Should Leqvio (inclisiran) be held before or after surgery?

Leqvio (Inclisiran) Does Not Need to Be Held Before or After Surgery

Leqvio (inclisiran) should be continued through the perioperative period without interruption, as it does not affect hemostasis, platelet function, or coagulation and poses no increased bleeding risk during surgery. 1, 2

Rationale for Continuation

Mechanism and Safety Profile

• Inclisiran is a small interfering RNA (siRNA) that reduces hepatic PCSK9 synthesis to lower LDL cholesterol, administered subcutaneously twice yearly after initial loading doses 1, 2
• The drug has no anticoagulant, antiplatelet, or hemostatic effects that would increase surgical bleeding risk 1
• Clinical trials demonstrated a safety profile similar to placebo, with only mild-to-moderate transient injection-site reactions being more common than placebo 1

Perioperative Management Framework

The established perioperative medication guidelines focus exclusively on medications that affect hemostasis:

• Anticoagulants (warfarin, LMWH, heparin) require specific timing protocols due to bleeding risk 3
• Antiplatelet agents (aspirin, clopidogrel) need individualized management based on cardiovascular risk versus bleeding risk 3
• Lipid-lowering therapies without hemostatic effects are not addressed in perioperative antithrombotic guidelines because they don't require interruption 4

Practical Management Algorithm

Before Surgery

• Continue inclisiran on its regular dosing schedule (Day 1, Day 90, then every 6 months) 1, 2
• No need to adjust timing of scheduled doses relative to surgery date 5
• Document continuation in the perioperative medication reconciliation 5

Day of Surgery

• No special precautions needed related to inclisiran 1
• Standard anesthetic management without modifications for inclisiran 5

After Surgery

• Resume or continue inclisiran without delay once patient can receive subcutaneous injections 5
• No waiting period required for wound healing, unlike medications affecting hemostasis 3

Key Distinctions from Other Medications

Medications Requiring Perioperative Interruption

• Warfarin: Stop 5 days before surgery 6
• LMWH: Last dose 24 hours before surgery 3
• Clopidogrel/prasugrel: Stop 5-7 days before surgery (unless recent stent) 3

Medications Continued Perioperatively

• Inclisiran: Continue without interruption 1, 2
• Hydroxychloroquine: Continue to prevent disease flares 7
• Statins: Generally continued for cardiovascular protection 5

Common Pitfalls to Avoid

• Do not confuse inclisiran with anticoagulants or antiplatelet agents that require specific perioperative protocols 4
• Do not delay scheduled inclisiran doses due to upcoming or recent surgery, as this provides no benefit and may compromise lipid control 1, 2
• Do not apply anticoagulation bridging protocols to inclisiran, as these are irrelevant to its mechanism of action 3

Clinical Context

The twice-yearly dosing schedule of inclisiran (after initial loading) means most patients will not have a dose due near their surgical date 1, 2. However, if a scheduled dose coincides with surgery:

• Administer the dose as scheduled if the patient can receive subcutaneous injections 1
• Brief delays of days to weeks for logistical reasons are acceptable given the 6-month dosing interval, but are not medically necessary 2