Preoperative Management of Endocrine, Hormonal and Urological Medication: SPAQI Consensus Statement

Perioperative medical management is challenging due to the rising complexity of patients presenting for surgical procedures. A key part of preoperative optimization is the appropriate management of long-term medications. However, SPAQI identified a lack of authoritative clinical guidance as an opportunity to utilize its multidisciplinary membership to improve evidence-based perioperative care. Therefore, a panel of experts drafted the following Consensus Statement to provide practical guidance on the preoperative management of endocrine, hormonal, and urologic medications. The authors identified common medications from each category and then utilized a modified Delphi approach to critically review the literature and generate consensus recommendations.

RECOMMENDATIONS ON INSULIN:

♦ Regarding long-acting Insulin, the panel recommended to, "Continue basal insulin both before and on the day of surgery. Administration of only 60%-80% of the usual dose the evening before surgery (or the morning of surgery, if normally taken in the morning) may be reasonable, especially in patients with type 2 DM and those prone to hypoglycemia."

♦ For intermediate-acting Insulin, the panel recommended "Continue intermediate-acting insulin before surgery and on the day of surgery; however, reduce the dose by 50% on the morning of surgery, and consider 25% dose reduction the evening before surgery, especially in patients with type 2 DM and those at increased risk for hypoglycemia."

♦ With regard to short-acting Insulin, the panel recommended, "Administer usual dose before the day of surgery but hold on the day of surgery unless required for correction of hyperglycemia."

RECOMMENDATION ON NON-INSULIN DM MEDICATIONS:

♦ With regard to Alpha-Glucosidase Inhibitors, Insulin Secretagogues, Thiazolidinidiones,Metformin and Dipeptidyl peptidase-4 (DPP-4) inhibitors, the panel recommended to, "Continue before surgery, but do not take on the morning of surgery."

♦ Concerning Sodium glucose Co-transporter 2 (SGLPT2) inhibitors, they recommended, "Canagliflozin, dapagliflozin, and empagliflozin should each be discontinued at least 3 days before scheduled surgery. Ertugliflozin should be discontinued at least 4 days before scheduled surgery. Blood glucose levels should be carefully monitored after discontinuation of the SGLT-2 inhibitor and managed as necessary with alternate methods before surgery."

♦ For Glucagon-like Peptide-1 Agonists, they recommended, Continue GLP-1 agonists before the day of surgery unless heightened concern for postoperative nausea, vomiting or gut dysfunction (eg, GI surgery). In these situations, consider holding 24 hours for once or twice daily preparations, and up to 1 week before surgery for weekly preparations (including holding dose within 7 days before surgery). Closer monitoring and adjustment to antidiabetic regimen may be necessary to avoid possible hyperglycemia before surgery. Withhold GLP-1 agonists on the morning of surgery. If a weekly dose is due on morning of surgery, delay taking until later in the day after surgery."

DPP-4 inhibitors-

Continue before surgery, but do not take DPP-4 inhibitors on the morning of surgery.

Thyroid Medications-

Continue both thyroid replacement and antithyroid medications without dose adjustments before and on the day of surgery.

Corticosteroids-

Continue chronic corticosteroid treatment before and on the day of surgery. Patients receiving longer-term, higher-dose therapy might need supplemental dosing intraoperatively and postoperatively.

Pituitary medications-

Continue pituitary medications both before and on the day of surgery.

Androgenic hormones-

Continue androgenic hormones medications both before and on the day of surgery, but consider the potential for postoperative venous thromboembolism (VTE) risk.

Estrogens-

Continue estrogens both before and on the day of surgery, but consider potential for increased risk of VTE if continued and pregnancy risk if withheld (if taken for contraception).

Progesterones-

Continue progestins both before and on the day of surgery.

Selective Estrogen receptor modulators-

Continue SERMs both before and on the day of surgery if taken for breast cancer prevention or treatment, but consider potential for increased wound complication and VTE risk if continued. If SERMs are taken for other indications and additional patient- or surgery-specific risk factors for VTE are present, stop SERMs at least 7 days before surgery.

Aromatase inhibitors-

Continue aromatase inhibitors both before and on the day of surgery, but consider potential for increased wound complications if continued.

Bone and Calcium disorder Medicines-

Continue parathyroid hormone, calcimimetics, calcitonin, and denosumab before surgery and on the day of surgery. Bisphosphonates can be taken before surgery, but they should not be taken on the day of surgery.

Urological Medicines-

Alpha-1 adrenergic antagonists-

Continue alpha-1 adrenergic antagonists up to and including the day of surgery. In patients undergoing cataract surgery, consider discussion with the ophthalmologist.

5 Alpha reductase Inhibitors-

Continue 5-ARIs up to and including the day of surgery.

Anticholinergic bladder dysfunction medications-

Continue before surgery but do not take anticholinergic bladder dysfunction medications on the morning of surgery.

Antineoplastic urologic medications-

Continue antineoplastic urologic medications up to and including the day of surgery.