Should aspirin and NSAIDs be discontinued preoperatively in rheumatic disease?
Patients treated with ASA and acetylsalicylate-containing medications may be at risk for increased surgical bleeding because these drugs impair platelet aggregation for the life of the platelet (7–10 days).
ASA should be discontinued 7 to 10 days before planned surgery except in patients taking the ASA for secondary prevention of CV events (some experts recommend cessation regardless of patient risk factors in intracranial, spinal, and posterior ocular surgeries).
Traditional NSAIDs may also decrease platelet aggregation; however, unlike ASA, NSAID binding to the COX-1 site in platelets is reversible and declines with discontinuation of the medicine. NSAIDs have also been associated with more frequent episodes of gastrointestinal bleeding when given perioperatively. These medications should be held preoperatively for approximately four half-lives of the drug to allow return of normal platelet function and may be restarted 2 to 3 days postoperatively provided the patient is stable. Due to concern regarding the CV risk of NSAIDs, they should be used cautiously (if at all) in the perioperative period, especially in patients at increased risk for CV events. Alternative medications for pain/inflammation may be preferred in the perioperative period and include acetaminophen, prednisone, and other non-NSAID pain medications (e.g., tramadol, narcotic analgesics). Salsalate is a nonacetylated salicylate that does not affect the prostaglandin synthesis pathway. As such, it does not affect platelet function and may be considered in this setting.
Pearl: Ask about nonprescription drugs and supplements. Many rheumatic disease patients may take complementary and alternative medicine therapies that can affect platelet function (e.g., ginkgo, ginger, turmeric) or interact with anesthesia.