Preoperative management of gastrointestinal and pulmonary medications: SPAQI consensus statement

The group derived consensus recommendations using the following guiding principles:

• Preference is given to not interrupting therapy unless there are potential risks fromcontinuation.
• Focus is placed on management of long-term medications.
• Preoperative initiation of therapy, supplemental treatment (eg, "stress dose steroids"), and postoperative management are outside the scope of this paper.
• Long-term oral corticosteroid management is covered in another publication within this series, entitled "Preoperative Management of Endocrine, Hormonal, and Urologic Medications: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement.

Pulmonary Medications

• Continue inhaled anticholinergic medications up to and including the day of surgery.
• Continue inhaled β₂-adrenergic agonists up to and including the day of surgery.
• Continue theophylline before the day of surgery but hold on the day of surgery because of its narrow therapeutic window, potential for drug interactions, and cardiac adverse effects. Consider discussion of long-term necessity with the prescriber.
• Continue roflumilast up to and including the day of surgery.
• Continue inhaled corticosteroids up to and including the day of surgery.
• Continue combination inhaled medications up to and including the day of surgery.
• Continue leukotriene inhibitors up to and including the day of surgery.
• Continue N-acetylcysteine up to and including the day of surgery.
• Continue antihistamines before the day of surgery but hold first-generation antihistamines and cetirizine on the day of surgery because of their potential for contributing to postoperative delirium and anticholinergic adverse effects.
• Continue arylalkylamine decongestants before the day of surgery but hold on the day of surgery because of their potential for contributing to cardiovascular adverse effects.
• Continue prostacyclin analogues up to and including the day of surgery.
• Continue selexipag up to and including the day of surgery.
• Continue endothelin receptor antagonists up to and including the day of surgery.
• Continue PDE-5 inhibitors up to and including the day of surgery when used for treatment of PH. Perioperative management of PDE-5 inhibitors prescribed for urologic indications is detailed in another publication within this consensus statement series.
• Continue riociguat up to and including the day of surgery, but discuss potential for bleeding complications with the surgeon or proceduralist.
• Continue nintedanib and pirfenidone up to and including the day of surgery, but discuss perioperative management with the surgeon and prescribing clinician.

Gastrointestinal Medications

• Continue proton pump inhibitors (PPIs) up to and including the day of surgery.
• Continue H₂ receptor antagonists up to and including the day of surgery.
• Continue antacids up to the day before surgery but hold on the morning of surgery. Nonparticulate antacids may be acceptable to take on the morning of surgery for patients at increased risk for pulmonary aspiration.
• Continue 5-HT₃ antagonists up to and including the day of surgery.
• Continue dopamine antagonists up to and including the day of surgery, unless there are concerns of significant QT prolongation.
• Continue aprepitant up to and including the day of surgery.
• Continue entecavir, tenofovir, lamivudine, and adefovir up to and including the day of surgery but consult with the prescribing clinician. Assess renal and hepatic function before surgery because of nephrotoxicity and hepatotoxicity of these agents.
• When interferons are used for treatment of viral hepatitis, stop them 1 to 2 weeks before surgery because of potential for perioperative complications but consult with the prescribing clinician.
• Continue ribavirin up to the day of surgery but hold on the morning of surgery. If hemoglobin level has not recently been obtained, check it before surgery.
• Continue sofosbuvir and ledipasvir/sofosbuvir up to and including the day of surgery. Continue sofosbuvir/valpatasvir, glecaprevir/pibrentasvir, dasabuvir/ombitasvir/paritaprevir/ritonavir, elbasvir/grazoprevir, and sofosbuvir/velpatasvir/voxilaprevir up to the day of surgery but hold on the morning of surgery. Discuss management with the patient's gastroenterology clinician.
• Continue gallstone solubilizing agents up to the day before surgery but hold on the morning of surgery.
• Continue pancreatic enzymes up to the day before surgery but hold on the morning of surgery.
• Continue 5-aminosalicylic acid medications up to and including the day of surgery but consider holding on the morning of surgery if glomerular filtration rate is below 50 mL/min.
• Continue antidiarrheals up to the day before surgery but hold on the morning of surgery because of the risk of opioid agonism and anticholinergic effects.
• Continue anticholinergics and antispasmodics up to the day before surgery but hold on the morning of surgery. Reexamine the long-term necessity of these medications (especially in elderly patients). Continuation of these agents is reasonable if it is absolutely needed for airway secretion control that could affect airway management.
• Continue lubiprostone up to and including the day of surgery.
• Continue guanylate cyclase C agonists up to and including the day of surgery.
• Continue serotonergic neuroenteric modulators up to and including the day of surgery.
• Continue laxatives up to the day before surgery but hold on the morning of surgery.
• For patients taking these agents to prevent solid organ transplant rejection, continue up to and including the day of surgery. For other indications, management must be individualized on the basis of patient and surgical factors, and the risks and benefits of continuation must be discussed with the surgeon and prescribing clinician.
• Continue purine analogues up to and including the day of surgery but consult with the surgeon and prescribing clinician.
• Continue methotrexate up to and including the day of surgery but consult with the surgeon and prescribing clinician.
• Withhold TNF inhibitors for at least 1 dosing interval before surgery (ie, if taken every 4 weeks, schedule surgery 5 weeks after the last dose) but consult with the surgeon and prescribing clinician to discuss the relevant risks and benefits of therapy interruption.
• Withhold vedolizumab, ustekinumab, and natalizumab for at least 1 dosing interval before surgery. Withhold ozanimod for 60 days and facilitation for 7 days before surgery but consult with the surgeon and prescribing clinician to discuss the relevant risks and benefits of therapy interruption. For vedolizumab, perioperative continuation may be reasonable for nonabdominal surgery.
• Withhold phentermine for at least 4 days before surgery.
• Withhold lisdexamfetamine for 72 hours before surgery if it is being taken for binge eating disorder. For patients at high risk for relapse of binge eating disorder, the medication may be continued before surgery and held only on the morning of surgery, but this requires discussion with the prescriber and anesthesiologist.
• Withhold phentermine/topiramate for at least 4 days before surgery. Either wean the patient off the medication during the course of a week before surgery (according to product insert) or, while withholding, provide topiramate alone at the same dose.
• Continue orlistat up to the day before surgery but hold onthe morning of surgery.
• Before the day of surgery, continue GLP-1 agonists unless there is heightened concern for postoperative nausea, vomiting, or gut dysfunction (eg, gastrointestinal 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 beforesurgery). Withhold GLP-1 agonists on the morning of surgery. If a weekly dose is due on the morning of surgery, delay taking it until later in the day after surgery.
• Withhold bupropion/naltrexone for 72 hours before surgery if opioids are expected to be used preoperatively.