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peri_operative_medication_management [2026/04/07 18:38] – 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 
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       * 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
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   * 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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   * 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.   * 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.
  
-==TNF Blockers==+===TNF Blockers===
  
   * Etanercept (Enbrel)—t ½ 3.5-5.5d, hold 7-10 days prior to surgery   * Etanercept (Enbrel)—t ½ 3.5-5.5d, hold 7-10 days prior to surgery
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   * Golimumab (Simponi)—t ½ 14d, hold 4 weeks prior to surgery   * Golimumab (Simponi)—t ½ 14d, hold 4 weeks prior to surgery
  
-ii.PDE-4 Inhibitor+===PDE-4 Inhibitor===
  
-Apremilast (Otezla) - t ½ 6-9 hrs, hold 3 days prior and resume when stitches are out+  * Apremilast (Otezla) - t ½ 6-9 hrs, hold 3 days prior and resume when stitches are out
  
-iii.T cell costimulator+===T cell costimulator===
  
-Abatacept (Orencia)—t ½ 13d, hold 4 weeks prior to surgery+  * Abatacept (Orencia)—t ½ 13d, hold 4 weeks prior to surgery
  
-iv.Interleukins antagonist+===Interleukins antagonist===
  
-Tocilizumab (Actemra)—t ½ 11-13d, hold 3 weeks prior to surgery+  * 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
  
-Anakinra (Kineret)—t ½ 4-6 hrs, hold 1 day prior to surgery+===B cell depleting agent and other biological modifiers===
  
-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)
  
-Rituximab (Rituxan)—t ½ 18 d, hold 4 weeks prior to surgery+====Gout Medications====
  
-Tofacitinib (Xeljanz)— t ½ 3-8 hrs, hold 5-7 d prior and resume 5-7 d post-op if ok+  * Hold colchicine, allopurinol and probenecid on day of surgery
  
-Belimumab (Benlysta)— t ½ 18.3-19.4 days, hold 3 wks prior to surgery and about 10-14 d after surgery+====Immunosuppressants for transplant====
  
-Alirocumab (Praluent)— t ½ 17-20 days, not immune modulating, do not need to stop for 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.
-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.