considerations* ® abatacept (Orencia ) adalimumab (Humira®) anakinra (Kineret®) certolizumab (Cimzia®) etanercept (Enbrel®) Stop 2 weeks prior to procedures Myelo/immunosuppression Resume when the wound is fully healed golimumab (Simponi®) infliximab (Remicade®) rituximab (Rituxan®) tocilizumab (Actemra®) Other medications to continue BEFORE and ON the MORNING of the procedure: • Alzheimer and dementia medications • Anti-psychotics • Anti-seizure medications • Anti-Parkinson's medications • Antibiotics* • Anxiolytics benzodiazepines • Gout medications ® o Allopurinol (Zyloprim ) ® ® o Colchicine (Colcrys , Mitigare ) • HIV medications ® • Mupirocin (Bactroban ) nasal ointment • Myasthenia Gravis medications o Notify Anesthesia pre-operatively • Thyroid medications** • Transplant immunosuppression*** * Unless otherwise directed by Surgeon or Proceduralist ** Can be held up for 5 - 7 days postoperatively if patient is NPO *** Sirolimus (Rapamune®), everolimus (Zortress®, Afinitor®), Temsirolimus (Torisel®) may be associated with impaired wound healing, but there are no formal recommendations for holding suggest consulting with the prescriber. 21 References: 1. OSUWMC Clinical Practice Guideline. Management of Antiplatelet Therapy in Patients with Arterial Stents Around the Time of Surgeries and Procedures. 2014. ® 2. Plavix (clopidogrel bisulfate) [package insert]. Bridgewater, NJ; Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership; Revised May 2009. ® 3. Effient (prasugrel hydrochloride) [package insert]. Indianapolis, IN; Eli Lilly and Company; Revised January 2011. ® 4. Brilinta (ticagrelor) [package insert]. Wilmington, DE; AstraZeneca; Revised September 2016. 5. Doherty JU, Gluckman TJ, Hucker WJ, et al. 2017 ACC Expert Consensus Decision Pathway for Periprocedural Management of Anticoagulation in Patients With Nonvalvular Atrial Fibrillation. J Am Coll Cardiol. 2017 Feb 21; 69 (7): 871-898. 6. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative Management of Antithrombotic Therapy. CHEST. 2012 Feb; 141 (2 Suppl): e326S-50S. 7. The Ohio State University Wexner Medical Center. Argatroban Dosing and Monitoring. Revised October 2016. 8. The Ohio State University Wexner Medical Center. Bivalirudin Dosing and Monitoring. Revised October 2016. ® 9. Reopro (abciximab) [package insert]. Horsham, PA; Janssen Biotech, Inc; Revised December 2016. ® 10. Integrilin (eptifibatide) [package insert]. Whitehouse Station, NJ; Merck Sharp & Dohme Corp; Revised April 2014. ® 11. Aggrastat (tirofiban) [package insert]. Somerset, NJ; Medicure Pharma, Inc; Revised 2016 12. Roshanov PS, Rochwerg B, Patel A, et al. Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or Angiotensin II Receptor Blockers before Noncardiac Surgery. Anesthesiology. 2017 Jan; 126(1): 16-27. 13. POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial). Lancet. 2008 May 31; 371(9627): 1839-47. ® 14. Uptravi (selexipag) [package insert]. South San Francisco; Actelion Pharmaceuticals US, Inc; Revised December 2015. 15. Shim JK, Choi YS, Oh YJ, et al. Effect of oral sildenafil citrate on intraoperative hemodynamics in patients with pulmonary hypertension undergoing valvular heart surgery. J Thorac Cardiovasc Surg. 2006 Dec; 132(6): 1420-5. ® 16. Adempas (riociguat) [package insert]. Whippany, NJ; Bayer HealthCare Pharmaceuticals Inc; Revised February 2017. 17. Nolan MB, Warner DO. Safety and Efficacy of Nicotine Replacement Therapy in the Perioperative Period: A Narrative Review. Mayo Clin Proc. 2015 Nov;90(11):1553-61 18. Wong JJ. Anesthesiology (Philadelphia): A perioperative smoking cessation intervention with varenicline: a double-blind, randomized, placebo-controlled trial. American Society of Anesthesiologists 2012; 117:755 ® 19. Chantix (varenicline) [package insert]. New York, NY. Pfizer Labs; Revised 2016 Dec. ® 20. Zyban (bupropion hydrochloride) [package insert]. Research Triangle Park, NC. GlaxoSmithKline; Revised 2016 June. ® 21. Campral (acamprosate) [package insert]. St. Louis, MO. Forest Pharmaceuticals, Inc.: 2004. 22. Revia® (naltrexone hydrochloride) [package insert]. Hazelwood, MO. Mallinckrodt, Inc: Revised 2014 Nov. ® 23. Vivitrol (naltrexone for extended-release injection) [package insert]. Waltham, MA. Alkermes, INC.: Revised 2015 Dec. ® 24. Suboxone (buprenorphine/naloxone) [package insert]. Richmond, VA. Indivior, Inc: Revised 2016 Dec. ® 25. Butrans (buprenorphine extended release) prescribing information. Stamford, CT. Purdue Pharma LLP: Revised 2016 Dec. 26. Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006 Jan 17;144(2):127-34. 22 References • • Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Journal of the American College of Cardiology (2014), doi:10.1016/j.jacc.2014.07.944. Kaufman RM, Djulbegovic B, Gernsheimer T, Kleinman S, Tinmouth AT, Capocelli KE, et al. Platelet Transfusion: A Clinical Practice Guideline From the AABB. Annals of Internal Medicine (2014), doi:10.7326/M14-1589 Guideline Authors • • • • • • • • • • Erica Stein, MD Barbara Rogers, MD Carl Schmidt, MD Michael Guertin, MD Kristin Brower, PharmD BCPS Danielle Blais, PharmD, BCPS Sarah Dickey, PharmD, BCPS Donna Heavener, RN Dawn Bachert, RN Joyce Porginski, RN Guideline Approved _June 28, 2017. Second Edition Disclaimer: Clinical practice guidelines and algorithms at The Ohio State University Wexner Medical Center (OSUWMC) are standards that are intended to provide general guidance to clinicians. Patient choice and clinician judgment must remain central to the selection of diagnostic tests and therapy. OSUWMC’s guidelines and algorithms are reviewed periodically for consistency with new evidence; however, new developments may not be represented. Copyright © 2017. The Ohio State University Wexner Medical Center. All rights reserved. No part of this document may be reproduced, displayed, modified, or distributed in any form without the express written permission of The Ohio State University Wexner Medical Center. Appendix A: Guideline for Antiplatelet and Anticoagulant Therapy Management Surrounding Regional Anesthesia • • • • 1 Neuraxial complications are extremely rare. Epidural hematomas are one possible complication of neuraxial anesthesia. 2 Antiplatelet or anticoagulant medications may increase the incidence of a neuraxial bleed. Contact the Department of Anesthesiology Acute Pain Team with questions about resuming antiplatelet or anticoagulant medications in relation to neuraxial anesthesia. These recommendations do not apply to patients with perineural catheter placement. Table 1: Medication Aspirin* 3 Aspirin/ Dipyridamole* ® 3 (Aggrenox ) Antiplatelet Agents Prior to Procedure While Catheter in Place Post Procedure Minimum recommended time between Restrictions while neuraxial catheter in Minimum recommended time between Dose last dose of antithrombotic agent and place neuraxial catheter removal or neuraxial neuraxial catheter placement or procedure and next dose of antithrombotic neuraxial procedure agent Refer to OSUWMC Clinical Practice Guideline: Management of Antiplatelet Therapy in Patients with Arterial Stents Around the Time of Surgeries and Procedures Patient- and procedure-specific decision should be made with patient and care team. All doses 7 days* 24 hours Clopidogrel* ® 3 (Plavix ) Refer to OSUWMC Clinical Practice Guideline: Management of Antiplatelet Therapy in Patients with Arterial Stents Around the Time of Surgeries and Procedures 12 hours; 75mg daily 7 days Avoid while catheter is in place 24 hours if administering a loading dose Dipyridamole ® 5 (Persantine ) All doses Prasugrel * ® 3 (Effient ) Ticagrelor* ® 3 (Brilinta ) Cilostazol ® 4 (Pletal ) 48 hours* 24 hours Refer to OSUWMC Clinical Practice Guideline: Management of Antiplatelet Therapy in Patients with Arterial Stents Around the Time of Surgeries and Procedures All doses 10 days** Avoid while catheter is in place 24 hours Refer to OSUWMC Clinical Practice Guideline: Management of Antiplatelet Therapy in Patients with Arterial Stents Around the Time of Surgeries and Procedures All doses 5 days Avoid while catheter is in place 24 hours All doses 48 hours* 24 hours No need to hold dose Non-Aspirin 5 NSAIDs Voraxapar ® (Zontivity ) Non-Selective If the decision is made to hold, the duration to hold should be based upon 5 half-lives of specific NSAID. Contact Pharmacy for assistance. See Table 3 COX-2 Selective No need to hold dose All doses Contraindicated 4 hours Avoid while catheter is in place Medication Dose Prior to Procedure Minimum recommended time between last dose of antithrombotic agent and neuraxial catheter placement or neuraxial procedure While Catheter in Place Restrictions while neuraxial catheter in place Post Procedure Minimum recommended time between neuraxial catheter removal or neuraxial procedure and next dose of antithrombotic agent GP IIb/IIIa inhibitors Abciximab ® 5 (Reopro ) Eptifibatide ® 5 (Integrilin ) Tirofiban ® 5 (Aggrastat ) Argatroban Bivalirudin ® (Angiomax ) Desirudin ® (Iprivask ) Alteplase ® 5 (TPA ) Alteplase (TPA®) 5 days All doses Avoid while catheter is in place 12 hours** 24 hours Continuous Infusion All doses Therapeutic dose for stroke, etc. 1mg – 2mg (catheter clearance) 5000 units SQ Q12H Heparin unfractionated 2,5 5000 units SQ Q8H 7500 units SQ Q8H IV Infusion Direct Thrombin Inhibitors (Injectable) If neuraxial anesthesia is needed, decision should be discussed with Avoid while catheter is in place Anesthesiologist, surgical team, and pharmacy specialist 24 hours Avoid while catheter is in place Thrombolytic Agents Not recommended, but maintain catheter if emergency thrombolytic Minimum 48 hours for emergency therapy is required and notify procedures Department of Anesthesiology Acute Pain Team. 24 hours 48 hours or normalization of fibrinogen No need to hold dose Injectable Anticoagulants Inpatients: No time restriction. 5000 units Q12H may be given Consider the peak effect of while indwelling catheter in place subcutaneous heparin at 2 hours with concurrent SCDs when placing catheter. Can be restarted a minimum of 2 Outpatients: 8 hours hours post-neuraxial anesthesia catheter placement. ASRA guidelines prefer the use of Q12H dosing, however risk of 8 hours bleed vs clot must be considered when using TID dosing 8 hours Avoid while catheter is in place 4 hours if normal PTT Avoid while catheter is in place 2 hours- Consider PTT if concern for bleeding risk Medication Dose Prior to Procedure Minimum recommended time between last dose of antithrombotic agent and neuraxial catheter placement or neuraxial procedure While Catheter in Place Restrictions while neuraxial catheter in place Post Procedure Minimum recommended time between neuraxial catheter removal or neuraxial procedure and next dose of antithrombotic agent CrCl > 30mL/min: 12 hours 5000 units SQ QDay Dalteparin ® 6 (Fragmin ) 200 units/kg SQ QDay 100 units/kg SQ Q12H 40mg SQ QDay Enoxaparin ® 5,7,8 (Lovenox ) 30mg SQ Q12H 40mg SQ Q12H CrCl ≤ 30mL/min: 24 hours (consider anti-Xa level to assess level of anticoagulation)*** CrCl > 30mL/min: 24 hours CrCl ≤ 30 mL/min: 48 hours (consider anti-Xa level to assess level of anticoagulation)*** CrCl > 30 mL/min: 12 hours 2.5mg SQ QDay Fondaparinux ® 5 (Arixtra ) 5 – 10mg SQ QDay 24 hours ** Avoid while catheter is in place 24 hours Must wait 12 hours post-catheter placement to re-initiate dosing CrCl ≤ 30mL/min: 72 hours (consider anti-Xa level to assess level of anticoagulation )*** CrCl > 30 mL/min: 24 hours 1mg/kg Q12H 1 – 1.5mg/kg SQ QDay Must wait 8 hours post-catheter placement to re-initiate dosing 24 hours** Avoid while catheter is in place CrCl ≤ 30 mL/min: 72 hours (consider anti-Xa level to assess level of anticoagulation)*** CrCl > 50 mL/min: 3 – 4 days 24 hours CrCl ≤ 50 mL/min: 4 days (consider anti-Xa level to assess level of anticoagulation)*** CrCl > 50 mL/min: 4 days 24 hours CrCl ≤ 50 mL/min: 5 days (consider anti-Xa level to assess level of anticoagulation)*** Avoid while catheter is in place 24 hours Oral Anticoagulants Medication Dose Apixaban ® 5 (Eliquis ) All doses Dabigatran ® 5 (Pradaxa ) All doses Edoxaban ® 5 (Savaysa ) All doses Prior to Procedure Minimum recommended time between last dose of antithrombotic agent and neuraxial catheter placement or neuraxial procedure While Catheter in Place Restrictions while neuraxial catheter in place Post Procedure Minimum recommended time between neuraxial catheter removal or neuraxial procedure and next dose of antithrombotic agent CrCl > 30 mL/min: 3 days Rivaroxaban ® 5 (Xarelto ) All doses Warfarin ®, (Jantoven ® 5 Coumadin ) All doses 24 hours CrCl ≤ 30mL/min: 5 days CrCl > 15 mL/min: 5 days 24 hours CrCl ≤ 15mL/min: 6 days CrCl > 50mL/min: 3 days Avoid while catheter is in place CrCl ≤ 50mL/min: 5 days CrCl > 50mL/min: 3 days 24 hours 24 hours CrCl ≤ 50mL/min: 5 days 5 days, normalization of INR 24 hours Hemorrheologic Agents Pentoxifylline (Trental®) No need to hold dose Herbal Agents Herbal Agents Including (but not limited to): Aloe, burdock root, chamomile, chondroitin, dong quai, evening primrose, flaxseed, fish oil, garlic, ginger, ginko, ginseng, glucosamine, green tea, hu zhang, saw palmetto, turmeric, vitamin a and e 7 days Avoid while catheter is in place Preferred hold time 24 hours. Contact Pharmacy Specialist for recommendation for specific medication recommendation. *Patient- and procedure-specific decision should be made with patient and care team whether to hold medication. ** For medications wherein ASRA guidelines recommend a range of holding, we have elected to recommend the more conservative holding time due to renal elimination of medications and lack of reversal agents. *** Order anti-Xa level specific to Low Molecular Weight Heparins (anti-Xa LMW Heparin). For other agents that effect Factor Xa, the presence of an elevated Xa indicates presence of the medication and does not necessarily reflect the degree of anticoagulation. Table 3: Half-Lives of Commonly Administered Non-Aspirin NSAIDs NSAID Diclofenac Etodolac Ibuprofen Indomethacin Ketorolac Meloxicam Nabumetone Naproxen Oxaprozin Piroxicam Half- life, h 1-2 6-8 2-4 5-10 5-6 15-20 22-30 12-17 40-60 45-50 5, 9-18 Discontinuation Time, 5 Half-lives, h 5-10 30-40 10-20 25-50 25-30 75-100 110-150 60-85 200-240 225-250 References: 1. Neal JM, Barringer MJ, et al. The Second ASRA Practice Advisory on Neurologic Complications Associated With Regional 2015 Sep-Oct; 40: 401-30. 2. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic therapy or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition). Reg Anesth Pain Med 2010; 35: 64–101. 3. OSUWMC Clinical Practice Guideline. Management of Antiplatelet Therapy in Patients with Arterial Stents Around the Time of Surgeries and Procedures. 2014. ® 4. Pletal (cilostazol) [package insert]. Otsuka America Pharmaceutical, Inc., Rockville, Maryland, USA, 1999. 5. Narouze S, Benzon HT, Provenzano DA, et al. Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications: Guidelines From the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med 2015; 40: 182–212. 6. Fragmin® (dalteparin sodium) [package insert]. Eisai,Inc, Woodcliff Lake, NJ, 2007. 7. Lovenox® (enoxaparin sodium) [package insert]. Sanofi-Aventis U.S. LLC (per FDA), Bridgewater, NJ, 2013. 8. Brophy DF, Wazny LD, & Gehr TWB: The pharmacokinetics of subcutaneous enoxaparin in end-stage renal disease. Pharmacotherapy 2001; 21: 169174. 9. Small RE. Diclofenac sodium. Clin Pharm. 1989; 8: 545–558. 10. Brocks DR, Jamali F. Etodolac clinical pharmacokinetics. Clin Pharmacokinet 1994; 26: 259–274. 11. Rainsford KD. Ibuprofen: pharmacology, efficacy and safety. Inflammopharmacology 2009; 17: 275–342. 12. Helleberg L. Clinical pharmacokinetics of indomethacin. Clin Pharmacokinet. 1981; 6: 245–258. 13. Mroszczak EJ, Jung D, Yee J, Bynum L, Sevelius H, Massey I. Ketorolac tromethamine pharmacokinetics and metabolism after intravenous, intramuscular, and oral administration in humans and animals. Pharmacotherapy. 1990; 10: 33S–39S. 14. Turck D, Roth W, Busch U. A review of the clinical pharmacokinetics of meloxicam. Br J Rheumatol 1996; 35 (suppl 1): 13–16. 15. Dahl SL. Nabumetone: a “nonacidic” nonsteroidal anti-inflammatory drug. Ann Pharmacother 1993; 27: 456–463. 16. Davies NM, Anderson KE. Clinical pharmacokinetics of naproxen. Clin Pharmacokinet 1997; 32: 268–293. 17. Miller LG. Oxaprozin: a once-daily nonsteroidal anti-inflammatory drug. Clin Pharm 1992; 11: 591–603. 18. Olkkola KT, Brunetto AV, Mattila MJ. Pharmacokinetics of oxicam nonsteroidal anti-inflammatory agents. Clin Pharmacokinet 1994; 26: 107–120.