Can imatinib (Gleevec) be skipped during nil by mouth (NBM) before surgery?

Can Imatinib Be Skipped During NBM Before Surgery?

Yes, imatinib can be safely stopped a few days or even 1 day before surgery during the nil by mouth (NBM) period, and should be resumed promptly when the patient recovers from surgery. 1

Perioperative Management of Imatinib

Timing of Discontinuation

• Imatinib can be safely stopped 1-7 days before surgery 1
• The ESMO-EURACAN-GENTURIS guidelines (2022) specifically state: "There are limited data to guide the physician on when to stop imatinib before surgery; however, it can be safely stopped a few days or even 1 day before surgery" 1
• The 2018 ESMO-EURACAN guidelines similarly confirm: "it can be safely stopped a few days or even one day before surgery" 1

Resumption After Surgery

• Resume imatinib promptly when the patient recovers from surgery and can tolerate oral intake 1
• The goal is to reach the total planned duration of treatment (typically 3 years for adjuvant therapy) 1
• For metastatic disease, imatinib should be continued as soon as the patient is able to tolerate oral intake 1

Clinical Context and Rationale

Why Brief Interruption Is Safe

The short perioperative interruption of imatinib does not significantly compromise disease control because:

• The drug has a relatively long half-life (approximately 18 hours for imatinib and 40 hours for its active metabolite), providing some continued therapeutic effect even after discontinuation
• The brief interruption (1-7 days) is minimal compared to the months-to-years duration of total therapy 1
• Studies have shown that surgery can be safely performed after stopping imatinib for this short period without increased risk of tumor progression 1

Important Caveats

Bleeding risk considerations: While not specifically mentioned in the GIST guidelines, one guideline notes that ibrutinib (a different tyrosine kinase inhibitor) should be held for 3-7 days before and after surgical procedures due to bleeding risk 1. Although this is for a different drug, it provides context that brief perioperative holds of tyrosine kinase inhibitors are standard practice when surgical hemostasis is a concern.

Do not delay resumption: The emphasis in all guidelines is on prompt resumption after surgery 1. Prolonged interruption of imatinib, particularly in the metastatic setting, is associated with rapid tumor progression 1

Practical Algorithm

1. Stop imatinib 1-7 days before scheduled surgery (coordinate with surgeon based on procedure complexity and bleeding risk) 1

2. Proceed with surgery as planned during NBM period

3. Resume imatinib as soon as:

   • Patient can tolerate oral intake 1
   • No contraindications from surgical complications exist
   • Typically within days of surgery 1

4. Continue imatinib to complete planned duration:

   • 3 years for adjuvant therapy 1
   • Indefinitely for metastatic disease 1