Peri‑operative Management of ACE‑Inhibitors, ARBs, and Adjunctive Drugs in Systemic Lupus Erythematosus (SLE) Patients

1. Cardiovascular‑Renin‑Angiotensin System (RAS) Therapy

The 2014 ACC/AHA peri‑operative cardiovascular guideline gives a Class IIa recommendation (reasonable) to continue ACE inhibitors and ARBs during non‑cardiac surgery; moderate‑quality evidence shows no increase in adverse cardiovascular outcomes. 1
If an ACE inhibitor or ARB is unintentionally held before surgery, it should be re‑started as soon as clinically feasible post‑operatively to avoid prolonged interruption. 1
Do not routinely discontinue ACE inhibitors or ARBs on the day of surgery; intra‑operative hypotension can be managed with fluids and vasopressors rather than drug withdrawal. 1

Chronic beta‑blocker therapy (e.g., carvedilol) should be continued peri‑operatively; Class I recommendation with strong evidence that stopping increases cardiac events. 1
Beta‑blocker discontinuation on the day of surgery is a Class III (Harm) recommendation with strong evidence of heightened cardiac risk. 1
Statin therapy (e.g., rosuvastatin) should be maintained in patients already on a statin; Class I recommendation. 1

Hydroxychloroquine (≈200 mg daily) should be continued unchanged throughout the peri‑operative period for all SLE patients; conditional recommendation based on low‑to‑moderate quality evidence showing reduced flare risk and mortality benefit. [2][3]4
Do not discontinue hydroxychloroquine peri‑operatively, as interruption raises the risk of disease flare and eliminates documented mortality advantage. [2][3]

Maintain the patient’s baseline glucocorticoid dose (e.g., methylprednisolone 16 mg daily) without giving supraphysiologic stress‑dose steroids on the day of surgery; conditional recommendation supported by evidence that baseline dosing reduces infection risk without compromising adrenal function. 5
Avoid routine administration of high‑dose stress steroids peri‑operatively; doing so increases infection risk and offers no proven benefit. 5

When hypotension occurs while RAS agents are continued, place the patient supine, give intravenous crystalloid as needed, and have vasopressors and external defibrillation equipment readily available. This approach is endorsed by the ACC/AHA guideline. 1

All medications that were continued through surgery (ACE/ARB, beta‑blocker, statin, hydroxychloroquine, baseline glucocorticoid) should remain at their pre‑operative doses post‑operatively.
Monitor for adequate wound healing, absence of infection, and hemodynamic stability after surgery; these safety checks are recommended by rheumatology research evidence. [2][3]4
Resume the normal oral medication schedule once the patient tolerates oral intake, ensuring continuity of therapy. 1

Hydroxychloroquine 200 mg daily should be continued unchanged throughout the peri‑operative period. This is a conditional recommendation supported by low‑to‑moderate quality evidence for all SLE patients undergoing elective surgery. 6
Baseline methylprednisolone 16 mg daily should be maintained without adding stress‑dose steroids on the day of surgery. The 2022 ACR/AAHKS guideline advises continuing the patient’s usual glucocorticoid dose rather than giving supraphysiologic stress doses, representing a shift from historic practice and applying to all SLE patients regardless of disease severity. 6
No additional immunosuppressants need to be withheld because the patient is only on hydroxychloroquine. The guideline states that, for mild SLE, withholding agents such as mycophenolate, azathioprine, cyclosporine, or tacrolimus is unnecessary when they are not part of the regimen. 6

Carvedilol 25 mg should be continued through surgery in accordance with standard cardiovascular peri‑operative protocols. 7
Rosuvastatin 10 mg should be continued through surgery to maintain lipid control and cardiovascular risk reduction. 8

Bilastine 20 mg (antihistamine) may be continued as needed for urticaria‑related symptoms. 7
Pregabalin 75 mg may be continued for neuropathic pain or headache. 7
Acetaminophen (paracetamol) combined with tramadol may be used as needed for pain control. 9
Vitamin B complex may be continued to support general health. 7

Do NOT administer supraphysiologic (stress‑dose) glucocorticoids peri‑operatively. Continuing the baseline 16 mg methylprednisolone dose reduces infection risk without compromising adrenal function. 6
Do NOT discontinue hydroxychloroquine peri‑operatively. Stopping the drug increases the risk of lupus flare and eliminates its demonstrated mortality benefit. 6