In a patient with mild systemic lupus erythematosus taking telmisartan/amlodipine, carvedilol, rosuvastatin, fenofibrate, hydroxychloroquine, methylprednisolone, bilastine, pregabalin, calcium carbonate, vitamin B, febuxostat, and PRN paracetamol/tramadol, should the angiotensin receptor blocker (telmisartan) and any angiotensin‑converting enzyme inhibitor be held on the day of surgery?

Perioperative Management of ARBs and ACE Inhibitors in SLE Patients

In a patient with mild SLE undergoing elective surgery, telmisartan (ARB) should be continued through the perioperative period rather than held on the day of surgery. 1

Evidence-Based Rationale

The 2014 ACC/AHA perioperative cardiovascular guideline provides a Class IIa recommendation (reasonable to continue) for maintaining ACE inhibitors and ARBs perioperatively in patients undergoing noncardiac surgery. 1 This represents a significant departure from older practices that routinely held these medications.

Key Supporting Evidence:

• Continuation of ACE inhibitors or ARBs is reasonable perioperatively based on moderate-quality evidence showing no increased risk of adverse cardiovascular outcomes when these agents are maintained. 1

• If held before surgery, ACE inhibitors or ARBs should be restarted as soon as clinically feasible postoperatively, emphasizing that any interruption should be brief. 1

• The primary concern with holding these medications is intraoperative hypotension, which can be managed with intravenous fluids and vasopressors if it occurs, rather than representing a contraindication to continuation. 2

SLE-Specific Considerations

For patients with mild SLE, cardiovascular medications including ARBs should be continued unchanged throughout the perioperative period. 3

Cardiovascular Protection in SLE:

• RAS-modifying antihypertensive drugs (ARBs and ACE inhibitors) significantly reduce cardiovascular disease risk in SLE patients (relative risk 0.80; 95% CI 0.74-0.87), with even greater benefit after propensity score matching (RR 0.62; 95% CI 0.57-0.68). 4

• This cardiovascular protection occurs regardless of lupus nephritis status, demonstrating extrarenal anti-inflammatory benefits beyond blood pressure control. 4

• RAS-modifying therapies increase cardiovascular disease-free survival probability to 86.0% versus 78.3% over 5 years in SLE patients compared to non-RAS antihypertensives. 4

Blood Pressure Management:

• Hypertensive SLE patients should be considered at high or very high cardiovascular risk, warranting optimal blood pressure control below 130/80 mmHg. 5

• ACE inhibitors and ARBs are the first-choice antihypertensive agents in lupus patients due to their safety profile and efficacy in reducing both cardiovascular and renal complications. 5

Other Medications to Continue

The following medications in this patient should also be continued through surgery:

• Carvedilol (beta-blocker) must be continued in patients on chronic beta-blocker therapy (Class I recommendation, strong evidence). 1 Stopping beta-blockers perioperatively increases risk of adverse cardiac events. 1

• Rosuvastatin should be continued in patients currently taking statins (Class I recommendation). 1

• Hydroxychloroquine 200 mg daily should be continued unchanged throughout the perioperative period for all SLE patients (conditional recommendation, low-to-moderate quality evidence). 3, 1

• Methylprednisolone 16 mg daily should be maintained at the baseline dose without stress-dose steroids on the day of surgery (conditional recommendation). 3, 1 This represents a paradigm shift from historic practice of supraphysiologic dosing. 1

Critical Pitfalls to Avoid

• Do NOT routinely discontinue ARBs or ACE inhibitors on the day of surgery. The evidence supports continuation, with management of any intraoperative hypotension as needed. 1

• Do NOT administer supraphysiologic stress-dose glucocorticoids perioperatively. Continue only the baseline 16 mg methylprednisolone dose to reduce infection risk without compromising adrenal function. 3, 1

• Do NOT stop beta-blockers on the day of surgery. This is a Class III (Harm) recommendation with strong evidence of increased cardiac risk. 1

• Do NOT discontinue hydroxychloroquine perioperatively. Stopping increases lupus flare risk and eliminates demonstrated mortality benefits. 3, 1

Management of Intraoperative Hypotension

If hypotension occurs with ARB continuation:

• Place the patient in supine position and administer intravenous normal saline infusion as needed. 2

• A transient hypotensive response is not a contraindication to further ARB treatment, which can usually be continued without difficulty once blood pressure stabilizes. 2

• Have external defibrillation equipment and vasopressors available for management of hemodynamic instability. 1

Post-Operative Medication Management

All medications that were continued through surgery should remain at their baseline doses postoperatively. 3

• Monitor for adequate wound healing, absence of infection, and hemodynamic stability. 1

• Resume normal medication schedule once the patient is tolerating oral intake. 1