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Whether to stop antithrombotics during vitreoretinal surgery depends on case, patient
Clinical judgment is the most important factor in deciding whether medications should be interrupted.
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Vitreoretinal surgeries do not always require the discontinuation of antithrombotics, and visual outcomes are usually the same whether or not patients continue their antithrombotic therapy, according to one ophthalmologist.
A number of recent studies indicate that continuing antithrombotic treatments during surgery “does not have the detrimental effects that we might think, and their discontinuation may place patients at a higher risk for thromboembolic complications,” Andrew J. McClellan, MD, told Ocular Surgery News. “Therefore, the decision should really be part of the informed consent process, a decision made between the patient and the surgeon, as well as a decision between the patient’s internist and ophthalmologist.”
Also weighing into that decision should be the exact procedure being performed and the risk for bleeding complications as ascertained by the surgeon.
McClellan was the lead author of an editorial, published in American Journal of Ophthalmology, on the use of perioperative antithrombotics in posterior segment ocular surgery.
“Some of the medical literature suggests that antithrombotics should always be discontinued,” McClellan said.
Referring to an article in The New England Journal of Medicine on managing antithrombotic therapy in patients undergoing invasive procedures in which vitreoretinal surgery was deemed “high risk” for bleeding complications, McClellan said he and colleagues thought such a classification was unnecessarily rigid and should be more flexible.
Decision-making
Still, McClellan stops short of stating that vitreoretinal surgeons are too conservative in their decision-making about suspending antithrombotics.
“Not all retinal surgeries are equal, and not all retinal diseases are equal,” he said.
For instance, a standard rhegmatogenous retinal detachment has a much different risk-of-bleeding profile than a diabetic tractional retinal detachment with active proliferative disease.
“In other words, a vascular disease is going to have a much different likelihood of bleeding as opposed to a nonvascular disease,” McClellan said.
According to specialists at Bascom Palmer Eye Institute, clinical judgment is the most important deciding factor, especially in retina surgery. Newer systemic antithrombotics such as Effient (prasugrel, Eli Lilly and Company) and Pradaxa (dabigatran etexilate mesylate, Boehringer Ingelheim Pharmaceuticals) have muddied the water, though.
“These medications are not monitored with blood tests, as is the case with old-fashioned warfarin that we are so familiar with,” McClellan said. “On the other hand, the advantage of these newer medications is that they do not require monitoring, despite being slightly more difficult in knowing exactly when it is acceptable to proceed with surgery.”
McClellan believes the trend with newer agents is to continue therapy during the perioperative period.
“Surgeons do not need to question whether the patient is back to a normal state of coagulation or not,” he said.
However, McClellan encourages eye care physicians to keep current on new antithrombotics.
“When you are looking at a list of a patient’s medications on electronic medical records, for example, it is important to realize if the patient is on one or more of these medications,” he said.
Goals of surgery
The goal of surgery is threefold: successful completion of surgery, a postoperative period that is not complicated by bleeding and avoidance of an adverse event that the antithrombotics were preventing in the first place.
McClellan is aware of a number of articles in the literature that address the risk of bleeding with anti-VEGF injections for age-related macular degeneration or any specific type of injection for patients on antithrombotics. The consensus is that these medications do not need to be discontinued.
“My overall feeling is that these injections do not carry a high risk of bleeding during the procedure,” he said.
“There is always a concern about the increased risk of stroke, heart attack or a deep vein thrombosis in the leg, and these should be weighed against the risk of hemorrhagic complications from the procedure,” McClellan said. – by Bob Kronemyer
References:
McClellan AJ, et al. Am J Ophthalmol. 2014;doi:10.1016/j.ajo.2014.08.003.Baron TH, et al. N Engl J Med. 2013;doi:10.1056/NEJMra1206531.
For more information:
Andrew J. McClellan, MD, can be reached at Bascom Palmer Eye Institute, University of Miami, Miller School of Medicine, 900 NW 17 St., Miami, FL 33133; 305-326-6000; email: andrew.mcclellan@med.miami.edu.Disclosure: McClellan has no relevant financial disclosures.
Perspective
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Andrew P. Schachat, MD
McClellan and colleagues offer thoughtful comments on the use of perioperative antithrombotics in posterior segment surgery. Once we recognize a patient is taking one of these drugs, it makes sense to understand why the patient is using it. For aspirin, it is my experience that some patients are not using it at the direction of their physician. Some assume it “must be good” or are taking it “just in case.” If a patient is using a medication for which there is no evidence it is helpful for them, I vote to stop it before surgery.
If you make a recommendation that a medication be stopped, do so rationally. To avoid aspirin’s antiplatelet activity, it needs to be stopped about 10 days before. If an antithrombotic is medically indicated, there is some benefit for the patient to be on it; stopping it risks loss of that benefit so know the literature that teaches if the ophthalmic risks presumably being avoided will be in balance with the risks to the patient of stopping the medicine.
There is scant data here to guide us. As far as aspirin and cataract surgery, the AAO Preferred Practice Pattern concludes, “There is insufficient evidence to recommend continuation or discontinuation of anticoagulant or antiplatelet therapy for cataract surgery.” For back of the eye surgery, McClellan concludes that “Physicians should weigh the risks and benefits of these agents and use their best clinical judgment for each individual patient.” Because I am not current on the new antithrombotic agents, my approach has been to advise the primary physician that eye surgery is anticipated and if the prescribing doctor believes it would be safe to stop the medicine before surgery, I would do so. If not, the incremental bleeding risk is likely low and usually manageable.
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