Clinical case: Should we stop raloxifene (Evista) prior to surgery?

A 69-year-old Caucasian female with a past medical history of hypertension, hyperlipidemia, osteoarthritis and severe osteoporosis takes the oral selective estrogen receptor modulator raloxifene. Her other medications include hydrochlorothiazide and atorvastatin. The patient takes ibuprofen and the combination of oxycodone and acetaminophen prn for knee pain.

She is seen by an internal medicine physician for preoperative evaluation three weeks prior to surgery for total knee replacement for osteoarthritis of the right knee. Physical examination reveals decreased range of motion of the right knee but is otherwise normal. The electrocardiogram recorder in her primary care physician's office shows normal sinus rhythm.

The patients and her primary care physician want to know whether she should stop taking raloxifene prior to surgery.

Should we stop Evista prior to surgery?

Yes.

Indications for use of selective estrogen receptor modulators (SERMs) such as tamoxifen and raloxifene (Evista) have expanded beyond breast cancer treatment to prevention and treatment of osteoporosis. Both tamoxifen and raloxifene increase the risk of VTE (DVT and PE).

A review in UpToDate recommends tamoxifen and raloxifene be discontinued for 4 weeks before surgeries associated with a moderate or high risk of venous thromboembolism (VTE).

If the patient takes those drugs for breast cancer treatment, a consultation with an oncologist is recommended.

This is one of the series of perioperative questions I will answer on this web site. They will be submitted as clinical vignettes to the Cleveland Clinic Annual Perioperative Summit next year. This year's summit is in September and several of the perioperative cases in nephrology will be presented as posters and published as abstracts in the Cleveland Clinic Journal of Medicine.

References:
Should selective estrogen receptor modulators be discontinued prior to noncardiac surgery? UpToDate (paid subscription required).
Hormone therapy and thromboembolic disease. Hemostasis and thrombosis. Current Opinion in Hematology. 14(5):488-493, September 2007.
The World Health Organization has an online Fracture Risk Assessment Tool.
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Updated: 12/14/2009