Should mesalamine be stopped prior to noncardiac surgery to avoid bleeding complications?

A 53-year-old Caucasian male with a past medical history of Crohn's disease, hypertension, hypercholesterolemia, osteoarthritis and atrial fibrillation takes mesalamine (Asacol) to control his diarrhea. His other medications include atenolol, warfarin and simvastatin. He also takes oxycodone and acetaminophen prn for hip pain. The physical examination is normal apart from irregularly irregular cardiac rhythm. The electrocardiogram shows atrial fibrillation with heart rate of 67 beats per minute. His exercise tolerance corresponds to 6 METs.

The patient is seen by an internal medicine physician for preoperative evaluation one week prior to surgery for total knee replacement for osteoarthritis of the left hip.

The patient inquires whether she should stop mesalamine to avoid bleeding complications during surgery. His primary care physician told him that non-steroidal anti-inflammatory drugs (NSAIDs) may increase the bleeding risk.

Should we stop mesalamine to avoid bleeding complications during surgery?

No.

Mesalamine (Asacol) does not affect platelets the same way aspirin and other NSAIDs do.

According to one study, there was not effect on platelet aggregation during normal treatment with 5-aminosalicylic acid when given at a dose of 1.5 gm po qd or even after IV administration. All in vivo and in vitro tests were negative for inhibition of platelet aggregation in contrast to the inhibition seen with aspirin (acetylsalicylic acid). Authors concluded that treatment with mesalazine does not constitute a hazard to patients with IBD in regard to prolonged bleeding time caused by an influence on platelet aggregation or fibrinolytic activity.

This is one of the series of perioperative questions I will answer on this web site. They will be submitted as clinical vignettes to the Cleveland Clinic Annual Perioperative Summit next year. This year's summit is in September and several of the perioperative cases in nephrology will be presented as posters and published as abstracts in the Cleveland Clinic Journal of Medicine.

References:
Lack of effect of 5-aminosalicylic acid on platelet aggregation and fibrinolytic activity in vivo and in vitro. Winther K, Bondesen S, Hansen SH, Hvidberg EF. Eur J Clin Pharmacol. 1987;33(4):419-22.
Image source: Wikipedia, Free Documentation License.

Updated: 12/14/2009

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