Does Pepcid (famotidine) need to be held prior to surgery?

Famotidine (Pepcid) Management Before Surgery

Famotidine does not need to be held prior to surgery and can be safely continued through the perioperative period.

Rationale for Continuing Famotidine

• Famotidine is a highly selective histamine H2-receptor antagonist that inhibits gastric acid secretion and has no recommendations for discontinuation before surgery in perioperative guidelines 1
• Unlike medications that require preoperative holding (such as certain muscle relaxants, SGLT2 inhibitors, or GLP-1 agonists), famotidine has no properties that would increase perioperative risk 1
• Famotidine does not interact with cytochrome P-450 of the hepatic enzyme system, so it does not affect the metabolism of anesthetic drugs or other perioperative medications 2

Benefits of Continuing Famotidine Perioperatively

• Continuing famotidine may actually provide benefit by reducing the risk of stress-related gastrointestinal bleeding and pulmonary aspiration of acid during surgery 3
• Famotidine has a relatively long duration of action (8-15 hours after a standard dose), making it effective for acid suppression throughout the perioperative period 4
• The medication is well-tolerated with minimal side effects (reported in only 0.43% of patients in post-marketing studies) 2

Potential Drug Interactions to Consider

• When famotidine is used with tizanidine (a muscle relaxant), there is a potential for increased hypotension, bradycardia, and sedation, but this does not require discontinuation of famotidine 1
• Unlike some medications that require specific timing considerations before surgery, famotidine has no documented interactions with anesthetic agents that would necessitate discontinuation 1

Special Considerations

• For patients receiving famotidine for NSAID-induced ulcer prophylaxis, continuing the medication is particularly important if NSAIDs will be used in the perioperative period 5
• In critically ill patients or those undergoing major surgery with risk of stress ulceration, famotidine may provide protective benefits, though the evidence for routine prophylaxis is mixed 6

Clinical Decision Algorithm

1. For routine surgeries: Continue famotidine at the usual dose including the morning of surgery 1, 3
2. For patients with gastroesophageal reflux disease: Continuing famotidine may be particularly beneficial to reduce the risk of acid reflux during intubation and surgery 3
3. For patients on multiple medications: Review for potential interactions, particularly with muscle relaxants like tizanidine, but famotidine itself does not need to be held 1

Common Pitfalls to Avoid

• Unnecessarily holding famotidine before surgery may lead to rebound acid hypersecretion and increased risk of reflux during the perioperative period 3
• Confusing famotidine with medications that do require preoperative holding (such as certain antihypertensives, anticoagulants, or hypoglycemic agents) 1
• Failing to recognize that famotidine may actually provide protective benefits in the perioperative setting by reducing gastric acid and the risk of aspiration pneumonitis 3, 6