Oral drug therapy guidelines in surgical patients



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ORAL DRUG THERAPY GUIDELINES IN SURGICAL PATIENTS
At the pre-operative assessment it is important that a full medication history is taken prior to any procedure, including herbal, homeopathic and topical medications. The pre-assessment nurse practitioner, pharmacist or doctor, as applicable, must inform the patient which medicines should be stopped and which medicines should be continued. For the medicines that are to be stopped, patients must be told how long before the day of surgery the medicines should be stopped and when they are likely to be restarted. If a patient requires emergency surgery then the surgical team should liaise with the anaesthetist to discuss which drugs should and should not be stopped prior to surgery and when to restart any discontinued drugs.
A patient may be ‘Nil-by-mouth’ for several reasons, e.g. non-functional gut, lack of swallowing reflex, patient unconscious or prior to surgery. Nausea or vomiting may also inhibit the use of oral medicines. Surgery is not an indication to stop the majority of medications a patient may be taking on admission. Where there is a need for medication to continue because the oral route is inappropriate consideration should be given to alternative routes or products. The table below aims to clarify those drugs which should be continued and those that should be stopped prior to surgery with suggested alternative routes when the oral route is unsuitable. Please also consult Pharmacy for guidance on the administration of drugs through enteral feeding tubes for alternatives to solid oral dosage forms for patients unable to swallow their medication.
When changing the route of administration of a drug care should be taken to ensure that the appropriate dose and frequency is prescribed, as these may not be the same as for the oral route.
Patients are at risk of aspirating their stomach contents during general anaesthesia. They are therefore usually prevented from eating at least 6 hours pre-surgery and can drink only water between 6 and 2 hours pre-operatively. Water leaves the stomach within 2 hours of ingestion and therefore, medicines can be given up to 2 hours before surgery with water.

General rule of thumb: do not stop analgesia, anti-epileptics, bronchodilators, corticosteroids, antidepressants, antipsychotics, benzodiazepines, Parkinsons disease medicines, cardiovascular drugs, glaucoma drugs, thyroid or anti-thyroid drugs and peptic ulcer drugs prior to surgery.
Stop all herbal medicines 2 weeks prior to surgery.
The table below is not exhaustive, although most drug groups not included in the table can be omitted pre/peri-operatively. If in doubt contact an anaesthetist or the ward pharmacist for further advice. Please note that recommendations for stopping for major surgery may differ to those for minor surgery
Key to table

Drugs that are usually stopped



Benefits of stopping need to be weighed against risks. Depends on Consultant surgeon / anaesthetist preference and surgery type

Drugs that must be continued to prevent relapse of the treated condition or to avoid the effects of drug withdrawal








BNF Class / Drug group

(examples)

Risk


Use pre-op. when NBM

Alternative post-op if unable to take po medication
Management

1. GASTRO-INTESTINAL

1.1 Antacids

(e.g. co-magaldrox, GavisconR)




Reduce risk of acid aspiration.

Continue







1.2 Antispasmodics, motility stimulants

(e.g. mebeverine)




Increased risk of ileus.


Discontinue during periods of NBM post operatively- prolonged periods of NBM increase the risk of paralytic ileus






1.3.1 H2 receptor antagonists

(e.g. ranitidine)




Reduce risk of acid aspiration.

Continue

i.v. ranitidine 50mg tds




1.3.5 Proton pump inhibitors

(e.g. omeprazole)




Reduce risk of acid aspiration.

NB: lansoprazole may increase action of vecuronium



Continue

i.v. proton-pump inhibitor

NB increased risk of C. difficile associated with PPI’s

1.6 Laxatives

Note contra-indications

Fybogel - intestinal obstruction and colonic atony

Docusate - abdominal pain , nausea, vomiting or intestinal obstruction

Senna - undiagnosed acute or persistent abdominal symptoms

Macrogols – intestinal perforation/obstruction, paralytic ileus, severe inflammatory conditions of the intestinal tract


Continue but note contra-indications

Omit if laxative action is undesirable









2. CARDIOVASCULAR

2.1 Digoxin

Increased toxicity with suxamethonium

Arrhythmias



Continue.

i.v.digoxin. Convert po to iv dose using conversion factor (0.65 tablets, 0.80 elixir), e.g digoxin 125micrograms tablet  100micrograms elixir  80 micrograms i.v.

Monitor digoxin level and K+. Level checked 6-8hrs after dose.



2.2 Diuretics

-thiazide and loop

(e.g. bendroflumethiazide, furosemide)


Arrhythmias

Prolonged N/M block

Hypokalaemia may provoke paralytic ileus


For diuretics the ESC guidelines recommend:

  • Hypertensive patients discontinue low dose diuretics on the day of surgery and resume orally when possible.

  • Heart failure patients continue up to the day of surgery, resume iv perioperatively and continue orally when possible.

  • Electrolyte disturbances be corrected before surgery



i.v. diuretics

(max rate for furosemide = 4mg/min)



Monitor BP, fluids,U+E’s


Diuretics - potassium sparing

(e.g. amiloride, spironolactone)





Tissue damage

Reduced kidney perfusion

Hyperkalaemia


Add potassium to fluids where needed.

Monitor U+E’s

2.3 Antiarrhythmics

To prevent relapse of arrhythmia

Some antiarrhythmics prolong the duration of action of non depolarising neuromuscular blockers



Continue

Use i.v. alternative within same class with ECG monitoring

ECG monitoring. Monitor U+E’s. Hypokalaemia can predispose to digoxin toxicity

Omit if bradycardic



2.4 Beta blockers

(e.g. atenolol, propranolol)



Hypotension

Bradycardia

Bronchospasm


Continue- improves c/v stability. Beta-blockers should not be discontinued abruptly in the peri-operative period. Rebound if withdrawn.
In post-thyroidectomy, dose may be gradually tapered to zero.


Give alternative i.v. beta-blocker (rarely needed) or GTN patch if patient symptomatic


Monitor BP and pulse

2.5.1 Vasodilators (e.g. hydralazine)


Reflex tachycardia

Hypotension.



Continue


i.v. alternatives available


Monitor BP and pulse

2.5.2 Central-acting anti-hypertensives

(e.g. clonidine, methyldopa)



Hypotension


Rebound hypertension if withdrawn-hypertensive crisis with one missed dose. Continue.



Monitor BP

2.5.4 Alpha blockers

(e.g. doxazosin)



Hypotension


Continue- improves c/v stability.

However, if for urinary retention and the patient is catheterised may withhold if at risk of hypotension.



GTN patch or, if BP remains high, alternative i.v. antihypertensive agent

Monitor BP
If for urinary retention then should discontinue post TURP

2.5.5.1 ACE inhibitors

(e.g.


short-acting :captopril

long-acting: lisinopril)

Hypotension (risk increases if volume depleted, be aware if substantial fluid shifts or bleeding is anticipated). Peri-operative ACEI’s carry a risk of hypotension under anaesthesia, in particular following induction and concomitant beta-blocker use.
Renal failure
Reduced cerebral blood flow

If prescribed for hypertension ONLY, they may be held on the morning of surgery. Longer acting drugs may need omitting on the day before and day of surgery.
If Prescribed for heart failure +/or MI continue as per the European Society of Cardiology guidelines and discuss with the anaesthetist.
Patients with a recent MI or clinically unstable must be reviewed by an anaesthetist.
Note substitution of shorter acting drugs (e.g. captopril) may allow more flexibility for patients with post-operative labile blood pressure.
For patients on 2 medicines that affect the renin angiotensin-aldosterone system

(e.g. ACEI+AIIRA or ACEI + aliskiren or AIIRA + aliskiren) discuss with the anaesthetist

For patients on combination products such as ACEI / AIIRA with diuretic or ACEI / AIIRA with calcium channel blocker discuss with the anaesthetist


GTN patch or, if BP remains high, alternative i.v. antihypertensive agent / i.v. diuretic.

Some ACE inhibitors absorbed s/l, e.g. captopril



Monitor BP and U+E’s.

Caution NSAIDS.


Resume cautiously post-operatively as long as the patient is not hypotensive and has normal renal function.

2.5.5.2 Angiotensin II antagonists

(e.g. losartan)



2.5.5.3 Renin inhibitors

(e.g. aliskiren)



Hypotension can occur in patients with marked volume depletion.

Continue







2.6.1 Nitrates

Hypotension

Continue

Topical, buccal, sublingual and iv forms available.

Monitor BP

2.6.2 Calcium antagonists


Hypotension

Bradycardia(verapamil)



Continue


GTN patch or, if BP remains high, alternative i.v. antihypertensive agent.

Avoid sublingual nifedipine capsules (associated with increased risk of stroke)




Monitor BP and pulse

--diltiazem,

- verapamil




Additive effect with enflurane, halothane


-dihydropyridines (nifedipine, amlodipine)

Additive effect with isoflurane

2.6.3 K+ channel activators (e.g. nicorandil)


Hypotension

Continue

Alternative anti-anginals (see nitrates)

Monitor BP

2.8 Anticoagulants-Parenteral

Heparin, LMWH,

Fondaparinux (see SPC re dose, timing, duration etc)





Refer to Trust Oral Anticoagulant Guidelines LINK / Anticoagulation guidelines for Neuraxial procedures LINK





For information regarding epidural analgesic infusions and anticoagulants see the CDDFT policy for the management of Epidural

Analgesia Infusions



Vitamin K antagonists

-Oral Anticoagulants

(e.g. warfarin)


Haemorrhagic risk if continued.

Risk of peri-operative thromboembolism if stopped



Refer to Trust Oral Anticoagulant Guidelines. LINK



See oral anticoagulant guidelines

INR, platelet counts (>5 days of heparin)

Check BNF for interacting drugs.




Direct thrombin inhibitors – Dabigatran
Refer also to Anticoagulation guidelines for Neuraxial procedures. LINK

Haemorrhagic risk

No antidote for rapid reversal in emergencies



Electives

CrCl<50ml/min: stop 3 to 5 days pre-op*

CrCl ≥50ml/min: stop 1 to 2 days pre-op

*also consider the longer withholding period in all circumstances where complete haemostasis required regardless of CrCl (e.g. major surgery, spinal puncture, spinal/epidural catheter)

Bridging not required

Emergencies

Delay at least 12 hours where possible.

Balance risk/benefit if delay not feasible.

Seek expert haematology advice



Before resuming ensure:

  • CrCl>30ml/min

  • >6hrs since epidural removal

  • Haemostasis adequate


Low bleeding risk

High bleeding risk / major surgery

When restarting, give 0-2 hours before next dose of LMWH would have been due.




Normal/near-normal

aPTT or thrombin time on morning of surgery;


renal function (Cockcroft-Gault estimation of CrCl)

Direct factor Xa inhibitors - Rivaroxaban
Refer also to Anticoagulation guidelines for Neuraxial procedures. LINK

Haemorrhagic risk

Prothrombin complex (Beriplex) may reverse in emergencies



Electives

CrCl<50ml/min: stop 3 to 5 days pre-op*

CrCl ≥50ml/min: stop 1 to 2 days pre-op

*also consider the longer withholding period in all circumstances where complete haemostasis required regardless of CrCl (e.g. major surgery, spinal puncture, spinal/epidural catheter)

Bridging may be required in those receiving drug for recurrent VTE, particularly if surgery within 4 weeks of an event – seek haematology advice.

Emergencies

May be able to reverse with Beriplex.

Seek expert haematology advice


Prescribe standard LMWH prophylaxis until drug restarted
Before resuming ensure:

  • CrCl>30ml/min

  • >6hrs since epidural removal

  • Haemostasis adequate


Low bleeding risk

  • resume 6 to 8hrs post-op

High bleeding risk / major surgery

  • resume ≥48hrs post-op

  • consider reduced dose initially

  • prescribe standard LMWH prophylaxis until drug restarted

When restarting, give 0-2 hours before next dose of LMWH due.




Normal/near-normal

aPTT or thrombin time on morning of surgery;


renal function (Cockcroft-Gault estimation of CrCl

2.9 Antiplatelets
-Aspirin
-platelet P2Y12 receptor blockers

(e.g. clopidogrel, prasugrel, ticagrelor and ticlopidine)




Haemorrhagic risk. Depends on surgery and / or choice of anaesthesia, i.e. epidural
Many patients take both aspirin and platelet P2Y12 receptor blocker therapy to prevent coronary stent thrombosis (which can be catastrophic).
It is essential to consider:

  • why the patient is on antiplatelet therapy*

  • risk of thrombosis if stopped

  • risk of bleeding if continued

  • site and nature of surgery


*Aspirin

Primary prevention can stop; secondary prevention, may require further discussion with surgeon / anaesthetist.


Aspirin should only be discontinued if the bleeding risk outweighs the potential cardiac benefit. If perioperative haemorrhage is a concern and the patient has not suffered a previous coronary syndrome, cerebrovascular event, angina or AF then aspirin (or clopidogrel if aspirin intolerant) will need to be stopped 7-10 days prior to surgery to reduce bleeding risk. Confirm with surgeons regarding local preferences.

DUAL THERAPY should be continued for at least the minimum recommended duration*. If surgery cannot be delayed beyond this then contact the cardiologist and surgeon for advice.

Seek advice in patients with severe IHD, history CVA/TIA or other high risk factors, e.g. cardiac stents, where may be safer to continue.

*Drug-eluting stents : essential to continue dual therapy for ONE year

ACS treated with bare metal stents or medically (stable patients) : preferable to continue dual therapy for 1 year but P2Y12 agents can be stopped after 3 months if high risk of bleeding and surgery cannot be delayed





Continuation may cause perioperative haemorrhage.
Discontinuation may increase the risk of vascular complications.
Can restart immediately post-op. providing risk of bleeding no longer significant. The 2008 ACCP guidelines on antithrombotic therapy recommend resuming aspirin approximately 24 hours (or the next morning) after surgery when there is adequate haemostasis.
Clopidogrel is a contraindication for patients receiving an epidural.


Dipyridamole

Haemorrhagic risk when used in combination with aspirin, warfarin or clopidogrel

As above consider balance between bleeding risk and thrombotic risk.
If used a sole agent, does not need to be stopped.
If stopping hold 48hrs pre-op and restart post-op. providing risk of bleeding no longer significant
Check if on Asasantin retard (dipyridamole and aspirin combination)-if yes seek advice








2.12 Lipid-regulating drugs
Statins

Niacin and fibric acid derivatives


Bile squestrants

Ezetimibe



Myopathy and rhabdomyolysis (numerous factors increase risk e.g. impaired renal function after major surgery, multiple drug use during anaesthesia)


Myopathy and rhabdomyolysis (risk increases in combination with statins)
May interfere with absorption of medications required perioperatively
The risks (or benefits) of ezetimibe in the perioperative period are unknown


Some manufacturers advise stopping a few days prior to major elective surgery and when any major medical or surgical condition supervenes. However, there is evidence that statins afford cardio-protection therefore continue but check CK post-op and monitor for signs of muscle toxicity

Discontinuation of niacin and fibric acid derivatives, bile sequestrants and ezetimibe is likely to be safe since these agents are given for the goal of long term reduction in vascular morbidity




Statins with a long half life/extended release formulations such as rosuvastatin, atorvastatin and fluvastatin bridge the period immediately after surgery when oral intake is not feasible.

Check CK
NB: post op analgesia and post op pain may mask signs of myopathy.

3. RESPIRATORY

Theophylline

Narrow therapeutic range leading to increased risk of toxicity.

Check for interacting drugs.



Stop evening before surgery

i.v. available.

Check levels pre-operatively.



Theophylline level

Inhaled bronchodilator therapy




Continue

Nebulised therapy if unable to use inhalers post-op




4. CNS

4.1 Benzodiazepines

(e.g. diazepam, temazepam)



Tolerance

Additive effects

Withdrawal syndrome


Continue

i.v. and rectal forms if necessary.

May need lower/higher doses for sedation

4.1 Hypnotics

(e.g. Zopiclone, zolpidem)



Additive effects

Withdrawal syndrome



Continue

i.v. and rectal alternatives

May need lower/higher doses for sedation

4.2 Antipsychotics

(e.g. haloperidol, clozapine, olanzapine)



Sedation

Arrhythmias




Continue (anti-emetic effect useful). Clozapine – recommended that it is withheld for 12 hours pre-op. After surgery patient receives his/her next dose at usual time. If withheld for more than 48 hours need to re-titrate.

i.v. alternatives available

U+E’s,

FBC (clozapine)



4.2.3 Lithium

Prolongs N/M blockade

Toxicity


Not essential to stop, but requires close monitoring of fluids and electrolytes. If discontinued stop 24 hours before major operations restart with next post op dose. Check Lithium levels pre-op.


Haloperidol +/- lorazepam in some cases

Check Lithium levels preassessment, monitor fluids and U+E’s.

Avoid NSAIDs.



4.3.1 TCAs

(e.g. amitriptyline, doselupin)



Increase effect of exogenous catecholamines e.g. adrenaline resulting in arrhythmias, hypotension

Continue. Avoid pro-arrhythmic anaesthetic agents. Use reduced doses of sympathomimetic agents.

Extended half-lives so can be omitted for few days.




4.3.2 MAOIs

-‘old type’, e.g. phenelzine

- ‘new’ type, e.g. moclobemide


Hypertension, hyperthermia, convulsions, coma with opioids esp. pethidine, and sympathomimetics.

Can be fatal.



Avoid interacting drugs during anaesthesia. Discuss with anaesthetist. Otherwise need to stop old type 2 weeks before surgery. Newer reversible MAOIs are reversible after 24-48 hours. Psychiatric advice must be sought before stopping.

Avoid use of interacting drugs, e.g. pethidine, dopamine, ephedrine, phenylephrine






Care with drug interactions

4.3.3 SSRIs

(e.g. citalopram, fluoxetine)



Interactions may cause Serotonin syndrome (agitation, coma, tachycardia, hypertension, fever, myoclonus), eg pethidine, pentazocine, tramadol

Continue- Fluoxetine has an extended half-live so can be omitted for 24-48 hours. Discontinuation of some SSRIs can precipitate withdrawal syndrome (especially paroxetine and venlafaxine), therefore withholding not advised.

Liquids available

Caution when initiating interacting agents

4.3.4 Antidepressants, Other (e.g. mirtazapine, duloxetine)




Continue







4.4 Psychostimulants (methylphenidate)


Hypertension, arrhythmias, reduced seizure threshold

Withhold on day of surgery




Consult specialist psychiatrist

4.5.1 Anti-obesity drugs acting on the GI tract

(Orlistat)



Involuntary bowel movement during admission/ under anaesthesia

Stop when NBM







4.7.2 Opioids

Hypotension, respiratory depression


Continue, anaesthetist and pain team must be informed especially in patients on substance misuse program.

Consider referral to pain team at pre-assessment for patients on buprenorphine as may need switching by primary care prior to admission. See also LINK



Other routes available including topical, IV, Liquids, SL

Consult pain team upon admission for management of acute on chronic pain

4.8. Anticonvulsants

Induce hepatic enzymes(phenytoin, barbiturates, carbamazepine)
Anaesthetics may depress hepatic drug elimination.
Resistance to non-depolarising muscle relaxants.

Continue

Phenytoin –liquid/ i.v.

Phenobarbitone - i.v.

Carbamazepine – rectal

(125mg pr  100mg po)

Sodium valproate - i.v.


Care with converting to different forms with variying bioavailabilities.

May need increased doses of induction agents and opiates.

Phenytoin levels pre and post - op.



4.9 Anti-parkinsonian drugs

Neuroleptic malignant syndrome, Arrhythmias, Hypertension (L-dopa)
Symptoms exacerbated by some antiemetics.
Selegiline/ rasagiline + pethidine can cause hyperpyrexia and CNS toxicity


-Continue L-dopa (sinemet/ madopar) as abrupt withdrawal can lead to neuroleptic malignant syndrome.

-Dopamine agonists (pramipexole/ ropinerole) should be continued with agreement of anaesthetist, or converted by Movement disorder team to a rotigotine patch. Rotigotine Patch should be continued.

- Entacapone/ tolcapone/ selegiline/ rasagiline/ zelapar/ amantadine may be safely omitted until able to swallow. If selegeline to continue, use ‘safe anaesthetic technique’. If stopped may need to increase L-dopa dose.


-NG L-Dopa- can convert Sinemet/Madopar to Madopar Dispersible

-Apomorphine available but needs specialist supervision and advice for use.

-Rotigotine patches also available – seek specialist advice.

-If NBM prolonged discuss with Specialist Parkinson’s team-

-See Appendix 3: ‘Acute Management of Parkinson’s disease patients with compromised swallow or nil by mouth’ for detailed conversions and information.


Antiemetics- Domperidone PR or NG before parkinsons meds, if required. Avoid metoclopramide and prochlorperazine
Discuss with Specialist Parkinson’s team


4.10 Alcohol & nicotine

e.g. acamprosate, disulfiram, varenicline



Abrupt withdrawal of varenicline leads to risk of relapse, depression, insomnia

Continue, avoid medication that contains alcohol as may precipitate reaction with disulfiram
Continue drugs for smoking cessation








4.11 Drugs for dementia,

(e.g. donepezil, rivastigmine, galantamine)



Increased muscle relaxation produced by suxamethonium resulting in prolonged neuromuscular blockade

Continue but inform anaesthetist
If suxamethonium to be used, donepezil advised to be stopped 2-3/52 pre-op but can lead to deterioration in mental function which will not recover. Therefore best to avoid suxamethonium and withhold max. 24 hrs pre-op.
Rivastigmine + galantamine can be withheld max. 24 hrs pre-op


Restart immediately post-op otherwise may lead to decline in patient’s mental function




5. ANTIBIOTICS, ANTIVIRALS & ANTIFUNGALS

5.1 / 5.2

Antibiotics & antifungals






Consult Microbiology







5.3 Antivirals used for HIV




Continue







6. ENDOCRINE

6.1.1 Insulin

Increased risk of post-op infection.

Altered requirements



Management depends on usual insulin regime.

Consult Diabetes Specialist Team for specific advice.



If patient anticipated to have long starvation period (i.e. 2 or more missed meals), switch to VRII to achieve and maintain normoglycaemia. Long-acting insulin may be continued.

Contact Diabetes team for further advice.www.diabetes.nhs.uk/our_work_areas/inpatient_care/







6.1 Oral hypoglycaemics

(e.g. gliclazide, rosiglitazone, metformin, repaglinide, sitagliptin, exenetide)



Peri-operative hypoglycaemia

Lactic acidosis (metformin)



Continue taking as normal prior to admission. Once NBM then omit dose (pioglitazone may be continued). Recommence once normal eating resumed.

www.diabetes.nhs.uk/our_work_areas/inpatient_care/







6.2.1 Levothyroxine

Impaired stress reaction if hypothyroid

Continue.

May discontinue therapy for several days due to long half-life. If NBM prolonged, convert to liothyronine (levothyroxine 100micrograms  liothyronine inj 20micrograms)


TFTs to ensure dose adequate.

6.2.2 Anti-thyroid drugs (e.g. carbimazole)




Continue







6.3 Corticosteroids

i.e. long-term steroids at doses >5mg/day prednisolone (or equivalent) or received same within last 3 months. Also high dose inhaled steroids (eg beclometasone doses over 1mg or equivalent.



Hypotension

Impaired stress reaction

Delayed wound healing

Altered immune function

Risk of bleeding with NSAIDs.


Continue usual dose on morning of surgery. Additional steroid cover, duration and type of surgery will determine risk, discuss with consultant.
Doses equivalent to >5mg prednisolone daily cause HPA axis suppression and will require glucocorticoid coverage.

Increase dose to cover surgery. Dose depends on usual steroid dose, duration and indication

Minor surgery

25mg iv hydrocortisone



Moderate surgery 25mg iv hydrocortisone at induction then 6hrly for 24hrs

Major surgery

25mg iv hydrocortisone at induction then 6hrly for 48 to 72hrs




6.4 Hormone replacement therapy + SERMS(Raloxifene)

Slight increased risk of DVT/PE but risks not established

(see OCP/HRT protocol – appendix 2)



Can be continued safely if benefits outweigh risks. If to discontinue then need to stop 4 weeks prior to surgery.

Restart after discharge as for COC.

Ensure adequate thrombo-prophylaxis prescribed

6.4.1.2 High dose progestogens ( eg used for menstrual disorders)

Increased risk of DVT/PE in major surgery

Discontinue 4 weeks prior to major surgery.

Restart with first menses that occur at least 2 weeks after discharge providing patient fully mobile




6.6.2 Bisphosphonates

(alendronic acid, risedronate)



Oesophageal irritation

Omit on morning of surgery, If due on morning of surgery advise patient to take day before.


Recommence when patient is able to sit upright and is drinking free fluids.




7. OBSTETRICS, GYNAECEOLOGY AND URINARY-TRACT DISORDERS

7.3 Combined oral contraceptive (COC) (oestrogen containing)
VTE and Hormonal Contraception RCOG guideline 2010

Increased risk of DVT/PE in major surgery or following any other surgery which involves prolonged periods of immobility

(see OCP/HRT protocol- appendix 2)



Discontinue 4 weeks prior to major surgery where immobilisation is expected and all lower limb surgery.
However, consider risks of unplanned pregnancy.
Progestogen-only pill is suitable alternative.

Restart with first menses that occur at least 2 weeks after discharge providing patient is fully mobilised

If decision is to continue ensure adequate thromboprophylaxis

7.3 Progestogen only contraceptives (includes injectables, IUD & implants)

No added risk of thrombo-embolic risk (see OCP/HRT protocol - appendix 2)

Continue







7.4.2 Drugs for urinary frequency (oxybutynin, solifenacin)




Continue







7.4.5 Drugs for erectile dysfunction

(sildenafil, tadenafil)



Mild transient hypotension due to vasodilator properties

Discontinue 24 hour before surgery except for pulmonary hypertension. Ensure anaesthetist aware







8./ 9. MALIGNANT DISEASE / BLOOD

8.1 Antineoplastic drugs




Discuss with specialist








8.3.4 Tamoxifen


Increased risk of DVT/PE in major surgery

Anovulatory infertility– discontinue 4-6 weeks prior to major surgery.
Women with history of breast cancer – continue


If discontinued, restart at least 4 weeks post-operatively providing patient fully mobile




9.1 Iron




Continue except for colonoscopy- stop 7 days pre-op








10. MUSCULO-SKELETAL / JOINT DISEASE

10.1.1 NSAIDS


GI haemorrhage

Impaired wound healing

Renal impairment


If haemorrhage likely to be a risk then stop:

  • short-acting drugs e.g diclofenac , ibuprofen, stop 1 day pre-op

  • long-acting e.g. piroxicam stop 3 days pre-op

  • COX 2 inhibitors e.g. celecoxib, etoricoxib, discontinue morning of op

Some some evidence that use of Ibuprofen pre-op reduces pain post-op. Benefit verses risk to be considered by specialist in each case

pr preps available

U+E’s

10.1.3 DMARDS and immunosuppressants



Impaired wound healing

Renal impairment



Methotrexate

Elderly/frail/co-morbidities/RI : stop ONE week pre-op. Can continue in otherwise healthy individuals.


Sulfasalazine / Azathioprine

Withold day of surgery


Hydroxochloroquine / Lefluonimide

Continue as normal


NB: if using for any other condition, e.g. haematological or post-transplantation, then the advice of the relevant specialist must be obtained

Restart as soon as possible once wound healed and providing renal function stable.

U+E’s. Caution with NSAIDs.

10.1.3 Cytokine inhibitors

e.g Adalimumab, Inflixamab, Anakinra, Etanercept




Increase risk of infection

Impaired wound healing



Withold prior to major surgical procedures. Risk/ benefits must be discussed with specialist.
General guidance stop 3-5 x half life (T1/2):

  • Adalimumab stop at 45 days

  • Etanercept stop 9 days

  • Infliximab stop 24 days




Treatment may be restarted once wound healing is satisfactory and no sign of infection.




10.2 Neuromuscular Disorders- anticholinesterases e.g. neostigmine, pyridostigmine

Respiratory complications, cholinergic crisis

Discuss with anaesthetist- manage according to severity of disease and type of surgery

IV pyridostigmine available. Dose adjustment required




11. TOPICAL EYE PREPS

Steroids, pilocarpine, beta-blockers (timolol)

Bradycardia due to systemic absorption (beta- blockers)

Continue







14 VACCINES

Flu vaccine

Flu like symptoms

Advise patients to avoid having vaccination within 7 days pre-op






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