Acyclovir Does Not Require Preoperative Discontinuation
Acyclovir can be continued through surgery without interruption, as it is an antiviral medication with no significant bleeding risk or perioperative complications that would necessitate stopping it before surgical procedures.
Key Principle: Acyclovir is Not a Perioperative Risk Medication
The provided evidence addresses perioperative management of anticoagulants (dabigatran, rivaroxaban, apixaban) and antiplatelet agents (aspirin, clopidogrel, ticagrelor), but notably contains no guidelines recommending discontinuation of acyclovir before surgery 1, 2. This absence is clinically significant—acyclovir lacks the bleeding risk, drug interactions, or pharmacologic properties that would require preoperative interruption.
Pharmacokinetic Profile Supports Continuation
- Acyclovir has a short half-life of 2.5 to 3.3 hours in patients with normal renal function, with rapid renal clearance 3, 4
- The drug is 9% to 33% protein-bound and does not interfere with coagulation pathways or platelet function 4
- Acyclovir's mechanism as a DNA polymerase inhibitor targeting viral thymidine kinase has no impact on surgical hemostasis 3
Clinical Context: When Acyclovir Should Be Maintained Perioperatively
High-Risk Scenarios Requiring Continuation
- Patients with history of HSV encephalitis undergoing intracranial procedures should receive prophylactic acyclovir pre-, peri-, and postoperatively to prevent viral reactivation 5
- Immunocompromised patients (transplant recipients, chemotherapy patients) require uninterrupted acyclovir prophylaxis through surgical procedures 1
- Patients undergoing facial resurfacing procedures should start acyclovir prophylaxis either the morning before or morning of surgery and continue for 14 days postoperatively 6
Standard Prophylactic Regimens
- For HSV prophylaxis in transplant patients, acyclovir is initiated between the start of conditioning therapy and day 1 after transplantation, continuing until day 30 1
- Valacyclovir 500 mg twice daily is 100% effective in preventing HSV reactivation when started the day before or day of facial resurfacing surgery 6
- In bone marrow transplant recipients, valacyclovir 500 mg twice daily or acyclovir 600 mg every 6 hours should continue until resolution of neutropenia 7
Renal Function Considerations
- Dose adjustment is required in patients with renal impairment, but discontinuation is not necessary 3, 4
- In patients with end-stage renal disease, acyclovir half-life extends to approximately 14 hours, requiring dosage reduction but not cessation 3
- Approximately one-third of acyclovir is removed during a 4-hour hemodialysis session, necessitating post-dialysis supplementation 3
Common Pitfalls to Avoid
- Do not confuse acyclovir with anticoagulants or antiplatelet agents that require preoperative interruption—acyclovir has an entirely different mechanism and risk profile 1, 2
- Do not discontinue acyclovir in immunocompromised patients perioperatively—this creates risk of severe HSV reactivation without providing any surgical benefit 1, 7
- Do not stop acyclovir prophylaxis prematurely in high-risk patients—viral reactivation can occur rapidly after discontinuation, particularly in the postoperative immunosuppressed state 5, 8
Drug Interactions Without Surgical Implications
- Coadministration with probenecid increases acyclovir levels by 49% but does not create perioperative contraindications 3
- Cimetidine increases acyclovir AUC by 32%, but this does not necessitate preoperative discontinuation 3
- These interactions may require dose adjustment but not drug interruption 3, 4
Postoperative Management
- Resume or continue acyclovir immediately postoperatively at the same dose used preoperatively 1, 6
- In patients who develop postoperative HSV infection, treatment should continue until all lesions have resolved or scabbed 1
- For systemic HSV infection postoperatively, intravenous acyclovir should be used with reduction in immunosuppressive medications 1