Perioperative Medication Management

Cardiovascular Medications

• The American Heart Association recommends continuing beta-blockers perioperatively in all patients already taking them to avoid severe exacerbation of angina, myocardial infarction, and ventricular arrhythmias 1, 2
• Discontinuation of ACE inhibitors and ARBs perioperatively may be considered due to increased risk of intraoperative hypotension requiring vasopressor support, and if held, restart as soon as clinically feasible postoperatively 1, 2
• The American College of Cardiology recommends continuing statins perioperatively without interruption, as discontinuation is potentially harmful 3
• Clonidine should be continued perioperatively to avoid abrupt discontinuation, which is potentially harmful 1

Antiplatelet Therapy

• The American Heart Association recommends continuing aspirin in patients on secondary prevention, and may discontinue 7-10 days before surgery for primary prevention only if bleeding risk exceeds cardiac risk 2, 3
• P2Y12 inhibitors, such as clopidogrel and ticagrelor, should be discontinued at least 5 days before elective surgery, and at least 24 hours before urgent surgery to reduce major bleeding 3
• In patients with recent PCI with stents, dual antiplatelet therapy should be continued and surgery delayed if possible for 30 days after bare-metal stent, 6-12 months after drug-eluting stent 2, 3

Diabetes Medications

• GLP-1 receptor agonists, such as semaglutide and liraglutide, should be continued through surgery, with full aspiration risk assessment and mitigation strategies implemented 4
• SGLT-2 inhibitors, such as empagliflozin and dapagliflozin, should be omitted the day before and day of surgery due to euglycemic ketoacidosis risk 4
• Basal insulin should be continued at reduced dose, and target postoperative glucose <180 mg/dL to reduce infection risk 3, 5

Psychiatric Medications

• Antidepressants, such as SSRIs, SNRIs, and TCAs, should be continued perioperatively to avoid withdrawal, and monitor for serotonin syndrome if multiple serotonergic agents used 6

Antirheumatic Medications

• Conventional DMARDs, such as methotrexate and hydroxychloroquine, should be continued through surgery, while mycophenolate, azathioprine, cyclosporine, and tacrolimus should be held for 1 week before surgery in non-severe SLE 7
• Biologic DMARDs should be planned around the dosing cycle, and JAK inhibitors, such as tofacitinib, baricitinib, and upadacitinib, should be held for at least 3 days before surgery 7

Pain Medications

• Chronic opioid therapy should be continued perioperatively to avoid withdrawal, and ergotamine derivatives, triptans, and CGRP antagonists should be continued or held according to specific guidelines 8

Critical Threshold for Surgery Delay

• Elective surgery should be deferred if blood pressure ≥180/110 mmHg, according to the American Heart Association and the American Society of Hypertension 1, 5

Perioperative Escitalopram Management

Introduction to Perioperative Management

• The risk of withdrawal outweighs theoretical concerns about drug interactions in the surgical setting, making continuation the safer approach for patient outcomes including quality of life and morbidity prevention 9

Quality of Life and Surgical Outcomes

• In patients undergoing CABG surgery, escitalopram treatment started 2-3 weeks preoperatively resulted in better quality of life and less pain after surgery, though it did not affect morbidity and mortality 10, 11

Serotonin Syndrome Risk and Monitoring

• Monitor for serotonin syndrome when escitalopram is combined with other serotonergic agents commonly used perioperatively, including opioids with serotonergic activity, antiemetics, other antidepressants, and triptans 12, 13, 9
• Serotonin syndrome presents with neuroexcitatory symptoms, autonomic dysfunction, and neuromuscular abnormalities 12
• While the risk exists, it is generally low when SSRIs are combined with other serotonergic agents in clinical practice, as these medications are frequently co-prescribed 13, 9

Postoperative Management and Medication Adjustment

• If prolonged NPO status is anticipated, consider alternative routes or temporary substitution of escitalopram, though this is rarely necessary given escitalopram's long half-life 11

Perioperative Escitalopram Use for Anxiety and Depression Management

Evidence and Guidelines

• The American Heart Association guidelines state that treating depression before CABG leads to improved psychological outcomes after surgery, supporting preoperative initiation when clinically indicated 14
• Initiation of escitalopram 10 mg daily 2-3 weeks preoperatively resulted in better quality of life and less postoperative pain compared to placebo, with no effect on morbidity and mortality, in a randomized controlled trial of 361 patients undergoing elective CABG surgery 14
• The American Heart Association recommends treating depression before CABG to improve psychological outcomes after surgery, and escitalopram can be safely started within 30 days of surgery for anxiety and depression management 14

Medication Safety and Avoidance

• Avoid benzodiazepines entirely, as they precipitate delirium and worsen postoperative cognitive dysfunction, according to the Journal of the American Geriatrics Society 15
• Avoid antihistamines (diphenhydramine, hydroxyzine, cyclizine) due to anticholinergic effects that increase delirium risk, as recommended by the Journal of the American Geriatrics Society 15
• Avoid sedative-hypnotics and anticholinergic medications (tricyclic antidepressants, paroxetine, promethazine, prochlorperazine), as advised by the Journal of the American Geriatrics Society 15

Treatment Algorithms

• Initiate escitalopram 10 mg daily 2-3 weeks before elective surgery when possible, based on randomized trial evidence showing improved quality of life and pain outcomes, as recommended by the American College of Cardiology 14
• Do not delay necessary psychiatric treatment due to upcoming surgery, as untreated depression increases risk of postoperative mortality, heart failure hospitalization, MI, cardiac arrest, and need for repeat revascularization, according to the American College of Cardiology 14
• Do not substitute benzodiazepines for escitalopram in the perioperative period, even if anxiety is prominent, as benzodiazepines significantly worsen cognitive outcomes and increase delirium risk, as advised by the Journal of the American Geriatrics Society 15

Special Population Considerations

• Apply Beers Criteria to avoid other inappropriate medications that compound cognitive risk in elderly patients, as recommended by the Journal of the American Geriatrics Society 15