Followup #Medthread #Tweetorial about #periop med management as promised!
Thank you to all who voted.
So...the answer was an MAO-I.
all the agents are ones to stop pre-op, but why was MAO-I the answer I was going for?? 1/x
First choice was Ephedra--definitely something to stop pre-op given it's sympathetic effect and risk of cardiovascular instability.
HOWEVER, Ephedra was banned by the FDA in 2/2004, so I haven't seen a patient on this in the preop setting in years 2/x
thinking about Ephedra is a good opportunity to this about herbal/nutraceutical/supplement management periop, given hypothetical or KNOWN risk of:
✅cytochrome up/down regulation
✅cardiovascular instability
✅changes to platelet/coagulation function
✅drug/drug interactions 3/x
it's a few years old at this point, but this 2001 JAMA piece is one of my favorite reads on the subject, with thoughtful background and reasoning, including a detailed section of periop risk of ephedra 4x…
next, an SGLT-2 such as canaglifozin? NOT a rare counseling decision anymore--something now linked with the risk of euglycemic DKA especially in the periop period (incl case reports), so I routinely counsel pts to hold for 2-3 days pre-op & resume once reliably taking po 5/x
btw, great recent publication to have available--how can we best manage all these new diabetes medications in the #periop period? 6/x…
next, lithium??
Lithium is one of my favorite "hodge podge" #periop pearls to discuss!
in a nutshell, Lithium is a funky drug and gets even funkier (and potentially dangerous) perioperatively. I/m almost always holding it pre-op except for really minor ambulatory surgeries...7/x
lithium has really complex pharmacokinetics and pharmacodynamics, with a narrow therapeutic index. Periop fluid shifts and changes to renal function can affect homeostasis and drug levels. Lithium also accumulates in tissue & has a really wide half-life (up to 60hrs??) 8/x
I divide post-op lithium risk into two big concerns:
1⃣unmasked subclinical nephrogenic diabetes insipidus
2⃣"chronic" toxicity--long term stable dose but acute changes drug levels, can present with neuro symptoms such as ataxia, agitation, tremor, fasciculations, seizures 9/x
PS--a Dr. Melissa Choi, a very recent @OHSUIMRes graduate, did a fantastic poster on this subject last year!
so, to the correct answer--MAO-I (and more specifically the MAO A inhibitors)
I can't remember the last time I've seen a patient on one in pre-op clinic (maybe never??)
The MAO B inhibitors with Parkinson's Disease? Occasionally, the MAO-I As? INCONCEIVABLE! 11/x
As correctly pointed out by @ktmurraymcw in his response to the first poll, MAO-Is can get dangerous periop!
❌risk HTNive crisis
❌risk interacting with periop sympathomimetics
❌risk serotonin syndrome esp meperidine
available advise says to stop 2 weeks pre-op 12/x
I hope you found this informative. I enjoy the #periop challenge of managing the risk/benefit of dozens of medication classes, not just antiplts/anticoagulants
Also, let me know if you're interested in a #medthread #tweetorial about HOW to counsel a patient about such! 13/FIN
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