What medications can a patient with hypertension and hypothyroidism taking cilacar (calcium channel blocker) and thyronorm (levothyroxine) 100mcg continue or stop before surgery for a humerus fracture?

Perioperative Medication Management for Humerus Fracture Surgery

Direct Answer

Continue both Cilacar (calcium channel blocker) and Thyronorm (levothyroxine) 100mcg through the morning of surgery without interruption. 1

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Medication-Specific Recommendations

Cilacar (Calcium Channel Blocker) - CONTINUE

The ACC/AHA guidelines explicitly recommend continuing antihypertensive medications until surgery for patients undergoing elective major surgery. 1

• Calcium channel blockers like Cilacar should be continued perioperatively to maintain blood pressure control and prevent rebound hypertension 1
• The 2024 ACC/AHA perioperative guidelines reinforce that chronically taken oral antihypertensive medications should be restarted as soon as clinically reasonable postoperatively to avoid complications from postoperative hypertension 1
• Abrupt discontinuation of antihypertensive therapy can lead to rebound hypertension, which increases risk for myocardial ischemia, acute heart failure, cerebral ischemia, and dysrhythmias 1

Key perioperative blood pressure targets:

• Maintain mean arterial pressure (MAP) ≥60-65 mm Hg or systolic blood pressure (SBP) ≥90 mm Hg intraoperatively to reduce risk of myocardial injury, acute kidney injury, and mortality 1, 2
• Intraoperative hypotension (MAP <65 mm Hg or SBP <90 mm Hg for >15 minutes) is associated with postoperative myocardial injury, acute kidney injury, and mortality 1

Thyronorm (Levothyroxine) 100mcg - CONTINUE

Levothyroxine should be continued through surgery without interruption. 3

• Hypothyroid patients undergoing surgery face increased perioperative risks, including intraoperative hypotension (61% vs 30% in euthyroid patients), postoperative gastrointestinal complications (19% vs 1%), and neuropsychiatric complications (38% vs 18%) 3
• Maintaining thyroid hormone replacement is critical to minimize these complications 3
• There is no evidence that levothyroxine increases surgical or fracture risk; in fact, levothyroxine was not associated with increased fracture risk in large population studies 4
• Hypothyroid patients are at increased fracture risk within the first 10 years after diagnosis, making adequate thyroid replacement particularly important in this patient with a humerus fracture 4

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Practical Implementation

Day Before Surgery

• Administer both Cilacar and Thyronorm 100mcg at usual times 1
• Ensure adequate hydration 1

Morning of Surgery

• Give both medications with small sips of water 2-4 hours before anesthesia 1
• Levothyroxine should be taken on empty stomach, at least 4 hours apart from any calcium supplements if applicable 5

Intraoperative Management

• Anesthesia team should anticipate potential intraoperative hypotension in this hypothyroid patient and treat aggressively with fluids and vasopressors to maintain MAP ≥60-65 mm Hg 1, 3
• Have intravenous antihypertensive agents (nicardipine, clevidipine, or labetalol) readily available for perioperative hypertension (BP ≥160/90 mm Hg or SBP elevation ≥20% from baseline persisting >15 minutes) 1

Postoperative Management

• Resume both Cilacar and Thyronorm 100mcg as soon as patient can tolerate oral medications 1, 2
• Delaying resumption of antihypertensive medications is associated with increased 30-day mortality risk 1, 2
• Monitor for postoperative hypotension, as hypothyroid patients are at higher risk 3

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Critical Pitfalls to Avoid

• Never discontinue calcium channel blockers abruptly perioperatively, as this can cause rebound hypertension and cardiovascular complications 1
• Never withhold levothyroxine on the day of surgery, as hypothyroid patients already face increased perioperative complications that worsen without adequate thyroid replacement 3
• Do not allow prolonged intraoperative hypotension (MAP <60-65 mm Hg for >15 minutes), as this dramatically increases risk of myocardial injury and acute kidney injury 1
• Anticipate that hypothyroid patients may not manifest fever with perioperative infections (35% vs 79% in euthyroid patients), requiring heightened clinical vigilance 3
• Monitor for gastrointestinal and neuropsychiatric complications postoperatively, as these occur more frequently in hypothyroid surgical patients 3

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Special Considerations for Hypothyroidism and Hypertension

• This patient's hypertension may be partially related to hypothyroidism, as hypothyroidism increases vascular resistance and aortic stiffness 6
• Adequate thyroid replacement with levothyroxine can improve blood pressure control in some patients with concurrent hypertension and hypothyroidism 6
• The combination of calcium channel blocker therapy and thyroid hormone replacement addresses both the primary hypertension and the thyroid-mediated vascular dysfunction 6