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peri_operative_medication_management [2026/03/23 21:04] – Scott Larsonperi_operative_medication_management [2026/04/09 03:30] (current) – Scott Larson
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 ====== Peri-Operative Medication Management ====== ====== Peri-Operative Medication Management ======
-FIXME+
 ====Cardiovascular and Hypertensive Medication==== ====Cardiovascular and Hypertensive Medication====
   * Beta Blockers- continue through surgery    * Beta Blockers- continue through surgery 
Line 45: Line 45:
       * Sitagliptin (Januvia), Saxagliptin (Ongliza), Linagliptin (Tradjenta), Alogliptin (Nesina)       * Sitagliptin (Januvia), Saxagliptin (Ongliza), Linagliptin (Tradjenta), Alogliptin (Nesina)
  
-===Hormone Medications===+====Hormone Medications====
   * Oral Contraceptives   * Oral Contraceptives
     * Low risk surgery for VTE can continue     * Low risk surgery for VTE can continue
Line 84: Line 84:
   * SPINAL OR EPIDURAL ANESTHESIA—hold Factor Xa inhibitors or Direct Thrombin Inhibitor 72 hours minimum before procedure.   * SPINAL OR EPIDURAL ANESTHESIA—hold Factor Xa inhibitors or Direct Thrombin Inhibitor 72 hours minimum before procedure.
  
-====Psychiatric Medications===+====Psychiatric Medications====
   * TCA—continue through surgery   * TCA—continue through surgery
   * SSRIs—may affect platelet function, generally continue   * SSRIs—may affect platelet function, generally continue
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       * For Stage 2 of the procedure, patients can continue their Parkinson medications as prescribed.       * For Stage 2 of the procedure, patients can continue their Parkinson medications as prescribed.
       * If DBS is being done as a Stage 1 procedure under general anesthesia, patients can take all usual Parkinson medications like normal up to and including the day of surgery.       * If DBS is being done as a Stage 1 procedure under general anesthesia, patients can take all usual Parkinson medications like normal up to and including the day of surgery.
 +    * Sinemet (levodopa/carbidopa)and Dopamine agonist—continue through surgery if patient will be taking oral meds. If expected period NPO (greater than or equal to several days) decrease dose by half the week prior to surgery to avoid Parkinsonism Hyperpyrexia Syndrome.
 +    * If patient is on a transdermal patch for Parkinson’s/dystonia (e.g. Neupro), apply according to schedule to avoid post-op rigidity but apply out of surgical field
 +  * MAOB-hold two weeks prior to surgery
 +  * Myasthenia Gravis
 +    * Pyridostigmine-continue as ordered, give day of surgery
  
-b) Sinemet (levodopa/carbidopa)and Dopamine agonist—continue through surgery if patient will be taking oral meds. If expected period NPO (greater than or equal to several days) decrease dose by half the week prior to surgery to avoid Parkinsonism Hyperpyrexia Syndrome.+====Rheumatologic Medications====
  
-c) If patient is on a transdermal patch for Parkinson’s/dystonia (e.g. Neupro), apply according to schedule to avoid post-op rigidity but apply out of surgical field+===Non-biologic DMARDS===
  
-MAOB-hold two weeks prior to surgery+  * Sulfasalazine, azathioprine, mycophenolate (Cellcept), cyclophosphamide—consider holding one week prior to surgery due to neutropenia 
 +  * Methotrexate, hydroxychloroquine, leflunomide—continue through surgery 
 +  * Nonacetylated NSAIDs (i.e. salsalate) have no effect on platelets and can continue through surgery
  
-Myasthenia Gravis+===Biologic DMARDS=== 
 +  * Best to discuss with Rheumatology and/or Surgeon for guidance of management in the Perioperative period. 
 +  * Hold for 2-3 half-lives before surgery—restart with wound closure ~ 2 weeks after surgery. Consult with rheumatology if any questions about medication management.
  
-a) Pyridostigmine-continue as ordered, give day of surgery+===TNF Blockers===
  
-9.  Rheumatologic Medications+  * Etanercept (Enbrel)—t ½ 3.5-5.5d, hold 7-10 days prior to surgery 
 +  * Apremilast (Otezla)— 
 +  * Infliximab (Remicade)—t ½ 9.5d, hold 3 weeks prior to surgery 
 +  * Adalimumab (Humira)—t ½ 10-20d, hold 4 weeks prior to surgery 
 +  * Certolizumab (Cimzia)—t ½ 14d, hold 4 weeks prior to surgery 
 +  * Golimumab (Simponi)—t ½ 14d, hold 4 weeks prior to surgery
  
-Non-biologic DMARDS+===PDE-4 Inhibitor===
  
-a)Sulfasalazine, azathioprine, mycophenolate (Cellcept), cyclophosphamide—consider holding one week prior to surgery due to neutropenia+  * Apremilast (Otezla) - t ½ 6-9 hrs, hold 3 days prior and resume when stitches are out
  
-b)Methotrexate, hydroxychloroquine, leflunomide—continue through surgery+===T cell costimulator===
  
-c)Nonacetylated NSAIDs (i.e. salsalate) have no effect on platelets and can continue through surgery+  * Abatacept (Orencia)—t ½ 13d, hold 4 weeks prior to surgery
  
-Biologic DMARDS-Best to discuss with Rheumatology and/or Surgeon for guidance of management in the Perioperative period.+===Interleukins antagonist===
  
-a)Hold for 2-3 half-lives before surgery—restart with wound closure ~ 2 weeks after surgery. Consult with rheumatology if any questions about medication management.+  * Tocilizumab (Actemra)—t ½ 11-13d, hold 3 weeks prior to surgery 
 +  * Anakinra (Kineret)—t ½ 4-6 hrs, hold 1 day prior to surgery
  
-i.TNF Blockers+===B cell depleting agent and other biological modifiers===
  
-Etanercept (Enbrel)—t ½ 3.5-5.5d, hold 7-10 days prior to surgery+  * Rituximab (Rituxan)—t ½ 18 d, hold 4 weeks prior to surgery 
 +  * Tofacitinib (Xeljanz)— t ½ 3-8 hrs, hold 5-7 d prior and resume 5-7 d post-op if ok 
 +  * Belimumab (Benlysta)— t ½ 18.3-19.4 days, hold 3 wks prior to surgery and about 10-14 d after surgery 
 +  * Alirocumab (Praluent)— t ½ 17-20 days, not immune modulating, do not need to stop for surgery 
 +  * Secukinumab (Cosentyx)— t ½ 22-31 days, hold 4 wks prior to surgery and about 10-14 d after surgery 
 +  * Upadacitinib (Rinvoq)- t ½ 8-14hrs, ok to continue through surgery for low-risk procedure (per Dr. Knibbe)
  
-Apremilast (Otezla)—+====Gout Medications====
  
-Infliximab (Remicade)—t ½ 9.5d, hold 3 weeks prior to surgery+  * Hold colchicine, allopurinol and probenecid on day of surgery
  
-Adalimumab (Humira)—t ½ 10-20d, hold 4 weeks prior to surgery+====Immunosuppressants for transplant====
  
-Certolizumab (Cimzia)—t ½ 14d, hold 4 weeks prior to surgery +  * Continue through surgery 
- +  * If patient is on an mTOR inhibitor (sirolimus or everolimus), recommend discussion with nephrology prior to surgery as these can cause post-op wound healing issues, seromas and lymphoceles.
-Golimumab (Simponi)—t ½ 14d, hold 4 weeks prior to surgery +
- +
-ii.PDE-4 Inhibitor +
- +
-Apremilast (Otezla) - t ½ 6-9 hrs, hold 3 days prior and resume when stitches are out +
- +
-iii.T cell costimulator +
- +
-Abatacept (Orencia)—t ½ 13d, hold 4 weeks prior to surgery +
- +
-iv.Interleukins antagonist +
- +
-Tocilizumab (Actemra)—t ½ 11-13d, hold 3 weeks prior to surgery +
- +
-Anakinra (Kineret)—t ½ 4-6 hrs, hold 1 day prior to surgery +
- +
-v.B cell depleting agent and other biological modifiers +
- +
-Rituximab (Rituxan)—t ½ 18 d, hold 4 weeks prior to surgery +
- +
-Tofacitinib (Xeljanz)— t ½ 3-8 hrs, hold 5-7 d prior and resume 5-7 d post-op if ok +
- +
-Belimumab (Benlysta)— t ½ 18.3-19.4 days, hold 3 wks prior to surgery and about 10-14 d after surgery +
- +
-Alirocumab (Praluent)— t ½ 17-20 days, not immune modulating, do not need to stop for surgery +
- +
-Secukinumab (Cosentyx)— t ½ 22-31 days, hold 4 wks prior to surgery and about 10-14 d after surgery +
- +
-Upadacitinib (Rinvoq)- t ½ 8-14hrs, ok to continue through surgery for low-risk procedure (per Dr. Knibbe) +
- +
-Gout Medications +
- +
-a) Hold colchicine, allopurinol and probenecid on day of surgery +
- +
-10.  Immunosuppressants for transplant +
- +
-Continue through surgery +
- +
-If patient is on an mTOR inhibitor (sirolimus or everolimus), recommend discussion with nephrology prior to surgery as these can cause post-op wound healing issues, seromas and lymphoceles. +
- +
-11.  Hematology/Oncology Medication-Best to discuss IN ADVANCE OF SURGERY with Hematologist and surgeon for guidance during perioperative period. +
- +
-Palbociclib (Ibrance)-- can cause neutropenia, dosed 3 weeks on/1 week off to allow ANC to recover. May need to be held before surgery and up to 1 week after to allow for healing but needs to be discussed with oncologist MUCH PRIOR to surgery to coordinate+
  
-Anastrozole (Arimidex), tamoxifen, letrozole, exemestane (Aromasin)-- hold 1 day prior to surgery and day of surgery due to risk for clotting. Should be held up to 1 week after surgery depending on mobility+====Hematology and Oncology Medications==== 
 +  * Best to discuss IN ADVANCE OF SURGERY with Hematologist and surgeon for guidance during perioperative period. 
 +  * Palbociclib (Ibrance)-- can cause neutropenia, dosed 3 weeks on/1 week off to allow ANC to recover. May need to be held before surgery and up to 1 week after to allow for healing but needs to be discussed with oncologist MUCH PRIOR to surgery to coordinate 
 +  * Anastrozole (Arimidex), tamoxifen, letrozole, exemestane (Aromasin)-- hold 1 day prior to surgery and day of surgery due to risk for clotting. Should be held up to 1 week after surgery depending on mobility
  
-12.  Parathyroid Hormone Analogs+====Parathyroid Hormone Analogs====
  
-Teriparatide (Forteo) and other similar osteoporosis agents are ok to continue through surgery.+  * Teriparatide (Forteo) and other similar osteoporosis agents are ok to continue through surgery.
  
-13.  PDE Inhibitors (i.e. sildenafil)+====PDE Inhibitors (i.e. sildenafil)====
  
-If for ED, hold for 24 hrs prior to surgery. Continue if for pulmonary HTN.+  * If for ED, hold for 24 hrs prior to surgery. Continue if for pulmonary HTN.
  
-14. Herbal Medications-see table I. CBD oil should also be held for 1 week prior to surgery. Stop ALL herbal supplements for 1 week prior to surgery.+====Herbal Medications==== 
 +  * CBD oil should also be held for 1 week prior to surgery.  
 +  * Stop ALL herbal supplements for 1 week prior to surgery.