Perioperative Medicines Management GL058

Perioperative medicines management

GL058

Approval

Approval Group Job Title, Chair of Committee Date Anaesthetics Clinical Governance Chair of Anaesthetics Clinical November Governance 2016

Change History

Version Date Author, job title Reason 3 November 2013 Jennie Rechner, Consultant Review and update Anaesthetist 4 January 2015 Jennie Rechner, Consultant Review and update Anaesthetist 5 September Jennie Rechner, Consultant Update 2015 Anaesthetist 6 November 2016 Jennie Rechner, Consultant Update Anaesthetist

Author: Jennie Rechner Date: November 2016

Job Title: Consultant Anaesthetist Review Date: November 2018

Policy Lead: Planned Care Group Director Version: Version 6

Location: Corporate Governance shared drive – GL058

November 2016

Perioperative medicines management

Perioperative medicines management–GL058  This guideline aims to guide health professionals advise patients undergoing general anaesthesia on which medications to continue and which to stop preoperatively.  The majority of medication should be continued up to and including the day of surgery.  Some medications interact with anaesthetic agents and need to be highlighted to the anaesthetist.  Advice on anticoagulants, antiplatelet agents and medications used for control of diabetes are outlined in separate guidelines, GL067 and GL059. Continue treatment. Conventional NSAIDS If other antiplatelet drugs are to be stopped, e.g. ibuprofen, diclofenac. discontinue for 3 days prior to surgery, especially for spinal surgery.

COX-2 inhibitors Continue treatment. e.g. meloxicam Paracetamol/codeine Continue treatment. combinations

e.g. co-codamol.

Buprenorphine patch. Continue treatment.

Fentanyl patch. Continue treatment.

Morphine. Continue treatment.

Opioids Oxycodone. Continue treatment. Pain killers e.g. tramadol, buprenorphine, Contact pain team preoperatively on fentanyl, morphine, oxycodone. [email protected] or postoperatively on bleep 158 for advice if patient receiving: Buprenorphine patch ≥ 35 mcg/h Fentanyl patch ≥ 50mcg/hr Morphine ≥ 100 mg/day. Oxycodone ≥ 60 mg/day Neuropathic agents Continue treatment. e.g. gabapentin, pregabalin, carbamazepine. Methadone Continue treatment. Advise patient to bring contact details of their GP, alcohol and drug addiction service provider, and chemist. Statins Continue treatment. e.g. simvastatin, atorvastatin, pravastatin.

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Perioperative medicines management

ACE inhibitors can cause profound hypotension perioperatively. Advise the patient to omit dose on the day of surgery ACE inhibitors and to bring the medication with them to e.g. enalapril, lisinopril, ramipril, hospital. The anaesthetist can then decide fosinopril, trandolapril, captopril. whether to administer/withhold the dose. Continue treatment if having local anaesthetic. Angiotensin II inhibitors As for ACE inhibitors. e.g. losartan, candesartan. Anti-anginal therapy Continue treatment. e.g. isosorbide mononitrate. Anti-arrhythmics Continue treatment. e.g. amiodarone, digoxin, Cardiac disopyramide, flecainide, medications verapamil. Anti-hypertensives Continue treatment. e.g. amlodipine, atenolol, See potassium sparing diuretics. hydralazine, clonidine, nicorandil. See alpha-blockers. Beta-blockers Continue treatment. e.g. atenolol, bisoprolol, metoprolol, sotalol. Thiazides Continue treatment. e.g. bendroflumethiazide. Loop diuretics Diuretics e.g. frusemide Potassium sparing Omit dose on morning of surgery. diuretics e.g. amiloride, spironolactone. Aspirin See GL067 Anti-platelet Clopidogrel, prasugrel, ticagrelor See GL067 medication Dipyridamole See GL067

See GL067 Oral anticoagulants e.g. warfarin, rivaroxaban

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Perioperative medicines management

Anti-epileptics Continue treatment. e.g. phenytoin, oxcarbazepine, carbamazepine, sodium

valproate, levitiracetam.

Anti-parkinsonian drugs Continue treatment.

e.g. cabergoline, madopar, Discontinue rasagiline and selegiline 2 weeks

sinemet, entacapone, prior to surgery if patient symptoms allow. pramipexole, rasagiline Neurological Anti-psychotics & Continue treatment. Anxiolytics Discontinue clozapine for 24hrs prior to e.g. diazepam, surgery. chlorpromazine, clozapine, sulpiride. Lithium Continue treatment.

Dementia Continue treatment. eg donepezil

Sleeping medication Continue treatment. e.g. nitrazepam, temazepam, zopiclone.

Tricyclic Antidepressants Continue treatment. e.g. amitriptyline, dosulepin, Highlight on assessment sheet for lofepramine, mianserin. anaesthetist Monoamine-oxidase Continue treatment. inhibitors Although drug manufacturers recommend Antidepressants e.g phenelzine, that these agents are discontinued for 2 isocarboxacid, moclobemide, weeks, in practice they are continued due to tranylcypromine. the risks of withdrawal. Highlight on assessment sheet for anaesthetist. Avoid concomitant use of tramadol, indirect sympathomimetics and cocaine Levothyroxine Continue treatment.

Anti-thyroid medications Continue treatment. e.g. carbimazole, propylthiouracil.

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Perioperative medicines management

Conventional Continue treatment. e.g. methotrexate, Withhold azathioprine and mercaptopurine on leflunomide, the day of surgery and restart once renal azathioprine, function is normal.

ciclosporin, Consider stopping immunosuppressives if the

hydroxychloroquine, patient develops a significant infection.

mercaptopurine Immunosuppression Anti-rejection medications Continue treatment medications

e.g. tacrolimus, sirolimus Anti TNF-a Discontinue 2 weeks prior to surgery for e.g. infliximab, patients treated for rheumatoid arthritis; etanercept, continue if prescribed for inflammatory bowel adalimumab. disease. Discuss with anaesthetist if unsure. Corticosteroids Continue treatment. Inform anaesthetist if e.g. prednisolone. taking steroids for congenital adrenal hyperplasia or Addisons disease. Insulin and oral hypoglycaemics See GL059 e.g. Insulin, gliclazide, glipizide, metformin, byetta, pioglitazone.

Inhalers Continue treatment. e.g. salbutamol, beclomethasone, serevent, seretide, spiriva, atrovent.

Anti-androgens Continue treatment. e.g. bicalutamide, cyproterone.

Bisphosphonates Omit dose on morning of surgery. e.g. alendronate, etidronate, risedronate.

Alpha-blockers Continue treatment. e.g. Alfuzosin, doxazosin, indoramin, tamsulosin, terazosin

Herbal medicines Discontinue 2 weeks before surgery.

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Perioperative medicines management

All women of childbearing age should be asked if they are on the contraceptive pill as some do not consider it a medication.

There is an increased risk of postoperative

VTE (2.5 fold) postoperatively and all women

should be informed of this.

Advise patients to discontinue 4 weeks before Combined major surgery, surgery to lower limbs, surgery Contraceptives (oral) which involves prolonged immobilisation or has other risk factors for VTE such as obesity, thrombophilia or previous history of

VTE. Advise patients to use other methods of contraception if stopping oral contraception. Progesterone only Continue treatment.

HRT is associated with a 1.3-3 fold increase in postoperative VTE. All women should be informed of this.

Advise patients to discontinue 4 weeks before Hormone Replacement Therapy (HRT) major elective surgery, surgery with a high

likelihood of prolonged immobilisation or in those with other risk factors for VTE. Low risk patients can continue treatment. Tamoxifen Continue treatment for day case procedures. Discontinue treatment for 2 weeks if moderate in-patient surgery and for 4 weeks if major in-patient surgery such as breast reconstruction.

Author: Jennie Rechner Date: November 2016

Job Title: Consultant Anaesthetist Review Date: November 2018

Policy Lead: Planned Care Group Director Version: Version 6

Location: Corporate Governance shared drive – GL058

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