# Bevacizumab and other anti-VEGF drugs around surgery: pausing before and restarting after

Source: https://onco.cc/protocols/anti-vegf-drugs-around-surgery/  
OnCo record `anti-vegf-drugs-around-surgery` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Drugs that block blood vessel growth, such as bevacizumab (Avastin), ramucirumab, aflibercept and tablets like cabozantinib, lenvatinib or sunitinib, slow the healing of wounds. Before planned surgery they are paused, for between 2 days and 4 weeks depending on the drug, and restarted only once the wound has healed, usually at least 2 to 4 weeks after a big operation.

## Summary

Every anti-VEGF agent's label carries a wound-healing warning with an interval, and the intervals track the drug's half-life. US labels: bevacizumab withhold at least 28 days before elective surgery and do not give for at least 28 days after major surgery (half-life about 20 days); ramucirumab 28 days before, at least 2 weeks after; ziv-aflibercept at least 4 weeks before and after (minor surgery such as port placement, biopsy or tooth extraction: resume once healed); cabozantinib and sunitinib at least 3 weeks before; tivozanib at least 24 days; regorafenib and fruquintinib 2 weeks; sorafenib at least 10 days; lenvatinib and pazopanib at least 1 week; axitinib at least 2 days; for all the TKIs, at least 2 weeks after major surgery and until the wound has healed. EU SmPCs are less specific: Avastin says therapy 'should be withheld for elective surgery' and not started for at least 28 days after major surgery; Lenvima says interruption 'should be considered'. In the Avastin colorectal trials, surgery 28 to 60 days before starting carried no extra risk, while operating during treatment gave wound or bleeding complications in 10 to 20%. A meta-analysis of 7 randomised trials (5147 people) found bevacizumab doubled wound complications (OR 2.32), mainly in colon cancer. No label establishes the safety of restarting after a wound-healing complication.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: holding bevacizumab before surgery; anti-angiogenic drugs and wound healing; VEGF inhibitor surgery interval; stopping TKI before surgery; Avastin before surgery

## Connected records

- protocols: [Routine tests before planned surgery, by size of operation and fitness](https://onco.cc/protocols/routine-preoperative-tests/), [Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care](https://onco.cc/protocols/surgical-site-infection-prevention/)
- technologies: [Anti-angiogenic therapy](https://onco.cc/technologies/antiangiogenic/)
- drugs: [Axitinib](https://onco.cc/drugs/axitinib/), [Bevacizumab](https://onco.cc/drugs/bevacizumab/), [Cabozantinib](https://onco.cc/drugs/cabozantinib/), [Fruquintinib](https://onco.cc/drugs/fruquintinib/), [Lenvatinib](https://onco.cc/drugs/lenvatinib/), [Pazopanib](https://onco.cc/drugs/pazopanib/), [Ramucirumab](https://onco.cc/drugs/ramucirumab/), [Regorafenib](https://onco.cc/drugs/regorafenib/), [Sorafenib](https://onco.cc/drugs/sorafenib/), [Sunitinib](https://onco.cc/drugs/sunitinib/), [Tivozanib](https://onco.cc/drugs/tivozanib/), [Ziv-aflibercept](https://onco.cc/drugs/ziv-aflibercept/)
- terms: [Anti-VEGF class toxicities (hypertension, proteinuria, bleeding, perforation)](https://onco.cc/terms/antiangiogenic-toxicities/)

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