Enzalutamide (Xtandi) Does Not Need to Be Held for Inguinal Hernia Repair Surgery
There is no evidence-based requirement to discontinue enzalutamide for inguinal hernia repair surgery. The available guidelines and drug interaction data do not identify any perioperative concerns that would necessitate holding this medication for routine surgical procedures.
Key Clinical Considerations
No Perioperative Contraindications Identified
- Enzalutamide has no documented interactions with anesthetic agents or perioperative medications that would require discontinuation for inguinal hernia repair 1
- The drug's primary interactions involve CYP450 enzyme induction (CYP3A4, CYP2C9, CYP2C19), which affects chronic medication metabolism rather than acute surgical safety 1
- Major clinical trials including PREVAIL, PROSPER, and AFFIRM did not require treatment interruption for surgical procedures 2, 3
Relevant Safety Profile
- The most clinically significant perioperative concern would be cardiovascular events, which occur in only 5% of enzalutamide patients versus 3% on placebo 2, 4
- Seizure risk remains extremely low at 0.6-0.9%, not elevated enough to warrant routine discontinuation for minor surgery 2, 4
- Hypertension (12%) and fatigue (33-34%) are common but do not contraindicate surgery 2, 4
Anticoagulation Considerations
- If the patient is on concurrent anticoagulation, enzalutamide's CYP3A4 induction properties may affect warfarin levels, but this is a chronic management issue, not a reason to hold enzalutamide itself 5, 1
- The anticoagulant would need perioperative management per standard surgical protocols, independent of enzalutamide continuation 5
Clinical Decision Algorithm
Continue Enzalutamide Through Surgery If:
- Patient is on stable dosing (standard 160 mg daily or reduced dose) 2, 6
- No active seizure disorder requiring medication adjustment 2
- Blood pressure is controlled (monitor given 12% hypertension risk) 2
- No concurrent medications requiring urgent CYP450-related dose adjustments 1
Consider Temporary Hold Only If:
- Patient has uncontrolled hypertension requiring urgent optimization before elective surgery 2
- Active drug-drug interaction crisis with narrow therapeutic index medications (though this would be managed by adjusting the interacting drug, not enzalutamide) 1
Important Caveats
Enzalutamide should be continued during the perioperative period because treatment interruption risks disease progression without providing surgical safety benefits 2. The median time to progression without treatment is only 14.7 months in non-metastatic disease and shorter in metastatic disease, making unnecessary treatment gaps clinically harmful 2.
Patients must continue concurrent androgen deprivation therapy (LHRH agonist/antagonist) throughout the surgical period as well, since all prostate cancer patients on enzalutamide require maintained castrate testosterone levels 7, 8.