Surgical Considerations

  • I have CML and need to have surgery for another condition next week. Do I need to stop my CML medications for surgery?

    Recommendations differ based on type of surgery and overall health and other risk factors in each patient’s history. What is most important in the peri-operative setting is adequate and/or ideal blood counts, especially platelets, which in certain cases may prompt or mandate a drug holiday, a transfusion, etc.

    In many patients, there is no need to stop tyrosine kinase therapy at all. These patients tolerate their CML medications well and their health care teams do not anticipate drug-drug interactions. There has been significant experience with the use of imatinib specifically, throughout the surgical period, in patients living with GIST (gastrointestinal stromal tumor). Studies have been done which monitor the effects of imatinib when started before, during and after the perioperative period. These studies revealed no unusual or additive effects of imatinib that were not already known and anticipated. Similar reports from experiences with imatinib and CML patients, are expected. 

    Other individuals may have safer and more comfortable surgical experiences when their CML medication is temporarily stopped for a brief period before, during or after surgery. These decisions are made on a case by case basis and should include the exact CML medication the patient is taking, since different medications have different side effect profiles and issues associated with them. An example of the need to stop CML medication for surgery might be a patient who is not allowed to eat before surgery, or having difficulty eating after surgery, who might be best served by holding administration of CML medication.  In an otherwise healthy adult, having general surgery, recommendations may include stopping tyrosine kinase inhibitors 3 (three) days prior to surgery and restarting on post operative day 2 (two). This eliminates the tyrosine kinase inhibitor as a contributor to certain other side effects of anesthesia, analgesia, antibiotics and the body’s general response to surgery, which may include risks of bleeding and infection, discomfort, nausea or vomiting. This may be particularly important with the newer tyrosine kinase inhibitors such as Bosulif™ (Bosutinib) and Iclusig™(Ponatinib). If you are taking Synribo™ (Omacetaxine), other factors may need to be considered and discussed with your healthcare team.

    It is very important to discuss this situation with your CML specialist, surgeon and anesthesiologist, so that they are fully aware of your CML diagnosis, response to treatment thus far, and any side effects you routinely experience on CML medication. Drug interactions will be important to prevent when possible, and monitoring of your PCR will be key following your surgery. If your CML medication was stopped for a surgical procedure, your CML specialist can work with your surgeon to advise you personally as to a safe day and time to restart your CML medication.