Perioperative Management of Telma H (Telmisartan/Hydrochlorothiazide)
Your patient should discontinue Telma H (telmisartan/hydrochlorothiazide) 24 hours before surgery to reduce the risk of severe intraoperative hypotension, particularly during anesthesia induction. 1
Rationale for Discontinuation
ACE Inhibitors and ARBs (Telmisartan Component)
The American College of Cardiology recommends that ACE inhibitors or ARBs may be discontinued 24 hours before surgery to reduce the risk of intraoperative hypotension. 1
Patients who continue ARBs on the day of surgery experience significantly more hypotensive episodes during anesthesia induction, with longer duration of hypotension (8 ± 7 minutes vs. 3 ± 4 minutes when discontinued), and require more vasopressor support. 2
Telmisartan is particularly problematic due to its exceptionally long half-life of approximately 24 hours—the longest among all ARBs—which means it persists in the system even after discontinuation on the day of surgery. 3, 4
A 2024 study demonstrated that patients taking telmisartan had significantly more time with mean arterial pressure <60 mmHg during anesthesia induction (11 minutes vs. 7 minutes) and higher vasopressor use (74.2% vs. 56.0%) compared to shorter-acting ARBs like valsartan, even when both were withdrawn on the day of surgery. 3
Diuretic Component (Hydrochlorothiazide)
Diuretics for hypertension can typically be discontinued on the day of surgery and resumed orally when possible. 1
Discontinuing diuretics helps avoid volume depletion and electrolyte disturbances that can exacerbate intraoperative hypotension. 1
Practical Implementation
Preoperative Instructions
Instruct the patient to take their last dose of Telma H 24 hours before the scheduled surgery time. 1
If the patient is on other antihypertensive medications (beta-blockers, calcium channel blockers), these should be continued with a small sip of water on the morning of surgery. 1
Beta-blockers must never be discontinued abruptly due to risk of rebound hypertension and should be continued throughout the perioperative period. 1
Blood Pressure Thresholds
If the patient's blood pressure is ≥180/110 mmHg on the day of surgery, consider deferring elective surgery until better control is achieved. 1
Target blood pressure control to <130/80 mmHg before major elective procedures. 1
Intraoperative Management
Anticipate potential hypotension during anesthesia induction, particularly during airway manipulation, which is the most vulnerable period. 1
Have intravenous vasopressors readily available (ephedrine, phenylephrine, or terlipressin) to manage hypotensive episodes. 2
Use IV antihypertensive medications (clevidipine, esmolol, or nicardipine) if hypertension develops intraoperatively until oral medications can be resumed. 1
Postoperative Resumption
Resume Telma H when the patient can tolerate oral intake and adequate hemostasis is achieved, typically 24-48 hours after low-to-moderate bleeding risk surgery. 1
For high-bleeding-risk procedures, consider waiting 48-72 hours before resuming. 1
Critical Pitfalls to Avoid
Do not allow the patient to take Telma H on the morning of surgery with a "sip of water"—this common instruction applies to beta-blockers and calcium channel blockers but NOT to ARBs. 1
Do not confuse telmisartan with shorter-acting ARBs—its 24-hour half-life means it requires earlier discontinuation than other medications in its class. 3, 4
Avoid starting the patient on beta-blockers on the day of surgery if they are beta-blocker-naïve, as this increases risk of harm. 1
Ensure adequate volume status and correct any electrolyte abnormalities (particularly hypokalemia and hypomagnesemia from the hydrochlorothiazide component) before surgery. 1