Can I continue ponatinib (ponatinib, a tyrosine kinase inhibitor) during surgery?

Perioperative Management of Ponatinib During Surgery

Ponatinib should be withheld for at least 1 week prior to elective surgery and not restarted until at least 2 weeks following major surgery and adequate wound healing has occurred. 1

FDA Recommendations

• The FDA drug label specifically states that ponatinib should be withheld for at least 1 week prior to elective surgery 1
• Ponatinib should not be administered for at least 2 weeks following major surgery and until adequate wound healing has occurred 1
• The safety of resumption of ponatinib after resolution of wound healing complications has not been established 1

Rationale for Discontinuation

• Ponatinib is associated with impaired wound healing, which can lead to complications during the perioperative period 1
• Ponatinib increases the risk of arterial occlusive events and venous thromboembolic events, which may be exacerbated during the hypercoagulable perioperative state 1, 2
• Cardiovascular events, particularly hypertension, occur in approximately 49% of patients on ponatinib therapy 3
• Cerebrovascular or vaso-occlusive disease has been reported in 10% of patients taking ponatinib 3

Perioperative Management Algorithm

1. Pre-operative phase:

   • Discontinue ponatinib at least 7 days before elective surgery 1
   • Consider cardiovascular risk assessment before surgery, as ponatinib is associated with increased cardiovascular events 4
   • Monitor for signs of thromboembolism during the pre-operative period 2

2. Intra-operative phase:

   • No specific recommendations for ponatinib during surgery as it should already be discontinued 1
   • Be vigilant for bleeding complications or thrombotic events 3, 2

3. Post-operative phase:

   • Do not restart ponatinib for at least 2 weeks after major surgery 1
   • Ensure adequate wound healing before resuming ponatinib 1
   • When restarting, consider dose reduction if there were any perioperative cardiovascular events 5

Special Considerations

• For patients at high risk of thromboembolism, consider prophylactic measures during the perioperative period 4
• In patients with high-risk chronic myeloid leukemia, the decision to withhold ponatinib should carefully balance the risks of disease progression against surgical complications 6
• Lower doses of ponatinib (15-30 mg daily) may be considered when restarting after surgery to reduce cardiovascular risk 5

Common Pitfalls

• Failing to discontinue ponatinib early enough before surgery, increasing the risk of wound healing complications 1
• Restarting ponatinib too soon after surgery before adequate wound healing has occurred 1
• Not monitoring for cardiovascular events in the perioperative period, which are common with ponatinib therapy 3, 4
• Overlooking the need for thromboprophylaxis during the perioperative period in patients with additional risk factors 2