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Perioperative & ERAS Pharmacotherapy

Systemic pharmacotherapy surrounding the perioperative window — VTE prophylaxis, anticoagulation reversal, bowel preparation, postoperative bowel / ileus management, and systemic corticosteroids. These pages are the drug-class hubs (agents, doses, FDA labels, evidence ceilings); the Perioperative Care section provides the bedside workflow companions (Caprini in urology, bridging, stress dosing, etc.). Each pair has explicit cross-reference boxes to keep facts in one place.

The most consequential recent shifts: the andexanet alfa US market withdrawal (4F-PCC now first-line for FXa-inhibitor reversal), the paradigm shift away from MBP before ileal-conduit construction (Simhal 2025 NSQIP), and alvimopan's ERAS-integrated benefit attenuation (Hanna 2021).

  • VTE ProphylaxisCaprini ≥ 7 threshold; Westerman 2022 apixaban compliance/safety data (70% of SUO members now use apixaban for extended prophylaxis); NCCN procedure-specific inpatient + 4-week extended prophylaxis; apixaban-after-bowel-resection absorption caveat; neuraxial-anesthesia timing.
  • Anticoagulation ReversalAndexanet alfa US withdrawal anchored as headline news → 4F-PCC now first-line for FXa-inhibitor reversal. Idarucizumab gold-standard for dabigatran (RE-VERSE AD). Vitamin K must be co-administered with PCC for warfarin. Protamine boxed warning + NPH/fish/vasectomy screening. Ciraparantag emerging.
  • Bowel PreparationFive-study paradigm-shift table for no-MBP-before-ileal-conduit; Simhal 2025 NSQIP diversion-type-dependent OABP signal (ileal conduit vs continent diversion); sodium phosphate APhN boxed-warning danger admonition; Nichols neomycin + erythromycin / metronidazole; Calaway 2019 C. diff screening.
  • Postop Bowel & Ileus ManagementAlvimopan (Lee 2014 + Hanna 2021 ERAS-integrated benefit attenuation), neostigmine-for-ACPO protocol, explicit de-prescribe-docusate rule, reconstructive-scope framing (diversion / augment / catheterizable channels). Companion to the Postoperative constipation & ileus workflow page.
  • CorticosteroidsSix-domain framework — PONV/ERAS, mCRPC steroid switch, transplant rejection, contrast premedication, IC/BPS Hunner-lesion, MET deflazacort. Cross-links to Perioperative steroids for stress dosing / adrenal crisis / wound healing.