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Case 9: Preoperative Medication Management in the Context of a Patient With Comorbidities Taking Multiple Medications Who Presents for Elective Surgery

Learning Objectives
1. Recognize polypharmacy and its harms
2. Describe the impact of potentially inappropriate medications
3. Conduct perioperative management of anticoagulants and antiplatelets in older adults
0.25 Credit CME

A 78-year-old man with a nonhealing ulcer of the right great toe is admitted to the hospital for diagnostic angiography and evaluation for therapeutic angioplasty or stent placement. The patient has a history of hypertension, ischemic cardiomyopathy, oxygen-dependent chronic obstructive pulmonary disease, type 2 diabetes mellitus, sleep apnea, generalized anxiety disorder, and mild dementia. The patient underwent percutaneous coronary intervention (PCI) of the left anterior descending artery and right coronary artery and drug-eluting stent placement one month ago based on results of preoperative stress testing. He has been taking hydrocodone every six hours for pain in the toe. He lives with his son who assists him with activities of daily living (ADLs). He reports that he has difficulty ambulating independently and recently started using a walker after falling twice. He is currently dual eligible on Medicare/Medicaid.

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Advisory Panel

The following members of the advisory panel had no relevant financial relationships with ineligible companies to disclose:

• Ruben Azocar, MD

• George Drach, MD

• Sandhya Lagoo-Deenadayalan, MD, PhD

• Andrew Lee, MD

• Mike Malone MD

• Myron Miller, MD

• Arvind Nana, MD

• Tom Robinson, MD

• Victoria Tang MD, MAS

The following members of the advisory panel have reported relevant financial relationships with ineligible companies that have been mitigated through peer review of planning decisions by persons without relevant financial relationships and recusal from any aspect of planning and content related to the financial relationship:

• Kevin Biese MD, MAT is a paid consultant for Call 9 Telemedicine Medical Advisor and Bristol Meyers Squibb/ Pfizer

• Daniel Mendelson, MS, MD is a paid consultant for Point Click Care Touchscreen

Writing Panel

The following members of the writing panel had no relevant financial relationships with ineligible companies to disclose:

• Tomas Griebling, MD

• Joseph Hejkal, MD

• Melissa Hornor, MD

• Jason Johanning, MD

• Sushila Murthy, MD, MPH

• Tony Rosen, MD, MPH

• Kate Schenning, MD, MPH

The following members of the writing panel have reported relevant financial relationships with ineligible companies that have been mitigated through peer review of content by persons without relevant financial relationships:

• Charles Brown, MD is a paid consultant for and receives grants from Medtronic

• Badrinath Konety, MD, MBA is a paid consultant for NxThera, and Bristol Myers Squibb, Opko and receives grant funding from Photocure, Genentech, and Genomic Health

Reviewers:

The following reviewers had no relevant financial relationships with ineligible companies to disclose:

• Shamsuddin Akhtar, MD

• Patrick Kortebein, MD

• Joseph LoCicero, MD

Support Statement

This CME activity is supported by a grant from the John A. Hartford Foundation.

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References:
1.
ACR Committee on Drugs & Contrast.  ACR Guidelines on Contrast. Version 10.3. 2017. https://www.acr.org/Quality-Safety/Resources/Contrast-Manual
2.
AGS Expert Panel.  American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults.  J Am Geriatr Soc. 2019;67(4):674–694. https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.15767Google Scholar
3.
Fleisher  LA, Fleischmann  KE, Auerbach  AD,  et al.  2014 ACC/AHA guidelines on perioperative cardiovascular evaluation of patients undergoing noncardiac surgery.  Circ. 2014;130:e278–e333. http://circ.ahajournals.org/content/130/24/e278Google Scholar
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