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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.
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.
Why: The pause has to start weeks ahead for some of these drugs, so it needs planning.
“Advise patients to contact their healthcare provider before any planned surgeries, including dental surgery”
AVEO / US FDA (DailyMed) 2026 · Label instruction (no grade)
Why: Bevacizumab stays in the body for weeks (its half-life is about 20 days), and wounds heal less well while it is active.
“Withhold for at least 28 days prior to elective surgery. Do not administer Avastin for at least 28 days following a major surgery, and until adequate wound healing.”
Genentech / US FDA (DailyMed) 2025 · Label instruction (no grade)
Why: Both are antibodies or fusion proteins that last for weeks, like bevacizumab.
“Withhold ZALTRAP for at least 4 weeks prior to elective surgery. Do not administer ZALTRAP for at least 4 weeks after major surgery and until wounds have adequately healed.”
Sanofi / US FDA (DailyMed) 2025 · Label instruction (no grade)
Why: Each tablet leaves the body at a different speed, so each label sets its own pause.
“Impaired Wound Healing: Withhold CABOMETYX for at least 3 weeks before elective surgery. Do not administer for at least 2 weeks following major surgery and adequate wound healing.”
Exelixis / US FDA (DailyMed) 2025 · Label instruction (no grade)
Why: Restarting too early can make a wound or a bowel join break down.
“Impaired Wound Healing : Withhold CYRAMZA for 28 days prior to elective surgery. Do not administer CYRAMZA for at least 2 weeks following a major surgical procedure and until adequate wound healing.”
Eli Lilly / US FDA (DailyMed) 2026 · Label instruction (no grade)
Why: Small wounds heal faster, so the gap after them can be shorter.
“For minor surgery such as central venous access port placement, biopsy, and tooth extraction, ZALTRAP may be initiated/resumed once the surgical wound is fully healed.”
Sanofi / US FDA (DailyMed) 2025 · Label instruction (no grade)
Why: No study has shown that restarting after a wound complication is safe.
“Withhold AVASTIN until adequate wound healing.The safety of resumption of AVASTIN after resolution of wound healing complications has not been established.”
Genentech / US FDA (DailyMed) 2025 · Label instruction (no grade)
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Follow the interval on the drug's own current label; there is no guideline that sets a different one. The US labels give explicit numbers before and after surgery for every agent; the EU SmPCs for Avastin and Lenvima give the post-surgery interval or a 'consider interrupting' instruction but no pre-surgery number, so a UK or EU team may use the US figure or its own policy. The evidence behind the bevacizumab interval is the colorectal trial experience reported in the labels (no extra wound or bleeding complications when surgery was 28 to 60 days before starting; 10 to 20% when operating during treatment) and a meta-analysis of randomised trials (OR 2.32 for wound complications).
Genentech / US FDA (DailyMed) 2025 · European Medicines Agency 2026 · European Medicines Agency 2026 · Oncotarget 2016
Where it differs: Says therapy should be withheld for elective surgery and not started for at least 28 days after major surgery or until the wound is fully healed, without a number of days before surgery.
Evidence: EU SmPC section 4.4; the same trial experience as the US label is reported in section 4.8.
Where it differs: Temporary interruption 'should be considered' before major surgery; the US label says withhold for at least 1 week.
Evidence: EU SmPC: no formal studies of lenvatinib on wound healing; limited experience on when to restart.
European Medicines Agency 2026 · Eisai / US FDA (DailyMed) 2026
Where it differs: The US label's dosing and warnings sections say at least 10 days before elective surgery; one line of its patient information says at least 2 weeks.
Evidence: Both appear in the current DailyMed text; the prescriber sections give 10 days.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Bevacizumab doubles wound-healing complications “The pooled estimate of odds ratio (OR) was 2.32, and the 95 % confidence intervals (CI) was 1.43 to 3.75. (P < 0.001).” | Meta-analysis of 7 randomised trials, 5147 participants | Oncotarget 2016 |
| No extra risk when major surgery was 28 to 60 days before starting bevacizumab “In clinical trials of metastatic carcinoma of the colon or rectum, there was no increased risk of post-operative bleeding or wound healing complications observed in patients who underwent major surgery 28-60 days prior to starting Avastin.” | Clinical trial experience reported in the SmPC | European Medicines Agency 2026 |
| Bevacizumab half-life “The estimated half-life is 20 days (11 to 50 days).” | Pharmacokinetics (label) | Genentech / US FDA (DailyMed) 2025 |
| Axitinib: shortest pre-surgery interval “Withhold INLYTA for at least 2 days prior to elective surgery.” | Label instruction | Pfizer / US FDA (DailyMed) 2025 |
| Lenvatinib and pazopanib: one week “Withhold LENVIMA for at least 1 week prior to elective surgery.” | Label instruction | Eisai / US FDA (DailyMed) 2026 |
| Regorafenib: two weeks “Withhold STIVARGA for at least 2 weeks prior to elective surgery.” | Label instruction | Bayer / US FDA (DailyMed) 2026 |
| Sunitinib: three weeks “Impaired Wound Healing : Withhold SUTENT for at least 3 weeks prior to elective surgery.” | Label instruction | Pfizer / US FDA (DailyMed) 2026 |
| Tivozanib: 24 days “Risk of Impaired Wound Healing: Withhold FOTIVDA for at least 24 days before elective surgery.” | Label instruction | AVEO / US FDA (DailyMed) 2026 |
| Fruquintinib: two weeks before major surgery “Impaired Wound Healing: Withhold FRUZAQLA for 2 weeks before major surgery.” | Label instruction | Takeda / US FDA (DailyMed) 2026 |
| Pazopanib: one week “Withhold VOTRIENT at least 1 week prior to elective surgery.” | Label instruction | Novartis / US FDA (DailyMed) 2025 |
| Sorafenib: ten days “Risk of Impaired Wound Healing : Withhold NEXAVAR for at least 10 days prior to elective surgery.” | Label instruction | Bayer / US FDA (DailyMed) 2024 |
| Ramucirumab EU SmPC: at least 4 weeks “Ramucirumab therapy should be temporarily discontinued for at least 4 weeks prior to elective surgery.” | Label instruction | European Medicines Agency 2026 |
Shares Sorafenib, Sunitinib, Regorafenib, Cabozantinib.
Shares Ziv-aflibercept, Fruquintinib, Regorafenib, Bevacizumab.
Shares Axitinib, Pazopanib, Sunitinib, Cabozantinib.
Shares Anti-VEGF class toxicities (hypertension, proteinuria, bleeding, perforation), Sorafenib, Regorafenib, Cabozantinib.
Shares Tivozanib, Cabozantinib, Anti-angiogenic therapy.
Shares Axitinib, Cabozantinib, Lenvatinib.
Shares Routine tests before planned surgery, by size of operation and fitness, Surgical site infection prevention: skin preparation, antibiotic timing, warming and wound care.