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Difficulty: HardGeneral Internal Medicine

Match each patient's preoperative medication profile with the most appropriate perioperative management strategy for that specific medication.

  • A 61-year-old taking empagliflozin for type 2 diabetes, scheduled for an elective bowel resection.Discontinue 3 to 4 days prior to surgery.
  • A 74-year-old taking lisinopril for hypertension, scheduled for an elective inguinal hernia repair.Withhold the dose specifically on the morning of surgery.
  • A 58-year-old taking warfarin for a mechanical mitral valve, scheduled for a partial nephrectomy.Discontinue 5 days prior to surgery and bridge with low-molecular-weight heparin.
  • A 65-year-old taking methotrexate for well-controlled rheumatoid arthritis, scheduled for a total joint arthroplasty.Continue the medication without interruption throughout the perioperative period.
  • A 71-year-old taking rivaroxaban for nonvalvular atrial fibrillation, scheduled for an elective open abdominal surgery.Discontinue 2 to 3 days prior to surgery without initiating bridging therapy.

Answer

Empagliflozin is stopped 3-4 days prior. Lisinopril is held the morning of surgery. Warfarin is stopped 5 days prior with LMWH bridging. Methotrexate is continued without interruption. Rivaroxaban is stopped 2-3 days prior without bridging.
Preoperative optimization requires individualized medication adjustments based on pharmacokinetics and surgical stress. SGLT2 inhibitors (empagliflozin) are stopped 3 to 4 days prior to avoid euglycemic DKA. ACE inhibitors (lisinopril) are held the morning of surgery to prevent severe vasoplegia. High-risk thromboembolic conditions (mechanical mitral valve) require warfarin cessation 5 days prior with LMWH bridging. DOACs (rivaroxaban) are held 2 to 3 days prior without bridging due to their rapid offset. Non-biologic DMARDs (methotrexate) are continued in stable rheumatoid arthritis to prevent disease flares that hinder recovery.

Step-by-Step Solution

1
Identify the indication and mechanism for empagliflozin.
It is an SGLT2 inhibitor used for diabetes.
SGLT2 inhibitors increase the risk of euglycemic DKA during perioperative fasting, requiring cessation 3-4 days prior.
2
Evaluate the surgical risk and indication for warfarin.
Mechanical mitral valve indicates high thromboembolic risk.
High-risk indications require heparin bridging when warfarin is stopped 5 days before surgery.
3
Assess the mechanism and offset of rivaroxaban.
It is a short-acting DOAC.
DOACs do not require bridging; they are simply held 2-3 days before moderate-to-high bleeding risk procedures.
4
Determine the perioperative risk of lisinopril.
ACE inhibitors can cause vasoplegic shock.
Holding the morning dose mitigates the risk of severe intraoperative hypotension under general anesthesia.
5
Analyze the management of methotrexate in stable rheumatoid arthritis.
Continuing is preferred over discontinuation.
The risk of a severe disease flare outweighs the theoretical risk of perioperative infection when holding methotrexate.

Key Concept

Optimal perioperative medication management involves balancing surgical risks (e.g., bleeding, hypotension, ketoacidosis) against the risk of underlying disease exacerbation.
Estimated Time:2m 0s
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General Internal Medicine

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