THEMATIC REIVEW ON PERIOPERATIVE MEDICINE

Preoperative Management of Endocrine,

Hormonal, and Urologic Medications: Society
for Perioperative Assessment and Quality
Improvement (SPAQI) Consensus Statement
Kurt J. Pfeifer, MD; Angela Selzer, MD; Carlos E. Mendez, MD;
Christopher M. Whinney, MD; Barbara Rogers, MD, MBOE; Vinaya Simha, MD;
Dennis Regan, MD; Richard D. Urman, MD, MBA; and Karen Mauck, MD, MSc

Abstract

Perioperative medical management is challenging due to the rising complexity of patients pre-
senting for surgical procedures. A key part of preoperative optimization is appropriate manage-
ment of long-term medications, yet guidelines and consensus statements for perioperative
medication management are lacking. Available resources utilize the recommendations derived
from individual studies and do not include a multidisciplinary focus or formal consensus. The
Society for Perioperative Assessment and Quality Improvement (SPAQI) identified a lack of
authoritative clinical guidance as an opportunity to utilize its multidisciplinary membership to
improve evidence-based perioperative care. SPAQI seeks to provide guidance on perioperative
medication management that synthesizes available literature with expert consensus. The aim of
this Consensus Statement is to provide practical guidance on the preoperative management of
endocrine, hormonal, and urologic medications. A panel of experts with anesthesiology, periop-
erative medicine, hospital medicine, general internal medicine, and medical specialty experience
was drawn together and identified the common medications in each of these categories. The au-
thors then utilized a modified Delphi approach to critically review the literature and generate
consensus recommendations.
ª 2020 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2021;96(6):1655-1669

M
anagement of chronic medications and postoperative urinary retention.
is an essential part of preoperative Balanced against these risks are the potential
optimization of patients requiring risks caused by medication withdrawal (eg, From the Department of
Medicine, Medical College
invasive procedures. Although continuation uncontrolled systemic disease and with- of Wisconsin, Milwaukee
of many medications is important to main- drawal syndromes). (K.J.P.); Department of
Anesthesiology, University
tain control of chronic health problems, cli- Recognizing and managing possible
of Colorado School of
nicians must be aware of and mitigate the medication issues in surgical patients is Medicine, Aurora (A.S.);
risks of potential perioperative complica- challenging because of the proliferation of Department of Medicine,
Medical College of Wis-
tions from some. For any medication, a clini- therapies approved by the US Food and consin, Milwaukee
cian must ascertain whether the medication Drug Administration (FDA) and the ongoing (C.E.M.); Department of
could affect bleeding risk (both for surgery evolution of anesthetic and surgical tech- Hospital Medicine, Cleve-
land Clinic Lerner College
and regional anesthesia) or interact with niques. Coupled with the lack of robust liter- of Medicine, OH
anesthetic or analgesic agents. Furthermore, ature on perioperative medication (C.M.W.); Department of
Anesthesiology, The Ohio
some medications can elevate the risk of management, clinicians are left without clear
common postoperative complications, such guidance regarding best practices. The Soci- Affiliations continued at
as perioperative neurocognitive dysfunction ety for Perioperative Assessment and Quality the end of this article.

Mayo Clin Proc. n June 2021;96(6):1655-1669 n https://doi.org/10.1016/j.mayocp.2020.10.002 1655

www.mayoclinicproceedings.org n ª 2020 Mayo Foundation for Medical Education and Research

Improvement (SPAQI) recognized this
practice gap and the potential to leverage its
resources to fill this need.
SPAQI is an international, multidisci-
plinary society dedicated to the promotion
of evidence-based perioperative medicine,
and it has produced a number of recommen-
dation papers and consensus statements in
this field.1-3 SPAQI drafted a comprehensive
plan for developing consensus recommenda-
tions for perioperative medication manage-
ment using perioperative medicine,
anesthesiology, internal medicine, hospital
medicine, and medical subspecialty experts.
This consensus statement contains the
work of a subgroup focused on providing
guidance on the perioperative management
of endocrine, hormonal, and urologic
medications. This statement is targeted to
practitioners providing general medical care
to patients before surgery, and it represents
a synopsis of available literature and expert
opinion related to preoperative medication
management. Burgeoning research,
specialty-level care, and the nuances of post-
operative medication management are
beyond the scope of this article.
PARTICIPANTS AND METHODS
The clinical areas for the SPAQI consensus
statements were chosen by SPAQI leadership
on the basis of knowledge and practice gaps
identified in a variety of the organization’s
educational forums. Endocrine, hormonal,
and urologic medications were combined
for one consensus group based on the num-
ber of medications and the goal of balancing
the content of all previous and forthcoming
consensus statements. The members of the
consensus group were faculty members at
several different academic institutions and
experts in the fields of perioperative
medicine, anesthesiology, general internal
medicine, hospital medicine, and subspe-
cialty internal medicine. Before the start of
the project, a leader was designated for guid-
ing the consensus development process.
After identifying all common FDA-
approved medications in the selected classes,
the group used a modified Delphi methodol-
ogy described in the first publication of
n n
1656 Mayo Clin Proc.
MAYO CLINIC PROCEEDINGS
SPAQI’s series of medication consensus
statements.4 To derive its recommendations,
the consensus group used the following
guiding principles:
d Preference given to not interrupting
therapy unless there were potential risks
from continuation.
d Focus placed on management of chronic
medications.
d Preoperative initiation of therapy, supple-
mental treatment (eg, “stress dose
steroids”), and postoperative management
are beyond the scope of this article.
Consensus was established for all
reviewed medications, and the completed
set of recommendations was reviewed and
endorsed by the Executive Committee of
SPAQI. What follows are specific recommen-
dations for each medication class.
ENDOCRINE AND HORMONAL
MEDICATIONS
Insulins
Appropriate adjustment of insulin therapy in
the perioperative period is essential to
maintain good glucose control to avoid post-
operative complications of both hyperglyce-
mia and hypoglycemia. Insulin decreases
blood glucose by stimulating peripheral
glucose uptake and decreasing hepatic
glucose release. The time course of insulin
action differs across the different insulin
preparations, which primarily determines
their perioperative dose adjustments. As
much as possible, clinicians should consult
with a patient’s diabetologist regarding
perioperative diabetes management. Howev-
er, the majority of patients will benefit from
development and adherence to evidence-
based, institutional protocols for periproce-
dural insulin management. Table 1
summarizes the following consensus
recommendations for the perioperative man-
agement of insulins.
Long-Acting Insulins. The three primary
long-acting insulin preparations used as
basal therapy are glargine, detemir, and
degludec, with half-lives ranging from 13 to
June 2021;96(6):1655-1669 https://doi.org/10.1016/j.mayocp.2020.10.002
www.mayoclinicproceedings.org
ENDOCRINE AND UROLOGIC PREOPERATIVE MEDICATION MANAGEMENT
TABLE 1. Summary of Recommendations for the Preoperative Management of Insulins
Medication class Examples
Insulin, intermediate- NPHa
acting
Insulin, long-acting Glargine, detemir,
degludec
Insulin, premixed Human NPH/regular Continue
70/30; insulin lispro
protamine/lispro 75/
25
Insulin, pump
Insulin, short-/rapid- Regular, aspart, lispro, Continue
acting glulisine
Insulin, U-500
a
NPH, neutral protamine Hagedorn.
b
See additional considerations.
24 hours. For patients with type 1 diabetes
mellitus (DM), it is important that there is
no interruption in long-acting basal insulin
therapy due to the risk of ketoacidosis. The
normal basal insulin dose should be given
the day before and the day of surgery unless
there is increased concern for hypoglycemia.
Patients with elevated risk for hypoglycemia
include those who experience frequent epi-
sodes of nocturnal hypoglycemia, regularly
eat a bedtime snack to avoid hypoglycemia,
experience an overnight decrease in blood
glucose readings by over 40 mg/dL, are
malnourished, or have renal or hepatic
insufficiency. In such patients, a 25%-50%
reduction in long-acting insulin dose would
be reasonable either the evening before or
the morning of surgery, whenever the
patient usually takes basal insulin. In a
retrospective analysis of patients with type 2
DM undergoing ambulatory surgery,
administration of 60%-87% (mean dose 73%
and mode dose 75%) of the usual basal dose
the evening before surgery was noted to
result in a greater number of patients having
optimal fasting blood sugars on the morning
of surgery compared with those receiving
less than 50% or 100% of the full dose.5 In a
Mayo Clin Proc. n June 2021;96(6):1655-1669 n https://doi.org/10.1016/j.mayocp.2020.10.002
www.mayoclinicproceedings.org
Administration Administration
before day of on morning of
surgery surgery Additional Considerations
Continueb Continueb Decrease dose by 50% on morning of surgery and consider 25%
dose reduction on evening before surgery
Continueb Continueb Administer 60%-80% of usual dose the evening before surgery (or
the morning of surgery, if normally taken in the morning) in
those with type 2 diabetes and those prone to hypoglycemia
Continueb If fasting hyperglycemia (>200 mg/dL), use half the usual dose of
premixed insulin on the morning of surgery; otherwise, do not
administer and give half the dose of the intermediate- or long-
acting component as intermediate- or long-acting insulin
Continue Continueb Continue basal infusion at 60%-80% of usual rate and do not
provide boluses
Hold May use on the morning of surgery for urgent treatment of
hyperglycemia
Continue Continueb Reduce dose on morning of surgery based on patient’s blood
glucose and risk factors for hypoglycemia
prospective, randomized, open-label trial of
410 patients with both type 1 and type 2
diabetes, empiric 20% reduction of basal
glargine dose the evening before surgery was
found to be just as efficacious as physician-
or dosing tableedirected insulin adjust-
ments for optimal glucose levels on the
morning of surgery.6 American Diabetes
Association (ADA) guidelines recommend
provision of 80% of usual long-acting insulin
on the morning of surgery.7
Consensus Recommendation. Continue
basal insulin both before and on the day of
surgery. Administration of only 60%-80%
of the usual dose the evening before surgery
(or the morning of surgery, if normally taken
in the morning) may be reasonable,
especially in patients with type 2 DM and
those prone to hypoglycemia.
Intermediate-Acting Insulins. Neutral prot-
amine Hagedorn (NPH) insulin usually has
a 12-hour duration of action, and it is
sometimes used as basal insulin in combi-
nation with short- or rapid-acting insulin;
however, it does have a peaking effect and it
provides prandial coverage for the mid-day
1657

meal, thus necessitating a dose reduction on
the morning of surgery. Similarly, mild dose
reduction in patients with type 2 DM the
evening before surgery might be appropriate.
ADA guidelines recommend patients take
only half of their usual NPH dose on the
morning of surgery.7
Consensus Recommendation. Continue
intermediate-acting insulin before surgery
and on the day of surgery; however, reduce
the dose by 50% on the morning of surgery,
and consider 25% dose reduction the
evening before surgery, especially in patients
with type 2 DM and those at increased risk
for hypoglycemia.
Short- and Rapid-Acting Insulins. This sub-
category includes regular human insulin
and analogues, such as aspart, lispro, and
glulisine, which all have a total duration of
action less than 4 hours and are used to pro-
vide prandial coverage. They should be
continued the day before surgery but held
on the day of surgery when a patient is fast-
ing. However, these insulins can be used on
the day of surgery as necessary for correction
of hyperglycemia. In this setting, short-
acting insulins should be administered sub-
cutaneously or via infusion based on insti-
tutional protocols.
Consensus Recommendation. Administer
usual dose before the day of surgery but
hold on the day of surgery unless required
for correction of hyperglycemia.
Other Insulin Preparations. Some patients
use premixed insulin preparations
combining intermediate and short rapid-
acting insulin, such as human insulin NPH/
regular 70/30, insulin aspart protamine/
aspart 70/30, or insulin lispro protamin/lis-
pro 75-25, and 50-50 suspensions. These
preparations should continue to be admin-
istered the day before surgery, but either
held or administered at a reduced dose on
the morning of surgery on the basis of the
patient’s blood sugar measurement. If there
is fasting hyperglycemia (>200 mg/dL), half
the usual dose of premixed insulin can be
n n
1658 Mayo Clin Proc.
MAYO CLINIC PROCEEDINGS
administered on the morning of surgery;
otherwise, only half the basal component
should be administered as intermediate- or
long-acting insulin.8
Patients who use concentrated regular
insulin U500 should also receive the usual
dose on the day before surgery and an
adjusted dose on the morning of surgery
based on blood sugars.
For patients on insulin pump therapy, one
should consult with their diabetologist. The
pump basal rate should usually be continued
at 60%-80% of usual until the patient presents
to the anesthesia preparation area on the
morning of surgery.7 Further management
on the morning of surgery (eg, management
of hypoglycemia or severe hyperglycemia),
intraoperatively, and postoperatively is beyond
the scope of this article.
Non-Insulin DM Medications (Table 2)
Alpha-Glucosidase Inhibitors. Acarbose and
miglitol are the two AGIs available in the
United States. They decrease blood glucose
by interfering with the breakdown of carbo-
hydrates in the gut, thus decreasing the ab-
sorption of sugars. Although sugars
decrease postprandial glucose excursions
and carry a low risk of hypoglycemia, the
increased delivery of carbohydrates to the
colon often results in increased gas produc-
tion and GI discomfort.9,10 No studies eval-
uating AGIs during the perioperative period
were available at the time of this review, but
ADA guidelines recommend holding these
on the morning of surgery.7
Consensus Recommendation. Continue
before surgery, but do not take AGIs on
the morning of surgery.
Metformin. Metformin is the most
commonly used medication for the manage-
ment of type 2 DM in the United States. Met-
formin exerts its antihyperglycemic effect by
suppressing excessive hepatic glucose pro-
duction through gluconeogenesis inhibition;
it does not lead to hypoglycemia when used
as monotherapy. Metformin has been re-
ported to increase the risk of lactic acidosis,
but a 2010 Cochrane systematic review
June 2021;96(6):1655-1669 https://doi.org/10.1016/j.mayocp.2020.10.002
www.mayoclinicproceedings.org
ENDOCRINE AND UROLOGIC PREOPERATIVE MEDICATION MANAGEMENT

TABLE 2. Summary of Recommendations for the Preoperative Management of Non-Insulin Diabetes Medications
Administration Administration on
before day of morning of
Medication class Examples surgery surgery Additional considerations
Alpha-glucosidase Acarbose, Miglitol Continue Hold d
inhibitors
Biguanides Metformin Continue Hold In patients without contraindications and with preserved
renal function (GFRa >50 mL/min) undergoing
ambulatory surgeries for which no more than one meal
is expected to be omitted, non-interruption may be
acceptable.
DPP-4 inhibitors Vildagliptin, sitagliptin, Continue Hold For patients undergoing ambulatory surgeries for which no
saxagliptin, linagliptin, more than one meal is expected to be omitted, non-
alogliptin interruption may be acceptable.
GLP-1 agonists Liraglutide, lixisenatide, Continueb Hold Before day of surgery: For GI surgeries or when concern
semaglutide, dulaglutide for nausea, vomiting, or gut dysfunction, consider
holding weekly dose within 7 days before surgery.
Day of surgery: If weekly dose is due on morning of
surgery, delay until later in day after surgery is complete.
Insulin secretogogues Glipizide, glyburide, glimepiride Continue Hold d
(sulfonylureas, repaglinide, nateglinide
glinides)
SGLT-2 inhibitors Dapagliflozin, canagliflozin, Hold Hold Canagliflozin, dapagliflozin, and empagliflozin should each
empagliflozin, ertugliflozin be discontinued at least three days before scheduled
surgery. Ertugliflozin should be discontinued at least four
days before scheduled surgery.
Thiazolidinediones Pioglitazone Continue Hold
a
DPP-4, dipeptidyl peptidase-4; GFR, glomerular filtration rate; GLP-1, glucagon-like peptide-1; SGLT-2, sodium glucose co-transporter 2.
b
See additional considerations.

reported no increase in the number of cases
of lactic acidosis in ambulatory patients
across 347 clinical trials with 70,490
patient-years of metformin use.11 In the
perioperative period, data on the safety and
potential benefits of metformin have been
limited to observational and single-center
interventional studies.12-15 Possible sug-
gested benefits of recent (8-24 hours preop-
eratively) metformin ingestion in cardiac
surgical patients have not been
confirmed.12,13 However, no definitive evi-
dence of harm from continuation of met-
formin up to the day of surgery was found
for this review.12-15 Given that the use of
metformin is contraindicated during condi-
tions that carry an inherent increased risk of
lactic acidosis, including several seen during
the perioperative period such as impaired
kidney function, heart failure, and contrast
dye exposure, extending recommendations
to routinely take metformin on the day
of surgery is difficult to justify at the time
of this review. ADA guidelines also
recommend holding metformin on the
day of surgery, but they do not recommend
the past common practice of withholding
longer than this.7 Similarly, we do not
recommend cancellation or delay of
surgical procedures if metformin is taken
on the morning of surgery. In patients
without contraindications and with pre-
served renal function (glomerular filtration
rate [GFR] > 50 mL/min) undergoing
ambulatory surgeries for which no more
than one meal is expected to be omitted,
continuation of metformin therapy may be
acceptable.
Consensus Recommendation. Continue
before surgery, but do not take metformin
on the morning of surgery.

Mayo Clin Proc. n June 2021;96(6):1655-1669 n https://doi.org/10.1016/j.mayocp.2020.10.002 1659

www.mayoclinicproceedings.org

Insulin Secretagogues. Sulfonylureas and
glinides exert their antidiabetic effect by
stimulating endogenous insulin secretion
independently of glycemia or food intake.
They increase the risk of hypoglycemia,
especially in patients with impaired renal
function or decreased oral intake.16 In the
inpatient setting, the use of sulfonylureas
has been shown to increase the prevalence of
hypoglycemia, especially in patients older
than 65 years and with a GFR < 30 mL/
min.17 Significant drug interactions are also
a limiting factor. Drugs that inhibit hepatic
cytochrome CYP2C9, including
fluoroquinolones, fluconazole, amiodarone,
trimethoprim-sulfamethoxazole, and val-
proate, can exaggerate the effect of
sulfonylureas, thereby increasing the risk of
hypoglycemia.18,19
Glinides available in the United States are
repaglinide and nateglinide. They also
enhance b-cell insulin production, but result
in faster onset and shorter duration of ac-
tion.20 These agents are not recommended in
the perioperative setting because of the poten-
tial risk of hypoglycemia and lack of random-
ized trials evaluating their safety and efficacy.7
Consensus Recommendation. Continue
before surgery, but do not take sulfonylureas
or glinides on the morning of surgery.
Thiazolidinediones. Pioglitazone is the only
thiazolidinedione (TZD) readily accessible
in the US. TZDs are considered insulin
sensitizers and increase peripheral glucose
uptake through direct activation of the
peroxisome proliferator-activated receptor
gamma.21 TZDs have been associated with
fluid retention and are contraindicated in
patients with congestive heart failure,
hemodynamic instability, or evidence of he-
patic dysfunction.16 Given the potential for
undesired effects, and lack of evidence
showing its safety or efficacy during the
perioperative period, its use on the day of
surgery is not recommended.
Consensus Recommendation. Continue
before surgery, but do not take thiazolidine-
diones on the morning of surgery.
n n
1660 Mayo Clin Proc.
MAYO CLINIC PROCEEDINGS
Sodium Glucose Co-Transporter 2 (SGLT-2)
Inhibitors. This class of antidiabetic medica-
tions increases urinary glucose excretion by
decreasing renal glucose reabsorption in
the proximal convoluted tubules. The use
of SGLT-2 inhibitors in the inpatient
setting is discouraged given the increased
risk of urogenital infections, acute kidney
injury, dehydration, and hypotension
because of their glycosuric effects.22,23 In
addition, euglycemic diabetic ketoacidosis
has been reported as a significant complica-
tion of these agents in the perioperative
setting.24 Considering these adverse events,
the FDA recently released a special bulletin
reporting a drug label change recommending
temporary discontinuation before scheduled
surgery.25
Consensus Recommendations. Canagli-
flozin, dapagliflozin, and empagliflozin
should each be discontinued at least 3 days
before scheduled surgery. Ertugliflozin
should be discontinued at least 4 days before
scheduled surgery. Blood glucose levels
should be carefully monitored after discon-
tinuation of the SGLT-2 inhibitor and
managed as necessary with alternate
methods before surgery.
Glucagon-Like Peptide-1 Ago-
nists. Glucagon-like peptide-1 (GLP-1)
agonists are popular in the management of
type 2 DM because of their potent antidia-
betic, weight loss, and cardiovascular bene-
fits.26 They exert their antihyperglycemic
effects through increased insulin production
in a glucose-dependent manner along with
glucagon suppression. They are also known
to slow gastric emptying, which can increase
risk of hypoglycemia when used with insulin
and lead to adverse GI effects, such as nausea
and vomiting.27 Newer GLP-1 agonists allow
for weekly injections and are better
tolerated, causing less nausea and vomiting.
In the perioperative setting, small studies
have evaluated the use of GLP-1 during car-
diac and noncardiac surgery and have shown
effectiveness in achieving glycemic control
while decreasing insulin requirements.28-30
Counter to these benefits, increased nausea
June 2021;96(6):1655-1669 https://doi.org/10.1016/j.mayocp.2020.10.002
www.mayoclinicproceedings.org
ENDOCRINE AND UROLOGIC PREOPERATIVE MEDICATION MANAGEMENT
when using liraglutide the night before sur-
gery has been reported.29 We identified no
studies in which the safety of these agents
was assessed in patients undergoing surgery
involving bowel manipulation where
peristalsis and gastric emptying might be
affected. Given the limited perioperative
data available and the high prevalence of
nausea in the postoperative period, larger tri-
als will be needed before the use of GLP-1
agonists can be widely endorsed for most
surgeries. In some scenarios, especially those
not involving GI surgery or concerns for
nausea and vomiting, its continued use
throughout the perioperative period might
be acceptable.
Consensus Recommendations. Continue
GLP-1 agonists before the day of surgery
unless heightened concern for postoperative
nausea, vomiting or gut dysfunction (eg, GI
surgery). In these situations, consider
holding 24 hours for once or twice daily
preparations, and up to 1 week before sur-
gery for weekly preparations (including
holding dose within 7 days before surgery).
Closer monitoring and adjustment to
antidiabetic regimen may be necessary to
avoid possible hyperglycemia before surgery.
Withhold GLP-1 agonists on the morning of
surgery. If a weekly dose is due on morning
of surgery, delay taking until later in the day
after surgery.
Dipeptidyl Peptidase-4 Inhib-
itors. Dipeptidyl peptidase-4 (DPP-4) in-
hibitors increase availability of native GLP-1
by decreasing its enzymatic breakdown.
They induce insulin production similarly to
GLP-1 agonists, but with the difference that
DPP-4 inhibitors rely on intestinal secretion
of GLP-1 triggered by food intake.31 The
safety and effectiveness of the DPP-4 in-
hibitors for the inpatient management of
diabetes and hyperglycemia have been
demonstrated recently in medical and sur-
gical patients.32-34 However, treatment with
a DPP-4 inhibitor 1 or 2 days before cardiac
and noncardiac surgery showed no benefit in
preventing postoperative hyperglycemia
compared to placebo in patients without
Mayo Clin Proc. n June 2021;96(6):1655-1669 n https://doi.org/10.1016/j.mayocp.2020.10.002
www.mayoclinicproceedings.org
diabetes.35,36 Although these drugs have a
relatively safe profile, in older patients with
known or suspected heart failure, the use of
DPP-4 inhibitors has been associated with
worsening of heart failure.37 Given the
limited data showing significant benefit from
DPP-4 inhibitors in preventing postoperative
hyperglycemia, recommending their
continued use on the day of surgery is not
warranted for most patients. However, for
patients undergoing ambulatory surgeries
for which no more than one meal is expected
to be omitted, uninterrupted DPP-4 inhibitor
therapy might be acceptable.
Consensus Recommendation. Continue
before surgery, but do not take DPP-4
inhibitors on the morning of surgery.
Thyroid Medications
Hypothyroidism is treated with thyroid
replacement therapy in the form of levothyr-
oxine, liothyronine, or dessicated thyroid
preparations. The usual replacement dose
can be administered on the day of surgery
via the enteral route without the need for
any additional supplementation or conver-
sion to a parenteral route of administra-
tion.38 There are no studies on the safety
and efficacy of antithyroid medications
(methimazole and propylthiouracil) in the
perioperative period. To avoid the possible
risk of thyroid storm in the perioperative
period, these medications should be
continued uninterrupted.
Consensus Recommendation. Continue
both thyroid replacement and antithyroid
medications without dose adjustments
before and on the day of surgery.
Corticosteroids
The corticosteroid group has many similar
medications that are used primarily for adrenal
insufficiency, autoimmune diseases, and in-
flammatory conditions. Most of these
medications, including betamethasone,
triamcinolone, hydrocortisone, cortisone,
prednisone, methylprednisolone, budesonide,
and dexamethasone, have different degrees of
1661

glucocorticoid and mineralocorticoid
activity, and they come in multiple administra-
tion forms (eg, oral, intravenous, intramus-
cular, inhaled, topical). Fludrocortisone
differs from these in that it has only
mineralocorticoid activity.
Most perioperative literature for cortico-
steroids is focused on new use in the surgical
setting (eg, postoperative nausea prevention)
and supplementation of chronic doses (ie,
“stress dosing”). These studies have
inconsistently shown the potential for corti-
costeroids to cause hyperglycemia, but few
other adverse effects.39,40 Although several
small studies have investigated the provision
of supplemental corticosteroids to patients
with adrenal insufficiency or chronic corti-
costeroid usage, none have investigated the
effects of continuation or interruption of
long-term therapy. Available guidelines
recommend that patients not interrupt
long-term corticosteroid therapy, although
when it is used for treatment of inflamma-
tory arthritis, the American College of Rheu-
matology and American Association of Hip
and Knee Surgeons recommend titrating
the daily dose to less than 20 mg of predni-
sone equivalent, if possible.41,42 The role and
indications for supplemental (ie, “stress-
dose”) steroids is a matter of ongoing debate
and is beyond the scope of this article.
Consensus Recommendations. Continue
chronic corticosteroid treatment before and
on the day of surgery. Patients receiving
longer-term, higher-dose therapy might
need supplemental dosing intraoperatively
and postoperatively.
Pituitary Medications
Pituitary medications are used in the treatment
of a variety of disorders. Patients with isolated
anterior and posterior pituitary deficiency, or
panhypopituitarism, receive replacement ther-
apy that can include recombinant growth hor-
mone (somatotropin) and desmopressin in
addition to glucocorticoids, thyroid hormone,
and androgen or estrogen therapy (discussed
later). The dopamine agonists cabergoline
and bromocriptine are used in the treatment
of pituitary prolactinomas. Mecasermin is
n n
1662 Mayo Clin Proc.
MAYO CLINIC PROCEEDINGS
recombinant insulin-like growth factor-1 that
is used in the treatment of growth hormone
deficiency in children. Tesamorelin is a growth
hormoneereleasing hormone analog used for
treatment of human immunodeficiency
viruseassociated lipodystrophy. Repository
corticotropin is used in the treatment of infan-
tile spasms, and rarely for recalcitrant multiple
sclerosis and other rheumatic conditions.
Although there are no studies examining the
safety and efficacy of these agents in the peri-
operative period, it is reasonable to continue
these both on the day before surgery and the
day of surgery. Similarly, medical therapies
for growth hormone excess, including somato-
statin analogues (octreotide, lanreotide, and
paseriotide) and growth hormone antagonists
(pegvisomont) have also not been studied in
the perioperative period, but they are
typically continued without interruption.
Consensus Recommendation. Continue
pituitary medications both before and on
the day of surgery.
Androgenic Hormones
The category of androgenic hormones in-
cludes testosterone and methyltestosterone,
which are used for the treatment of hypogo-
nadism in men and advanced breast cancer
in women, and oxymetholone, which is
used for the treatment of cancer-associated
anemia. Another indication for androgenic
hormone use is transgender hormone
therapy. Despite concerns for increased risk
for thromboembolism in the nonsurgical
population, available literature has not
demonstrated an association between
perioperative thromboembolic events and
androgenic hormone use.43,44
Consensus Recommendation. Continue
androgenic hormones medications both
before and on the day of surgery, but
consider the potential for postoperative
venous thromboembolism (VTE) risk.
Estrogens
Estrogens are used for treatment of postmen-
opausal estrogen withdrawal symptoms
(estradiol, conjugated estrogens, and
June 2021;96(6):1655-1669 https://doi.org/10.1016/j.mayocp.2020.10.002
www.mayoclinicproceedings.org
ENDOCRINE AND UROLOGIC PREOPERATIVE MEDICATION MANAGEMENT
estropipate) and as part of estrogen-
containing contraceptives (ethinyl estradiol).
Like androgens, they are also used as gender
affirmation therapy. Estrogens are associated
with an increased risk of VTE, and the risk
rises with increasing estrogen content and
age. Despite the widespread use of estrogens,
data on the risk of postoperative VTE with
estrogens are sparse and limited to small,
older studies. One study of patients taking
postmenopausal hormone replacement ther-
apy (which contains much lower doses of
estrogen) showed no increased VTE risk af-
ter major orthopedic surgery.45 Manufac-
turer package inserts for both oral
contraceptives and hormone replacement
therapy recommend discontinuation of these
medications 4 weeks before major surgery,
but this is based on evidence of VTE risk
in the general population. The risks of
discontinuation, including undesired preg-
nancy (even when alternative contraception
methods are used), must be carefully
balanced against the potential for VTE.
Consensus Recommendation. Continue
estrogens both before and on the day of sur-
gery, but consider potential for increased
risk of VTE if continued and pregnancy
risk if withheld (if taken for contraception).
Progestins
Available progestins include megestrol,
levonorgestrel, progesterone, hydroxypro-
gesterone, norethindrone, medroxyproges-
terone, etonogestrel, and drospirenone.
There is no literature addressing periopera-
tive management of these medications.
Evidence from general population studies
of progestins shows minimal VTE risk asso-
ciated with progestin-only contraceptives.46
Consensus Recommendation. Continue
progestins both before and on the day of
surgery.
Selective Estrogen Receptor Modulators
Selective estrogen receptor modulators
(SERMs) are used primarily for breast cancer
prevention and treatment (toremifene,
tamoxifen, and raloxifene), but they are
Mayo Clin Proc. n June 2021;96(6):1655-1669 n https://doi.org/10.1016/j.mayocp.2020.10.002
www.mayoclinicproceedings.org
also prescribed for osteoporosis (raloxifene)
or postmenopausal vaginal atrophy (ospemi-
fene). All SERMs are associated with
increased thrombotic risk, although one
study of patients undergoing breast cancer
surgery found no association between
tamoxifen use and VTE.47 Studies have iden-
tified increased risk of breast reconstruction
wound complications in patients taking
tamoxifen.47,48 Balanced against these risks
are the unknown consequences of short-
term cessation of antiestrogen therapy in
patients with breast cancer.
Consensus Recommendations. Continue
SERMs both before and on the day of surgery
if taken for breast cancer prevention or treat-
ment, but consider potential for increased
wound complication and VTE risk if
continued. If SERMs are taken for other
indications and additional patient- or
surgery-specific risk factors for VTE are
present, stop SERMs at least 7 days before
surgery.
Aromatase Inhibitors
Aromatase inhibitors, including anastrozole,
exemestane, and letrozole interfere with
peripheral tissue production of estradiol,
and they are used in the treatment of breast
cancer. One retrospective cohort study
found an association between perioperative
aromatase inhibitor use and wound compli-
cations, but no other data on perioperative
management are available.47 The risk of
breast cancer recurrence from temporary
cessation is not known.
Consensus Recommendation. Continue
aromatase inhibitors both before and on
the day of surgery, but consider potential
for increased wound complications if
continued.
Bone and Calcium Disorder Medications
The category of bone and calcium disorder
medications includes recombinant parathy-
roid hormone preparations (teriparatide
and abaloparatide), which can be used in
the treatment of osteoporosis or hypopara-
thyroidism, and calcimimetics, such as
1663
 MAYO CLINIC PROCEEDINGS

TABLE 3. Summary of Recommendations for the Preoperative Management of Hormonal and Non-Diabetes Endocrine Medications
Administration Administration
before day of on morning of
Medication Class Examples surgery surgery Additional Considerations
Androgenic hormones Testosterone, methyltestosterone Continue Continue Consider potential for increased
risk for postoperative VTE.a
Antidiuretic hormone Desmopressin Continue Continue
Antithyroid medications Methimazole, propylthiouracil Continue Continue
Aromatase inhibitors Anastrozole, exemestane, letrozole Continue Continue Consider potential for increased
wound complications.
Bisphosphonates Continue Hold
Calcimetics Cinacalcet, etelcalcetide Continue Continue
Calcitonin Continue Continue
Corticosteroids, systemic Betamethasone, triamcinolone, Continue Continue Patients on longer term, higher
hydrocortisone, cortisone, prednisone, dose therapy may need
methylprednisolone, budesonide, supplemental dosing
dexamethasone, fludricortisone intraoperatively and
postoperatively.
Denosumab Continue Continue
Dopamine agonists, pituitary Cabergoline, bromocriptine Continue Continue
Estrogens Estradiol, conjugated estrogens, estropipate, Continue Continue Consider potential for increased
ethinyl estradiol risk of postoperative VTE if
continued and pregnancy risk if
withheld (if taken for
contraception).
Growth hormone Somatotropin Continue Continue
Growth hormone antagonist Pegvisomont Continue Continue
Growth hormone-releasing Tesamorelin Continue Continue
hormone analog
Parathyroid analogues Teriparatide, abaloparatide Continue Continue
Progestins Megestrol, levonorgestrel, progesterone, Continue Continue
hydroxyprogesterone, norethindrone,
medroxyprogesterone, etonogestrel,
drospirenone
Recombinant insulin-like growth Mecasermin Continue Continue
factor-1
Repository corticotropin Continue Continue
b
SERMs Toremifene, tamoxifen, raloxifene, Continue Continueb Consider potential for increased
ospemifene wound complications and VTE
risk if continued. If not taken for
breast cancer prevention and
additional patient- or surgery-
specific risk factors for VTE are
present, stop at least 7 days
prior to surgery.
Somatostatin analogs Octerotide, lanreotide, paseriotide Continue Continue
Thyroid replacement Levothyroxine, liothyronine, thyroid extract Continue Continue
a
SERMs, selective estrogen receptor modulators; VTE, venous thromboembolism.
b
See additional considerations.

n n
1664 Mayo Clin Proc. June 2021;96(6):1655-1669 https://doi.org/10.1016/j.mayocp.2020.10.002
www.mayoclinicproceedings.org
ENDOCRINE AND UROLOGIC PREOPERATIVE MEDICATION MANAGEMENT
cinacalcet and etelcalcetide, which are used
for the treatment of hyperparathyroidism.
Calcitonin inhibits osteoclasts and is used
to reduce bone resorption in osteoporosis
and Paget disease; it is also used to treat
hypercalcemia of malignancy. In the absence
of any data suggesting potential harm, all
these medications should be continued in
the perioperative period. Similarly, other
medications used in the treatment of osteo-
porosis, including bisphosphonates and
denosumab, have no data suggesting periop-
erative risks. Calcium and vitamin D also
appear to be safe, and recommendations for
these supplements are provided in another
article in this series. However, given the
risk of esophagitis when lying supine shortly
after ingestion and the potential for
decreased lower esophageal sphincter
pressure from anesthetics, bisphosphonates
should not be taken on the morning of
surgery.
Consensus Recommendation. Continue
parathyroid hormone, calcimimetics, calci-
tonin, and denosumab before surgery and
on the day of surgery. Bisphosphonates can
be taken before surgery, but they should
not be taken on the day of surgery.
Recommendations for hormonal and
nondiabetes endocrine medications are sum-
marized in Table 3.
UROLOGIC MEDICATIONS (TABLE 4)
Alpha-1 Adrenergic Antagonists
Among the urologic medications discussed
in this section, alpha-1 adrenergic antago-
nists are the most commonly prescribed
drugs for initial medical treatment of benign
prostatic hypertrophy (BPH). These medica-
tions antagonize the alpha-1 adrenoreceptor,
thereby inhibiting smooth muscle contrac-
tion, leading to decreased smooth muscle
tone in the prostatic urethra and bladder
neck.49 Medications of this class have similar
efficacies, but they differ in their level of uro-
selectivity. Less uroselective medications
(eg, doxazosin, terazosin, prazosin) are
more likely to result in hypotension than
Mayo Clin Proc. n June 2021;96(6):1655-1669 n https://doi.org/10.1016/j.mayocp.2020.10.002
www.mayoclinicproceedings.org
the more uroselective medications
(eg, alfuzosin, tamsulosin, silodosin).49,50
Literature supports that there may be a
reduced incidence of postoperative urinary
retention when these medications are
continued perioperatively.51 Cataract
surgeries in patients who are taking these
medications are associated with floppy iris
syndrome, and patients who take tamsulosin
seem to be at the highest risk.52,53 However,
discontinuation of the medication before
surgery does not necessarily eliminate the
risk.
Consensus Recommendations. Continue
alpha-1 adrenergic antagonists up to and
including the day of surgery. In patients
undergoing cataract surgery, consider dis-
cussion with the ophthalmologist.
5-Alpha Reductase Inhibitors
5-Alpha reductase inhibitors (5-ARIs) inhibit
the enzyme 5-alpha reductase, which con-
verts testosterone to dihydrotestosterone in
the prostate, reducing overall prostatic size.
Dutasteride and finasteride are the 5-ARIs
prescribed in the United States. No interac-
tion between 5-ARIs and anesthesia has
been noted in the literature, and some
studies show a reduction in estimated surgi-
cal blood loss during transurethral resection
of the prostate surgery in patients who take
finasteride.54-56
Consensus Recommendation. Continue 5-
ARIs up to and including the day of surgery.
Anticholinergic Bladder Dysfunction
Medications
Anticholinergic agents inhibit muscarinic
activity of the parasympathetic nervous
system and contribute to bladder detrusor
activity. Detrusor overactivity is responsible
for the symptoms of overactive bladder syn-
drome, which includes urinary frequency,
urgency, urge incontinence, and nocturia.
Most medications in this class act as compet-
itive antagonists to acetylcholine at the
muscarinic receptors with varying
selectivity. Available medications include
darifenacin, fesoterodine, oxybutynin,
1665
 MAYO CLINIC PROCEEDINGS

TABLE 4. Summary of Recommendations for the Preoperative Management of Urologic Medications

Management prior to the Management on the
Medication class Examples morning of surgery morning of surgery Additional considerations
5-Alpha reductase inhibitors Dutaseride, finasteride Continue Continue
Alpha-1 adrenergic antagonists Alfuzosin, doxazosin, prazosin, Continue Continue Prior to cataract surgery notify
silodosin, tamsulosin, terazosin ophthalmologist of
increased risk of floppy iris
syndrome
Anticholinergic bladder Darifenacin, fesoterodine, Continue Hold May reduce catheter-related
dysfunction medications flavoxate, oxybutynin, bladder discomfort but carry
solifenacin, tolterodine, trospium high potential for adverse
effects in older patients
Anti-neoplastic urologic Abiraterone acetate, apalutamide, Continue Continue
medications bicalutamide, degarelix,
enzalutamide, goserelin acetate,
leuprolide acetate, nilutamide
Betha chloride Continue Hold
Mirabegron Continue Hold
a
PDE-5 inhibitors Avanafil, sildenafil, tadalafil, Hold for 3 days (see Hold Recommendation is for
vardenafil additional urologic use of these
considerations) medications. Continue
uninterrupted if used for
pulmonary hypertension.
a
PDE-5, Laukkanen phosphodiesterase-5.

tolterodine, and trospium. Flavoxate acts hyperplasia, polycystic ovary syndrome,

directly on the bladder smooth muscle to
reduce contraction.
Although literature supports the use of
these medications perioperatively to reduce
catheter-related bladder discomfort for
patients undergoing urologic surgery pa-
tients, they have undesirable anticholinergic
adverse effects and can contribute to
delirium.57,58 For this reason, all medica-
tions in this class are considered cautionary
in older patients.59,60
Consensus Recommendation. Continue
before surgery but do not take anticholin-
ergic bladder dysfunction medications on
the morning of surgery.
Antineoplastic Urologic Medications
Medications used for the treatment of
prostate cancer primarily work by inhibiting
androgen release, synthesis, or activity. They
are also prescribed for other indications,
such as breast or uterine cancers, adrenal
alopecia, and gender affirmation therapy.
Abiraterone inhibits the CYP17A1 enzyme,
which is required for synthesis of androgens.
Apalutamide, bicalutamide, enzalutamide,
and nilutamide are nonsteroidal androgen
receptor inhibitors. Degarelix and goserelin
inhibit pituitary gonadotropin-releasing
hormone (GnRH) secretion, leading to a
reduction in testosterone release. Leuprolide
acetate is an agonist at the pituitary GnRH
receptors, and this eventually leads to
GnRH desensitization and decreased
hormone levels.
Known adverse effects of these medica-
tions include: increased cardiovascular
risk, anemia, hepatic dysfunction, QT pro-
longation, interstitial lung disease, and
decreased bone density. However, there
are no perioperative studies for these medi-
cations, and most of these adverse effects
are chronic in nature or can be obviated
with appropriate screening and periopera-
tive precautions.

n n
1666 Mayo Clin Proc. June 2021;96(6):1655-1669 https://doi.org/10.1016/j.mayocp.2020.10.002
www.mayoclinicproceedings.org
ENDOCRINE AND UROLOGIC PREOPERATIVE MEDICATION MANAGEMENT
Consensus Recommendation. Continue
antineoplastic urologic medications up to
and including the day of surgery.
Phosphodiesterase Type 5 (PDE-5)
Inhibitors
PDE-5 inhibitors are used in the treatment of
erectile dysfunction, BPH, and pulmonary
hypertension (discussed in a separate
consensus statement in this series). These
medications selectively block the degrada-
tion of cyclic GMP by the PDE-5 enzyme,
thereby leading to an increased production
of nitric oxide, relaxation of endothelial
smooth muscle cells, and vasodilation.
Available PDE-5 inhibitors in the United
States are avanafil, sildenafil, tadalafil, and
vardenafil, and these vary substantially in
their onset and duration of action (half-life
ranges 4-15 hours).
Investigations of safety during anesthesia
are applicable only to patients with pulmo-
nary hypertension. All these medications
have the potential to cause intraoperative
hypotension, and no studies have deter-
mined safe timing of anesthesia after use.
Consensus Recommendation. If taken for
erectile dysfunction or BPH, hold PDE-5
inhibitors for 3 days before surgery.
Other Urologic Medications
Bethanechol chloride stimulates the release
of acetylcholine with selective activity at
the muscarinic receptor, thereby leading to
detrusor muscle stimulation and treatment
of urinary retention. Bethanechol has been
studied for the prevention of postoperative
urinary retention, and it has shown a modest
benefit.61 However, given its effects on
acetylcholine, it also has the potential for
interaction with anesthetic agents.
Mirabegron is used in the treatment of
overactive bladder syndrome; similar to anti-
cholinergic agents, it works by relaxing
detrusor smooth muscles, but it does so by
stimulating the beta-3 adrenoreceptor
located in the detrusor muscle. Mirabegron
can lead to hypertension, but no periopera-
tive data on this medication were identified.
Mayo Clin Proc. n June 2021;96(6):1655-1669
www.mayoclinicproceedings.org
Consensus Recommendation. Continue
bethanechol and mirabegron up to the day
before surgery, but hold on the morning of
surgery.
CONCLUSION
Perioperative medication management is a
critical part of optimal care of surgical
patients. Instructional literature to support
best practices in this area remains lacking,
and perioperative decision making is
primarily guided by knowledge of medica-
tion mechanisms of action and adverse effect
profiles. Summarized in Tables 1-4, this
consensus statement provides recommenda-
tions of experts in anesthesiology, internal
medicine, perioperative medicine, and
medical subspecialties for the management
of common endocrine, hormonal, and
urologic medications.
Abbreviations and Acronyms: 5-ARI = 5-alpha reductase
inhibitors; ADA = American Diabetes Association; AGI = a-
glucosidase inhibitor; BPH = benign prostatic hypertrophy;
DM = diabetes mellitus; DPP-4 = dipeptidyl peptidase-4;
FDA = US Food and Drug Administration; GFR =
glomerular filtration rate; GI = gastrointestinal; GLP-1 =
glucagon-like peptide-1; GnRH = gonadotropin-releasing
hormone; NPH = neutral protamine Hagedorn; PDE =
phosphodiesterase; PDE-5 = phosphodiesterase type 5;
SGLT-2 = sodium glucose co-transporter 2; SPAQI = So-
ciety for Perioperative Assessment and Quality Improve-
ment; VTE = venous thromboembolism
Affiliations (Continued from the first page of this
article.): State Wexner Medical Center, Columbus (B.R.);
Division of Endocrinology, Mayo Clinic, Rochester, MN
(V.S.); Division of General Internal Medicine, Mayo Clinic,
Rochester, MN (D.R.); Department of Anesthesiology, Peri-
operative and Pain Medicine, Brigham and Women’s Hospi-
tal, Boston, MA (R.D.U.); and Division of General Internal
Medicine, Mayo Clinic, Rochester, MN (K.M.)
Potential Competing Interests: The authors report no
competing interests.
Correspondence: Address to Kurt J. Pfeifer, MD, Depart-
ment of Medicine, Medical College of Wisconsin, 9200
West Wisconsin Ave, Milwaukee, WI 53226 (kpfeifer@
mcw.edu; Twitter: @KurtPfeifer).
ORCID
Kurt J. Pfeifer: https://orcid.org/0000-0003-3982-8190;
Barbara Rogers: https://orcid.org/0000-0002-5135-6475
n https://doi.org/10.1016/j.mayocp.2020.10.002 1667
 MAYO CLINIC PROCEEDINGS

REFERENCES 19. Tirkkonen T, Heikkila P, Huupponen R, Laine K. Potential

CYP2C9-mediated drug-drug interactions in hospitalized type
1. Wong J, An D, Urman RD, et al. Society for Perioperative
2 diabetes mellitus patients treated with the sulphonylureas gli-
Assessment and Quality Improvement (SPAQI) consensus
benclamide, glimepiride or glipizide. J Intern Med. 2010;268(4):
statement on perioperative smoking cessation. Anesth Analg.
359-366.
2020;131(3):955-968.
20. Dornhorst A. Insulinotropic meglitinide analogues. Lancet.
2. Arias F, Wiggins M, Urman RD, et al. Rapid in-person cognitive
2001;358(9294):1709-1716.
screening in the preoperative setting: Test considerations and
21. Ahmadian M, Suh JM, Hah N, et al. PPARgamma signaling and
recommendations from the Society for Perioperative
metabolism: The good, the bad and the future. Nat Med. 2013;
Assessment and Quality Improvement (SPAQI). J Clin Anesth.
19(5):557-566.
2020;62:109724.
22. Komoroski B, Vachharajani N, Boulton D, et al. Dapagliflo-
3. Alvarez-Nebreda ML, Bentov N, Urman RD, et al. Recommen-
zin, a novel SGLT2 inhibitor, induces dose-dependent glu-
dations for Preoperative Management of Frailty from the
cosuria in healthy subjects. Clin Pharmacol Ther. 2009;85(5):
Society for Perioperative Assessment and Quality Improve-
520-526.
ment (SPAQI). J Clin Anesth. 2018;47:33-42.
23. Vasilakou D, Karagiannis T, Athanasiadou E, et al. Sodium-
4. O’Rourke MJKM, Keshock MC, Boxhorn CE, et al. Preoperative
glucose cotransporter 2 inhibitors for type 2 diabetes: A sys-
management of opioid and non-opioid analgesics: Society for
tematic review and meta-analysis. Ann Intern Med. 2013;
Perioperative Assessment and Quality Improvement (SPAQI)
159(4):262-274.
consensus statement. Mayo Clin Proc. 2020.
24. Kuzulugil D, Papeix G, Luu J, Kerridge RK. Recent advances in
5. Demma LJ, Carlson KT, Duggan EW, Morrow JG 3rd,
diabetes treatments and their perioperative implications. Curr
Umpierrez G. Effect of basal insulin dosage on blood glucose
Opin Anaesthesiol. 2019;32(3):398-404.
concentration in ambulatory surgery patients with type 2 dia-
25. US Food and Drug Administration. FDA Approves Label
betes. J Clin Anesth. 2017;36:184-188.
Changes to SGLT2 Inhibitors Regarding Temporary Discontinu-
6. Rosenblatt SI, Dukatz T, Jahn R, et al. Insulin glargine dosing
ation of Medication Before Scheduled Surgery. 2020. Available at:
before next-day surgery: Comparing three strategies. J Clin
http://s2027422842.t.en25.com/e/es?s¼2027422842&e¼3122
Anesth. 2012;24(8):610-617.
20&elqTrackId¼376c7bc788024cd5a73d955f2e3dcbdc&e
7. 15. Diabetes Care in the Hospital: Standards of Medical Care in
lq¼88805802632f4dc88dd18426307959d3&elqaid¼11643&
Diabetesd2020. Diabetes Care. 2020;43(Suppl 1):S193-S202.
elqat¼1. Accessed May 12, 2020.
8. Simha V, Shah P. Perioperative glucose control in patients with
26. Drucker DJ. Mechanisms of action and therapeutic application
diabetes undergoing elective surgery. JAMA. 2019;321(4):399-
of glucagon-like peptide-1. Cell Metab. 2018;27(4):740-756.
400.
27. Meier JJ. GLP-1 receptor agonists for individualized treatment
9. Derosa G, Maffioli P. Efficacy and safety profile evaluation of
of type 2 diabetes mellitus. Nat Rev Endocrinol. 2012;8(12):
acarbose alone and in association with other antidiabetic drugs:
728-742.
A systematic review. Clin Ther. 2012;34(6):1221-1236.
28. Hulst AH, Visscher MJ, Godfried MB, et al. Liraglutide for
10. Nathan DM, Buse JB, Davidson MB, et al. Medical management of
perioperative management of hyperglycaemia in cardiac surgery
hyperglycemia in type 2 diabetes: A consensus algorithm for the
patients: A multicentre randomized superiority trial. Diabetes
initiation and adjustment of therapy: A consensus statement of
Obes Metab. 2020;22(4):557-565.
the American Diabetes Association and the European Association
29. Polderman JAW, van Steen SCJ, Thiel B, et al. Peri-operative
for the Study of Diabetes. Diabetes Care. 2009;32(1):193-203.
management of patients with type-2 diabetes mellitus
11. Salpeter SR, Greyber E, Pasternak GA, Salpeter
undergoing non-cardiac surgery using liraglutide, glucose-
Posthumous EE. Risk of fatal and nonfatal lactic acidosis with
insulin-potassium infusion or intravenous insulin bolus regi-
metformin use in type 2 diabetes mellitus. Cochrane Database
mens: A randomised controlled trial. Anaesthesia. 2018;
Syst Rev. 2010;(4):CD002967.
73(3):332-339.
12. Duncan AI, Koch CG, Xu M, et al. Recent metformin ingestion
30. Hulst AH, Plummer MP, Hollmann MW, et al. Systematic
does not increase in-hospital morbidity or mortality after car-
review of incretin therapy during peri-operative and intensive
diac surgery. Anesth Analg. 2007;104(1):42-50.
care. Crit Care. 2018;22(1):299.
13. El Messaoudi S, Nederlof R, Zuurbier CJ, et al. Effect of metfor-
31. Drucker DJ, Nauck MA. The incretin system: glucagon-like
min pretreatment on myocardial injury during coronary artery
peptide-1 receptor agonists and dipeptidyl peptidase-4 in-
bypass surgery in patients without diabetes (MetCAB): a
hibitors in type 2 diabetes. Lancet. 2006;368(9548):1696-
double-blind, randomised controlled trial. Lancet Diabetes Endo-
1705.
crinol. 2015;3(8):615-623.
32. Pasquel FJ, Gianchandani R, Rubin DJ, et al. Efficacy of sitagliptin
14. Deden LN, Aarts EO, Aelfers SCW, et al. Risk of metformin-
for the hospital management of general medicine and surgery
associated lactic acidosis (MALA) in patients after gastric bypass
patients with type 2 diabetes (Sita-Hospital): a multicentre,
surgery. Obes Surg. 2018;28(4):1080-1085.
prospective, open-label, non-inferiority randomised trial. Lancet
15. Nazer RI, Alburikan KA. Metformin is not associated with lactic
Diabetes Endocrinol. 2017;5(2):125-133.
acidosis in patients with diabetes undergoing coronary artery
33. Umpierrez GE, Cardona S, Chachkhiani D, et al. A randomized
bypass graft surgery: A case control study. BMC Pharmacol Tox-
controlled study comparing a DPP4 inhibitor (Linagliptin) and
icol. 2017;18(1):38.
basal insulin (Glargine) in patients with type 2 diabetes in
16. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hy-
long-term care and skilled nursing facilities: Linagliptin-LTC trial.
perglycemia in type 2 diabetes: a patient-centered approach:
J Am Med Dir Assoc. 2018;19(5):399-404.e393.
Position statement of the American Diabetes Association
34. Garg R, Schuman B, Hurwitz S, Metzger C, Bhandari S. Safety
(ADA) and the European Association for the Study of Diabetes
and efficacy of saxagliptin for glycemic control in non-critically
(EASD). Diabetes Care. 2012;35(6):1364-1379.
ill hospitalized patients. BMJ Open Diabetes Res Care. 2017;
17. Deusenberry CM, Coley KC, Korytkowski MT, Donihi AC. Hy-
5(1):e000394.
poglycemia in hospitalized patients treated with sulfonylureas.
35. Cardona S, Tsegka K, Pasquel FJ, et al. Sitagliptin for the
Pharmacotherapy. 2012;32(7):613-617.
prevention of stress hyperglycemia in patients without diabetes
18. Mohr JF, McKinnon PS, Peymann PJ, Kenton I, Septimus E,
undergoing coronary artery bypass graft (CABG) surgery. BMJ
Okhuysen PC. A retrospective, comparative evaluation of dys-
Open Diabetes Res Care. 2019;7(1):e000703.
glycemias in hospitalized patients receiving gatifloxacin, levo-
36. Fayfman M, Davis G, Duggan EW, et al. Sitagliptin for
floxacin, ciprofloxacin, or ceftriaxone. Pharmacotherapy. 2005;
prevention of stress hyperglycemia in patients without diabetes
25(10):1303-1309.

n n
1668 Mayo Clin Proc. June 2021;96(6):1655-1669 https://doi.org/10.1016/j.mayocp.2020.10.002
www.mayoclinicproceedings.org
ENDOCRINE AND UROLOGIC PREOPERATIVE MEDICATION MANAGEMENT
undergoing general surgery: A pilot randomized study.
J Diabetes Complications. 2018;32(12):1091-1096.
37. Nauck MA, Meier JJ, Cavender MA, Abd El Aziz M, Drucker DJ.
Cardiovascular actions and clinical outcomes with glucagon-like
peptide-1 receptor agonists and dipeptidyl peptidase-4
inhibitors. Circulation. 2017;136(9):849-870.
38. Syed AU, El Watidy AF, Akhlaque NB, et al. Coronary bypass
surgery in patients on thyroxin replacement therapy. Asian
Cardiovasc Thorac Ann. 2002;10(2):107-110.
39. Nurok M, Cheng J, Romeo GR, Vecino SM, Fields KG,
YaDeau JT. Dexamethasone and perioperative blood glucose
in patients undergoing total joint arthroplasty: A retrospective
study. J Clin Anesth. 2017;37:116-122.
40. Tien M, Gan TJ, Dhakal I, et al. The effect of anti-emetic doses
of dexamethasone on postoperative blood glucose levels in
non-diabetic and diabetic patients: A prospective randomised
controlled study. Anaesthesia. 2016;71(9):1037-1043.
41. Woodcock T, Barker P, Daniel S, et al. Guidelines for the
management of glucocorticoids during the peri-operative
period for patients with adrenal insufficiency. Anaesthesia.
2020;75(5):654-663.
42. Goodman SM, Springer B, Guyatt G, et al. 2017 American Col-
lege of Rheumatology/American Association of Hip and Knee
Surgeons Guideline for the Perioperative Management of
Antirheumatic Medication in Patients With Rheumatic Diseases
Undergoing Elective Total Hip or Total Knee Arthroplasty.
Arthritis Care Res (Hoboken). 2017;69(8):1111-1124.
43. Argalious MY, Steib J, Daskalakis N, et al. Association of testos-
terone replacement therapy and the incidence of a composite
of postoperative in-hospital mortality and cardiovascular events
in men undergoing cardiac surgery. Anesth Analg. 2020;130(4):
890-898.
44. Argalious MY, You J, Mao G, et al. Association of testosterone
replacement therapy and the incidence of a composite of
postoperative in-hospital mortality and cardiovascular events
in men undergoing noncardiac surgery. Anesthesiology. 2017;
127(3):457-465.
45. Hurbanek JG, Jaffer AK, Morra N, Karafa M, Brotman DJ.
Postmenopausal hormone replacement and venous thrombo-
embolism following hip and knee arthroplasty. Thromb
Haemost. 2004;92(2):337-343.
46. Tepper NK, Whiteman MK, Marchbanks PA, James AH,
Curtis KM. Progestin-only contraception and thromboembo-
lism: A systematic review. Contraception. 2016;94(6):678-700.
47. Billon R, Bosc R, Belkacemi Y, et al. Impact of adjuvant anti-
estrogen therapies (tamoxifen and aromatase inhibitors) on
perioperative outcomes of breast reconstruction. J Plast
Reconstr Aesthet Surg. 2017;70(11):1495-1504.
48. Parikh RP, Odom EB, Yu L, Colditz GA, Myckatyn TM. Compli-
cations and thromboembolic events associated with tamoxifen
therapy in patients with breast cancer undergoing microvascular
breast reconstruction: A systematic review and meta-analysis.
Breast Cancer Res Treat. 2017;163(1):1-10.
49. Oelke M, Bachmann A, Descazeaud A, et al. EAU guidelines on
the treatment and follow-up of non-neurogenic male lower
Mayo Clin Proc. n June 2021;96(6):1655-1669 n https://doi.org/10.1016/j.mayocp.2020.10.002
www.mayoclinicproceedings.org
urinary tract symptoms including benign prostatic obstruction.
Eur Urol. 2013;64(1):118-140.
50. Lepor H, Hill LA. Silodosin for the treatment of benign pros-
tatic hyperplasia: pharmacology and cardiovascular tolerability.
Pharmacotherapy. 2010;30(12):1303-1312.
51. Patel DN, Felder SI, Luu M, Daskivich TJ, Zaghiyan KN,
Fleshner P. Early urinary catheter removal following pelvic colo-
rectal surgery: A prospective, randomized, noninferiority trial.
Dis Colon Rectum. 2018;61(10):1180-1186.
52. Prata TS, Palmiero PM, Angelilli A, et al. Iris morphologic
changes related to alpha(1)-adrenergic receptor antagonists
implications for intraoperative floppy iris syndrome.
Ophthalmology. 2009;116(5):877-881.
53. Chang DF, Campbell JR. Intraoperative floppy iris syndrome
associated with tamsulosin. J Cataract Refract Surg. 2005;31(4):
664-673.
54. Aminsharifi A, Salehi A, Noorafshan A, Aminsharifi A, Alnajar K.
Effect of preoperative finasteride on the volume or length
density of prostate vessels, intraoperative, postoperative blood
loss during and after monopolar transurethral resection of pros-
tate: A dose escalation randomized clinical trial using stereolog
methods. Urol J. 2016;13(1):2562-2568.
55. Bansal A, Arora A. Transurethral resection of prostate and
bleeding: A prospective, randomized, double-blind placebo-
controlled trial to see the efficacy of short-term use of
finasteride and dutasteride on operative blood loss and
prostatic microvessel density. Journal of endourology. 2017;
31(9):910-917.
56. Zhu YP, Dai B, Zhang HL, Shi GH, Ye DW. Impact of pre-
operative 5a-reductase inhibitors on perioperative blood
loss in patients with benign prostatic hyperplasia: A meta-
analysis of randomized controlled trials. BMC Urol. 2015;
15:47.
57. Chung JM, Ha HK, Kim DH, et al. Evaluation of the efficacy of
solifenacin for preventing catheter-related bladder discomfort
after transurethral resection of bladder tumors in patients
with non-muscle invasive bladder cancer: A prospective,
randomized, multicenter study. Clin Genitourin Cancer. 2017;
15(1):157-162.
58. Srivastava VK, Nigam R, Agrawal S, Kumar S, Rambhad S,
Kanaskar J. Evaluation of the efficacy of solifenacin and
darifenacin for prevention of catheter-related bladder
discomfort: A prospective, randomized, placebo-
controlled, double-blind study. Minerva Anestesiol. 2016;
82(8):867-873.
59. 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.
60. Wagg A, Verdejo C, Molander U. Review of cognitive
impairment with antimuscarinic agents in elderly patients
with overactive bladder. Int J Clin Pract. 2010;64(9):1279-
1286.
61. Lim SW, Kwoun SP. The effect of oral premedication using
bethanechol on bladder dysfunction following spinal anesthesia.
Korean J Anesthesiol. 1999;37(4):551-555.
1669