A patient undergoing open cholecystectomy is taking febuxostat, colchicine, candesartan, losartan, and sodium bicarbonate. Which medications should be discontinued perioperatively?

Perioperative Medication Management for Open Cholecystectomy

Continue all medications except colchicine, which should be held perioperatively due to significant drug interaction risks and potential for severe toxicity in the surgical setting.

Medications to Continue

Candesartan and Losartan (ARBs)

• Both ARBs should be continued through surgery and restarted immediately postoperatively 1
• The 2024 AHA/ACC guidelines emphasize that delaying resumption of preoperative ACEi/ARBs was associated with increased 30-day mortality risk in propensity-matched cohort studies
• Chronically taken oral antihypertensive medications should be restarted as soon as clinically reasonable to avoid complications from postoperative hypertension 1
• Critical caveat: While perioperative hypotension can occur with ARBs, the mortality risk from withholding them outweighs this concern. Manage any hypotension with fluids and vasopressors rather than discontinuing the medications

Note: You are taking both candesartan AND losartan, which is unusual as both are ARBs. Verify this is intentional dual ARB therapy rather than a prescribing error, though both should still be continued perioperatively.

Febuxostat

• Continue febuxostat through the perioperative period
• No specific guidelines recommend discontinuation for surgery
• Stopping urate-lowering therapy risks precipitating acute gout flares in the postoperative period
• The medication is well-tolerated and does not pose significant perioperative risks 2, 3

Sodium Bicarbonate

• Continue sodium bicarbonate
• No contraindications for perioperative use
• Likely prescribed for metabolic acidosis, renal protection, or urine alkalinization—conditions that remain relevant perioperatively

Medication to Discontinue

Colchicine - HOLD PERIOPERATIVELY

Colchicine should be discontinued before surgery due to multiple serious concerns:

• Drug interaction risk: Colchicine is a P-glycoprotein substrate and CYP3A4 substrate. Fatal drug interactions have been reported 4
• Gastrointestinal toxicity: Up to 26% of patients experience GI adverse effects (diarrhea, nausea, vomiting, abdominal pain) which can complicate postoperative recovery 4
• Neuromuscular toxicity: Risk of myopathy and rhabdomyolysis, particularly concerning given potential perioperative statin use or other interacting medications 4
• Myelosuppression risk: Can cause leukopenia, granulocytopenia, thrombocytopenia—particularly dangerous in the surgical setting 4
• Multisystem toxicity: Can cause injury to renal, hepatic, circulatory, and CNS systems with accumulation 4

Timing of discontinuation: Hold colchicine at least 24-48 hours before surgery, longer if renal impairment exists (colchicine accumulates with reduced clearance).

Postoperative management: Restart colchicine only after:

• Patient tolerating oral intake
• No signs of infection (contraindication to colchicine with IL-1 blocker consideration) 5
• Adequate renal function confirmed
• No interacting medications being used

Common Pitfalls to Avoid

1. Do not discontinue ARBs "to prevent hypotension" - The mortality data clearly favors continuation 1
2. Do not restart colchicine too early postoperatively - Wait for stable GI function and verify no drug interactions
3. Monitor for gout flare postoperatively - Surgical stress can precipitate flares; if colchicine held, have alternative anti-inflammatory plan ready (low-dose NSAIDs if not contraindicated, or corticosteroids) 5
4. Verify the dual ARB regimen - Clarify if both candesartan and losartan are intentionally prescribed