Perioperative NSAID Management

Introduction to NSAID Discontinuation

• The American Academy of Family Physicians recommends that naproxen be discontinued before surgical procedures due to its antiplatelet effects, with consideration of the patient's cardiovascular thrombotic risk 1

Bleeding Risk Considerations

• Concurrent anticoagulant or antiplatelet therapy increases the severe bleeding risk by 2.5 times when using NSAIDs 2
• Patient factors, including older age, poor health, and bleeding history, contribute to an increased bleeding risk when using NSAIDs 2

Procedure-Specific Exceptions

• For minor procedures such as dental extractions and cataract surgery, continuation of NSAIDs may be acceptable due to low bleeding risk 3
• The European Heart Journal suggests that for patients with significant cardiovascular thrombotic risk, continuing NSAIDs may be reasonable for low-bleeding-risk procedures 3

Postoperative Resumption

• Strong evidence supports the use of NSAIDs postoperatively for multimodal analgesia, reducing morphine consumption, sedation, nausea/vomiting, and ileus when bleeding risk permits 2
• Both non-selective NSAIDs and COX-2 inhibitors show equivalent analgesic efficacy postoperatively 2

Critical Contraindications

• The Anaesthesia journal recommends avoiding NSAIDs perioperatively in patients with renal insufficiency, active renal hypoperfusion, history of atherothrombosis, or recent coronary stent placement 2
• Patients with a history of atherothrombosis should avoid COX-2 inhibitors entirely 2
• Recent coronary stent placement is a contraindication for elective surgery, and NSAIDs should be avoided 4

Common Pitfalls

• Failing to ask about over-the-counter NSAID use during medication reconciliation can lead to increased bleeding risk 1
• Not accounting for increased risk when NSAIDs are combined with anticoagulants can lead to severe bleeding complications 1, 2
• Continuing NSAIDs beyond 7 days postoperatively in patients with atherothrombosis is not recommended 2