HealthRX.com · Printable surgery planning sheet
Peptide disclosure sheet for your surgeon and anesthesia team
Puts any MOTS-c or other peptide product on the record before an operation, with the questions to settle with the surgical team and a place to note injection-site or wound changes afterwards.
What to put on the record
Include products bought online as well as anything prescribed.
Product name exactly as labeled
Seller or pharmacy, and lot number if shown
Date first used and date last used
Other peptides used now or recentlyfor example BPC-157 or TB-500
Glucose-lowering or blood-thinning medicines
Date and type of planned surgery
What the surgical team may want to know
- FDA's July 2026 review identified no clinical studies or human exposure data for MOTS-c by any route.[1]
- FDA lists a risk of immunogenicity and peptide-related impurities for compounded MOTS-c.[2]
- FDA does not verify the safety, effectiveness or quality of compounded drugs before they are marketed.[3]
- The registered surgery study measures patients' own MOTS-c before anesthesia induction and before extubation; it does not give the peptide.[4]
- MOTS-c treatment experiments related to surgical injury were done in laboratory animals, for example Sprague-Dawley rats pretreated before heart ischemia-reperfusion; no patient was given the peptide.[5]
To settle with the surgeon or anesthesiologist
- Do you want me to stop any non-prescribed peptide before the operation, and from what date?
- Could a recent injection site be confused with a wound or infection problem when you examine me?
- Does anything I use change how my blood sugar or bleeding will be checked around surgery?
- Who decides whether anything can be restarted afterwards, and when?
- Who should I call about redness, swelling, warmth or fever after I go home?
After surgery: changes you noticed
| Date | Where (wound or injection site) | What you saw or measured | Who you told |
|---|---|---|---|
Bring to the pre-operative visit
- This sheet, filled in
- Photos of every product label
- A full list of prescription medicines and supplements
- Recent lab results if you have them
Sources for the facts on this sheet
- U.S. Food and Drug Administration. FDA Briefing Document: MOTS-c-Related Bulk Drug Substances (MOTS-c (free base) and MOTS-c acetate), Pharmacy Compounding Advisory Committee, July 23-24, 2026. Accessed 2026-10-19. https://www.fda.gov/media/193347/download
- U.S. Food and Drug Administration. Certain Bulk Drug Substances for Use in Compounding that May Present Significant Safety Risks. Accessed 2026-10-19. https://www.fda.gov/drugs/human-drug-compounding/certain-bulk-drug-substances-use-compounding-may-present-significant-safety-risks
- U.S. Food and Drug Administration. Compounding and the FDA: Questions and Answers. Accessed 2026-10-19. https://www.fda.gov/drugs/human-drug-compounding/compounding-and-fda-questions-and-answers
- U.S. National Library of Medicine, ClinicalTrials.gov (API v2 record). NCT07678073: Comparison of the Effects of General Anesthesia and Combined Spinal-Epidural Anesthesia on Ferroptosis, Humanin and MOTS-c Levels in Renal Transplantation. Accessed 2026-10-19. https://clinicaltrials.gov/api/v2/studies/NCT07678073
- Lu P, Li X, Li B, Li X, Wang C, Liu Z, Ji Y, Wang X, Wen Z, Fan J, Yi C, Song M, Wang X. The mitochondrial-derived peptide MOTS-c suppresses ferroptosis and alleviates acute lung injury induced by myocardial ischemia reperfusion via PPARγ signaling pathway. Eur J Pharmacol 2023. PMID 37290680. https://pubmed.ncbi.nlm.nih.gov/37290680/
This sheet records information for a conversation with your prescriber or pharmacist. It does not replace their instructions or the medication's prescribing information.