Perioperative Medicines Optimisation in Elective Adult

Perioperative Medicines Optimisation in Elective Adult Surgical Patients | Page 1

Date Approved 11/04/2016

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Perioperative Medicines Optimisation in Elective Adult Surgical Patients


Ratifying Body Drugs & Therapeutics Committee

Related Documents Fasting Policy, The Medicines Policy (MP05) – Medicines

Reconciliation, Adult Diabetes Policy

Author Specialist Pharmacist - Pre-Operative Assessment

Owner (Executive Director)

Mat Shaw

Directorate Nursing and Clinical

Superseded Documents New policy

Subject Medicines Optimisation, Medicines Safety

Review Date April 2018

Keywords and Phrases Medicines Optimisation; NIL by mouth; Herbal; Peri-operative;

Medicines Safety; medicines; Pre-Admission

External References (See Appendix 4)

Consultation Group/Approving Bodies

Pre-Operative assessment Clinical Staff

Drugs & Therapeutics Committee

Readership All staff (inc. Clinical)



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Table of Contents

1. Introduction and aims of policy ......................................................................................................... 3

2. Definitions ......................................................................................................................................... 3

3. Duties and Responsibilities ................................................................................................................ 3

3.1 Anaesthetists, Pre-admission nurses, Pre-Operative Assessment pharmacist and Ward

pharmacists ........................................................................................................................................... 3

3.2 Pre-Operative Assessment Pharmacist ..................................................................................... 4

4. Body of Policy .................................................................................................................................... 4

4.1 BNF Chapter 1: Gastro-intestinal System .................................................................................. 6

4.2 BNF Chapter 2: Cardiovascular System ..................................................................................... 7

4.3 BNF Chapter 3: Respiratory System ........................................................................................ 10

4.4 BNF Chapter 4: Nervous System.............................................................................................. 11

4.5 BNF Chapter 5: Infection ......................................................................................................... 16

4.6 BNF Chapter 6: Endocrine System ........................................................................................... 17

4.7 BNF Chapter 7: Genito-urinary system.................................................................................... 19

4.8 BNF Chapter 8: Malignant disease .......................................................................................... 20

4.9 BNF Chapter 9: Blood and Nutrition ........................................................................................ 21

4.10 BNF Chapter 10: Musculoskeletal System ........................................................................... 22

4.11 Herbal and Homeopathic Medicinal Products .................................................................... 24

5. Monitoring and the effectiveness of this policy .............................................................................. 26

Appendix 1: Diabetic medications (43) .................................................................................................. 27

Appendix 2: Glossary of Terms ................................................................................................................ 30

Appendix 3: Other linked trust policies and guidelines........................................................................... 31

Appendix 4: Extra sources of information and support .......................................................................... 32

Appendix 5: Privacy Impact Assessment and Equality Analysis .............................................................. 35



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1. Introduction and aims of policy

The purpose of this guideline is to guide clinical practitioners on the management of medications and

herbal medicinal products in the peri-operative period including pre-admission and recovery of

elective adult surgical patients.

It does not cover children or young people under the age of 18, or women who are pregnant.

The purpose of this guideline is to give guidance on when and how to restart medication which may

have been withheld in the peri-operative period.

Although this guideline is believed to be an accurate reflection of the most up-to-date evidence based

literature available at the time of writing, it is important to bear in mind that this is not an exhaustive

list and it is intended to be used as a guide only. Further discussion or advice must be sought from the

relevant consultant, anaesthetist or specialist pharmacist if any concerns or doubts arise whilst

assessing individual patients.

2. Definitions

- Peri-operative: the period from pre- intra- and post-operative phases of the patient’s surgical

journey

- The fasting period: The duration of time the patients should be fasting (nil by mouth) prior to

undergoing anaesthesia.

- Healthy adults are allowed intake of clear oral fluids 2 hours pre-operatively and solid foods a

minimum of 6 hours pre-operatively.

- Pre-medication and any other regularly prescribed medications can be taken 2 hours prior to

undergoing anaesthesia with up to 30ml of clear fluid. (1)

3. Duties and Responsibilities

3.1 Anaesthetists, Pre-admission nurses, Pre-Operative Assessment

pharmacist and Ward pharmacists

- To obtain and document an accurate medication and allergy history from the patient.

Medication histories must be taken in accordance to the Trust policy – Refer to Medicines

Policy (MP5, Medicines Reconciliation Policy, Section 4.3 – Procedure for taking a

medication history) (2)

- Where necessary, advice on stopping or changing medication prior to surgery and

document these instructions in the patient’s medical notes and on the patient’s medication

passport.



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- Notify the surgical team and anaesthetist where the recommendation for discontinuing

medications cannot be followed in any circumstance e.g. due to a limited time period

between pre-assessment and intended procedure date.

- Advise patients to contact the pre-admission clinic if any of their medication therapy is

changed after being assessed in the pre-admission clinic.

- Advise patients to bring adequate supplies of their medications and provide a Green

Medicine bag for these.

- Seek advice or refer complex patients to specialist teams where appropriate e.g.

anaesthetists, surgeons, specialist pharmacists, specialist nurses, pain team, psychiatry,

cardiologists etc.

- Liaise with the specialist pharmacist about any new medications that are not listed in the

policy or highlight any requirements or areas that require further clarification.

3.2 Pre-Operative Assessment Pharmacist

- Provide expert advice to patients and the multidisciplinary team and support medicines

optimisation in the pre-admission interface.

- Review and make amendments to this policy as appropriate to ensure optimal medicines

management.

4. Body of Policy

Unless advised otherwise, patients should continue to take their regular medications for as long as

feasibly possible to ensure the patient is as safe and stable as possible to undergo anaesthesia and the

procedure.

Pre-operative doses can be taken up to 2 hours prior to the procedure with sips of clear oral fluids (1).

Refer to the RNOH Fasting Policy for further details.

Unless stated otherwise, medications can be restarted at the pre-operative dose at the earliest point

post-surgery/during recovery, as soon as the patient is able to tolerate sips of oral fluids.

If the patient is likely to be NBM for a longer period, alternative routes such as rectal, transdermal,

parenteral or nasogastric administration may be considered (3). Seek advice from the pharmacist when

switching between formulations due to differing bioavailabilities.

Refer to separate guidelines for the peri-operative management of antiplatelet and anticoagulant

medications.



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The following factors need to be considered when deciding whether to continue or withhold

medications in the peri-operative period (3; 4):

- Risk of rebound exacerbation of underlying disease on discontinuation of essential

medications e.g. anti-epileptic or anti-parkinsonism medications.

- Risk of precipitating withdrawal symptoms when stopped abruptly.

- Slow tapering of doses when stopping and restarting medications.

- Potential for fatal interactions between the medication and anaesthesia used during surgery

or causing intra-operative complications.

- The body’s stress response releasing catabolic hormones and cytokines therefore leading to

e.g. increased heart rate and levels of cortisol, adrenaline and noradrenaline.

- The NBM period – e.g. antidiabetic medications and considering inability to take medications

e.g. due to post-op N&V.

- Consider alternative administration routes where the NBM period is prolonged or doses

cannot be omitted.

- Risk of bleeding and thromboembolism.

- Medications with special administration requirements e.g. the volume of water to be taken

with alendronic acid and need to sit/stand upright thereafter.

- For any discontinued medications, when and how they should be restarted post-operatively.

Key:

Safe to continue pre-operatively

Requires caution

May need to be stopped peri-operatively



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4.1 BNF Chapter 1: Gastro-intestinal System

Medicine class/Examples Recommendation Additional information

Aminosalicylates

e.g. Mesalazine , Sulfasalazine Continue (5)

- Declining kidney function may precipitate toxicity - ensure adequate hydration.

- Alternative formulations: Rectal Mesalazine (non-formulary).

Laxatives

e.g. Senna, Sodium docusate, Bisacodyl Continue (5) - Alternative formulations: Glycerin suppository, Phosphate enema.

Laxatives

e.g. Fybogel®, Movicol®, Laxido®, Celevac® Withhold on morning of surgery

- These preparations require to be taken with large amounts of water.

- Restart when eating and drinking post-operatively.

Antimotility drugs

e.g. Loperamide, Co-phenetrope Continue (5)

- Use with caution in patients on opioids or ondansetron post-operatively as may

worsen constipation.

Alginates & Antacids

e.g. Gaviscon®, Maalox®, Mucogel®, Peptac® Continue (5; 6) - To help reduce risk of acid aspiration.

H2 receptor antagonists

e.g. Ranitidine, Cimetidine, Nizatidine,

Famotidine

Continue (6; 7) - To help reduce risk of acid aspiration.

- Alternative formulations: Ranitidine injection and liquid.

Proton Pump Inhibitors

e.g. Omeprazole, Lansoprazole,

Esomeprazole, Pantoprazole, Rabeprazole

Continue (7)

- To help reduce risk of acid aspiration.

- Alternative formulations: Omeprazole/Pantoprazole injection, Lansoprazole

dispersible tablets.

Antimuscarinics

e.g. Hyoscine Butylbromide, Dicycloverine Continue (5) - Alternative formulations: Hyoscine injection and patch.



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Antispasmodics

e.g. Mebeverine, Alverine

Bile acid sequestrants

e.g. Colestyramine Withhold on day of surgery (8)

- Other drugs to be taken at least one hour before or 4-6 hours after

colestyramine to minimise possible interference with their absorption.

- Required to be taken with large amount of water.

- Restart next day after surgery.

Pancreatic enzymes

e.g. Pancreatin Withhold whilst NBM (9)

- To be administered with meals only.

- Restart when eating and drinking post-operatively.

Bile acids

e.g. Ursodeoxycholic acid Continue (5)

4.2 BNF Chapter 2: Cardiovascular System


Anti-arrhythmics

e.g. Amiodarone, Flecainide, Dronedarone,

Disopyramide

Continue (10; 11) - Possible recurrence of arrhythmias if stopped.

- Alternative formulations: Amiodarone, Disopyramide and Flecainide injection.

Cardiac glycosides

e.g. Digoxin Continue (10; 12)

- Good practice to carry out TDM monitoring to ensure therapeutic levels.

- Electrolyte imbalance increases toxicity – monitor closely as N&V associated with

toxicity may be mistaken with post-op N&V.

- Suxamethonium may precipitate cardiac arrhythmias – use with caution.

- Alternative formulations: Digoxin injection and liquid. Seek pharmacist advice

due to differing bioavailability between formulations.



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Anticoagulants and antiplatelets Seek advice from Specialist pharmacists - Haemostasis & Thrombosis Pharmacist blp 806 or Pre-Operative Assessment

Pharmacist blp 699 whilst separate guidelines on antiplatelets and anticoagulants are developed.

ACE inhibitors

e.g. Captopril, Enalapril, Lisinopril,

Perindopril, Ramipril

Withhold at least 24 hours prior to

surgery (5; 6; 7; 13)

- Risk of refractory hypotension and bradycardia after induction of anaesthesia. (14)

- Restart morning dose next day after surgery, according to BP and U&Es.

Angiotensin-II receptor antagonists

e.g. Candesartan, Irbesartan, Losartan,

Valsartan, Telmisartan, Olmesartan

Withhold at least 24 hours prior to

surgery (5; 6; 7; 13)

- Risk of refractory hypotension and bradycardia after induction of anaesthesia. (14)


Centrally acting antihypertensives

e.g. Clonidine, Methyldopa, Moxonidine Continue (11; 12)

- Risk of precipitating hypertensive crisis if stopped abruptly.

- Enhanced hypotensive effect with general anaesthetics. (14)

- Alternative formulations: Clonidine injection.

Beta-adrenoceptor blockers

e.g. Propranolol, Atenolol, Bisoprolol,

Carvedilol, Metoprolol, Sotalol, Nebivolol

Continue (7; 10; 11)

- Risk of withdrawal effects if stopped abruptly.

- May help supress tachycardia and increased blood pressure provoked by

anaesthesia and surgery.


- Alternative formulations: Propranolol, Esmolol, Metoprolol and Labetalol

injection; Atenolol liquid.

Calcium-channel blockers

e.g. Amlodipine, Diltiazem, Felodipine,

Nifedipine, Lacidipine, Verapamil

Continue (5; 15) - Enhanced hypotensive effect with general anaesthetics. (14)

- Alternative formulations: Verapamil injection.

Peripheral Vasodilators

e.g. Hydralazine Withhold on morning of surgery (5)


- Restart morning dose next day after surgery, according to BP.



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- Alternative formulations: Hydralazine injection.

Potassium sparing diuretics

e.g. Amiloride

Aldosterone antagonists

e.g. Spironolactone, Eplerenone

Withhold on morning of surgery (4;

10; 11; 13)

- Risk of developing hyperkalaemia secondary to post-op tissue damage and

reduced kidney perfusion.


Lipid-regulating drugs

e.g. Fenofibrate, Bezafibrate, Ciprofibrate,

Simvastatin, Atorvastatin, Pravastatin,

Rosuvastatin, Ezetemibe

Continue (5; 12) - Provide potential peri-operative cardioprotection.

Antianginal drugs

e.g. Ivabradine, Nicorandil, Ranolazine Continue (5; 7)

Nitrates

e.g. Isosorbide mononitrate, Isosorbide

dinitrate

Continue (4) - Enhanced hypotensive effect with general anaesthetics. (14)

- Alternative formulations: Isosorbide dinitrate injection, Glyceryl trinitrate patch.

Loop diuretics

e.g. Bumetanide, Furosemide, Co-amilofruse,

Torasemide


13)

- Enhanced hypotensive effect with general anaesthetics (14)


- Alternative formulations: Furosemide injection and liquid.

Thiazide diuretics

e.g. Bendroflumethiazide, Indapamide,

Metolazone


13)

- Ensure adequate U&E monitoring due to risk of hypokalaemia.



Alpha-adrenoceptor blockers

e.g. Doxazosin, Prazosin, Indoramin Continue (5; 15) - Enhanced hypotensive effect with general anaesthetics. (14)



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4.3 BNF Chapter 3: Respiratory System


Inhaled bronchodilators

Antimuscarinics

e.g. Tiotropium, Ipratropium

Beta agonists

e.g. Salbutamol, Salmeterol, Terbutaline,

Formoterol

Continue (3; 4; 6) - Alternative formulations: Salbutamol and Ipratropium nebules.

Inhaled corticosteroids

e.g. Beclomethasone, Fluticasone,

Budesonide, Mometasone

Continue (3; 4) - Alternative formulations: Budesonide nebules.

Leukotriene receptor antagonists

e.g. Montelukast, Zafirlukast Continue (5; 12)

Xanthines

e.g. Theophylline, Aminophylline Continue (5; 12)


- Increased risk of convulsions with Ketamine and Theophylline. (14)

- Alternative formulations: Aminophylline injection.

Antihistamines

e.g. Cetirizine, Desloratidine, Fexofenadine,

Chlorphenamine, Loratidine, Hydroxyzine,

Promethazine

Continue (5; 12) - Alternative formulations: Chlorphenamine, Cyclizine and Promethazine injection;

Chlorphenamine, Cetirizine and Hydroxyzine liquid.



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4.4 BNF Chapter 4: Nervous System


Drugs for dementia

e.g. Galantamine, Rivastigmine

Withhold 24 hours prior to surgery

(5; 7)

- NOTIFY ANAESTHETIST.

- Reversible acetylcholinesterase inhibitors - prolong effect of depolarising

neuromuscular blocking agents e.g. Suxamethonium.

- Restart normal dose as soon as sips of fluid tolerated post-surgery .

Drugs for dementia

e.g. Donepezil, Memantine Continue (13; 16)

- NOTIFY ANAESTHETIST.

- May enhance effects of suxamethonium and antagonise effects of non-

depolarising muscle relaxants.

- Increased risk of CNS toxicity with Memantine and Ketamine (14)

- May need to be discontinued 2-3 weeks prior to surgery if possible. (5; 7)

Drug for mania and hypomania

e.g. Lithium

Continue in minor surgery (3; 6; 7; 17)

May need to be stopped 24 hours

before major surgery (6; 17; 18; 19)

- INFORM ANAESTHETIST.

- MUST CONSULT PATIENT’S PSYCHIATRIST BEFORE DISCONTINUATION.

- For minor surgery where little metabolic disturbance is expected, normal dose

can be continued.

- Can prolong action of depolarising and non-depolarising muscle relaxants.

- Closely monitor renal function, fluid and electrolyte balance (specifically serum

sodium levels) due to risk of lithium toxicity.

- If signs of possible toxicity, carry out TDM monitoring to ensure therapeutic

levels.

- Restart normal dose as soon as sips of fluid tolerated post-surgery.



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- Avoid NSAIDs for post-operative analgesia due to increased risk of lithium

toxicity.

Antidepressants – Irreversible MAOIs

e.g. Phenelzine, Isocarboxazid

Discontinue 2 weeks prior to

surgery (7; 17; 20)



- Risk of discontinuation symptoms if stopped abruptly therefore dose may

need to be tapered down.

- Restart 48 hours post-operatively.

- May be continued with ‘MAOI safe anaesthesia’. If continued:

- Check drug interaction with potential anaesthetic agent.

- Check drug interaction with opioids for post-op analgesia. Avoid Pethidine,

Methadone, Tramadol, Tapentadol and Dextromethorphan.

- Risk of hypertensive crisis when used with sympathomimetics e.g.

Noradrenaline, Ephedrine, Phenylephrine.

Antidepressants – Reversible MAOIs

e.g. Moclobemide


17; 20)



- Risk of discontinuation symptoms if stopped abruptly.

- Restart 24 hours post-operatively.

- May be continued with ‘MAOI safe anaesthesia’. If continued:

- Check drug interaction with potential anaesthetic agent.



- Risk of hypertensive crisis when used with sympathomimetics e.g.

Noradrenaline, Ephedrine, Phenylephrine.



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Antidepressants – SSRIs

e.g. Citalopram, Escitalopram, Fluoxetine,

Paroxetine, Sertraline

Continue (4; 14; 17; 19)

- Risk of serotonin syndrome with Tramadol - consult psychiatrist if Tramadol

absolutely necessary.

- Increased risk of bleeding with NSAIDs.


- Alternative formulations: Citalopram and Fluoxetine liquid.

Antidepressants – TCAs

e.g. Amitriptyline, Dosulepin, Imipramine,

Lofepramine, Trazodone, Nortriptyline

Continue (3; 6; 15; 17; 19)



- Increased risk of developing hypotension or cardiac arrhythmias during

anaesthesia. (14)


- Alternative formulations: Amitriptyline liquid.

Other antidepressants

e.g. Mirtazapine, Venlafaxine Continue (4; 19)



- Increased risk of bleeding with NSAIDs and Venlafaxine.


- Alternative formulations: Mirtazapine orodispersible tablets.

Antipsychotic drugs

e.g. Haloperidol, Flupentixol, Sulpride,

Amisulpride, Aripiprazole, Clozapine,

Olanzapine, Quetiapine, Risperidone,

Chlorpromazine

Continue (4; 7; 15; 17)

- Risk of acute withdrawal syndrome or rapid relapse if stopped abruptly.

- Enhanced hypotensive effect with antipsychotics and general anaesthetics. (6; 14)

- Alternative formulations: Haloperidol injection and liquid, Risperidone liquid and

injection (NF).

Antipsychotic depot injections

e.g. Flupentixol, Haloperidol, Risperidone Continue (5)



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Drugs in parkinsonism

e.g. Pramipexole, Ropinirole, Co-beneldopa,

Co-careldopa, Entacapone

Continue (4; 6)

- Where possible, ensure usual drug regimen including timing of administration is

maintained to allow optimal symptom control.

- Risk of arrhythmias or hypertension during anaesthesia in patients on Co-

beneldopa or Co-careldopa.

- Avoid anti-emetics such as Metoclopramide and Prochlorperazine which can

cause extrapyramidal side effects

- Alternative formulations: Co-beneldopa dispersible tablets, Rotigotine patch.

Drugs in parkinsonism

e.g. Rasagiline, Selegiline


surgery (5; 16; 20)


- MUST CONSULT PATIENT’S NEUROLOGIST BEFORE DISCONTINUATION.

- Risk of withdrawal symptoms if stopped abruptly therefore dose may need

to be tapered down.

- Restart 48 hours post-operatively

- MAOI.

- Avoid anti-emetics such as Metoclopramide and Prochlorperazine which can

cause extrapyramidal side effects.



Drugs in nausea and vertigo

e.g. Cyclizine, Ondansetron, Betahistine,

Prochlorperazine, Metoclopramide

Continue (5) - Alternative formulations: Cyclizine, Ondansetron, Prochlorperazine,

Metoclopramide injection.

Analgesics – Non-opioid

e.g. Paracetamol Continue (5; 21) - (See 4.10 for NSAIDs)

Analgesics – Opioid Continue (5; 21) - Risk of acute withdrawal symptoms.



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e.g. Codeine, Dihydrocodeine, Tramadol,

Morphine, Oxycodone, Fentanyl,

Diamorphine, Methadone, Buprenorphine,

Pethidine

- Additional post-operative analgesia may be required.

- Refer/seek advice from acute pain team.

- NOTIFY ANAESTHETIST if Buprenorphine patch in situ. It may be difficult to

obtain adequate analgesia with full opioid agonists (e.g. Morphine, Fentanyl and

Oxycodone) in patients on Buprenorphine.

Antimigraine drugs – Treatment

e.g. Sumatriptan, Naratriptan Continue (5) - Do not use Aspirin in the treatment of migraine immediately before surgery.

Antimigraine drugs – Prophylaxis

e.g. Pizotifen, Clonidine Continue (5)

Neuropathic pain

e.g. Amitriptyline, Nortriptyline, Gabapentin,

Pregabalin, Duloxetine

Continue (21)

Antiepileptics

e.g. Phenytoin, Carbamazepine, Gabapentin,

Lamotrigine, Levetiracetam, Sodium

Valproate

Continue (3; 4; 6; 17)

- Risk of severe rebound seizures if stopped abruptly.


- Alternative formulations: Phenytoin liquid and injection, Carbamazepine liquid

and suppositories, Lamotrigine dispersible tablets, Levetiracetam injection and

liquid, Sodium Valproate injection and liquid. Seek pharmacist advice due to

differing bioavailability between formulations.

Hypnotics and anxiolytics

e.g. Zopiclone, Zolpidem

Benzodiazepines

e.g. Nitrazepam, Temazepam, Diazepam,

Lorazepam

Continue (4; 5; 6; 17)

- Risk of withdrawal syndrome if benzodiazepines and barbiturates stopped

abruptly.

- Increased sedative effect with general anaesthetics. (14)

- Alternative formulations: Diazepam injection, rectal solution and liquid;

Lorazepam injection, Temazepam liquid.



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Drugs in substance dependence - Alcohol

e.g. Acamprosate Continue (5; 6)

- Avoid oral liquid formulations containing alcohol e.g. Ranitidine liquid, oral

Morphine liquid.

Drugs in substance dependence - Nicotine

e.g. Nicotine, Varenicline Continue (5; 6)

- Abrupt withdrawal of nicotine replacement therapy may precipitate nicotine

withdrawal symptoms.

Drugs in substance dependence - Opioid

e.g. Methadone, Buprenorphine (Subutex®) Continue (4; 5; 6; 17)

- INFORM ANAESTHETIST AND PHARMACIST.

- May require increased anaesthetic doses.

- Naloxone may cause opioid withdrawal symptoms if given to reverse opioid

effects.

- Must verify the following details and document in medical notes:

- Daily dose

- Key worker name and contact details

- Community pharmacy that supplies medication – name and contact details

- Nature of administration i.e. supervised/unsupervised

- Frequency of prescriptions e.g. daily, weekly

4.5 BNF Chapter 5: Infection


Antibacterials

e.g. Amoxicillin, Doxycycline Continue (5)

- Liaise with microbiology.

- Risk of hypersensitivity-like reactions with IV vancomycin and general

anaesthetics. (14)

Linezolid Continue (20) - Has MAOI activity. Avoid Pethidine, Methadone, Tramadol, Tapentadol and



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Dextromethorphan.

Antituberculosis drugs

e.g. Ethambutol, Isoniazid, Rifampicin Continue (5)

Antifungals

e.g. Fluconazole, Itraconazole Continue (5)

Anti-virals

e.g. Lamivudine, Emtricitabine, Tenofovir,

Atazanavir, Darunavir, Ritonavir, Efavirenz

Continue (5; 12) - Protease inhibitors significantly reduce metabolism of Midazolam causing

prolonged sedation and respiratory depression.

Anti-malarials

e.g. Proguanil, Chloroquine Continue (5)

4.6 BNF Chapter 6: Endocrine System


Insulins and Antidiabetic drugs See appendix 1

Corticosteroids

e.g. Prednisolone, Hydrocortisone,

Dexamethasone, Fludrocortisone

Continue (6; 22)

- Give Hydrocortisone IV 25-50mg at induction.

- For minor surgery, continue usual dose after surgery.

- For moderate surgery, Hydrocortisone IV 25-50mg TDS for 24 hours then

continue usual dose after stopping injection.

- For major surgery, Hydrocortisone IV 25-50mg TDS for 48-72 hours then

continue usual dose after stopping injection.

- Alternative formulations: Prednisolone soluble tablets, Dexamethasone injection

and solution.



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Bisphosphonates

e.g. Alendronic acid, Risedronate Withhold on morning of surgery (4)

- Must be taken with a full glass of water whilst standing or sitting upright – risk of

oesophageal ulceration.

- Can be given a day early if required and can re-start the following week on the

usual day.

Sex hormones – HRT

e.g. Prempak-C®, Evorel®, Elleste-Duet®,

Premarin®, Kliofem®, Kliovance®

Tibolone, Ethinylestradiol


surgery (4; 6; 23; 24; 25)

- HRT increases the risk of peri-operative VTE.

- Ensure appropriate VTE prophylaxis is prescribed.

- Restart when patient fully mobile.

Raloxifene Withhold 3 days prior to surgery (12;

26)

- Increased risk of VTE.


- Restart when patient fully mobile.

Anti-androgens

e.g. Cyproterone Continue (5)

Antithyroid drugs

e.g. Carbimazole, Propylthiouracil Continue (6; 12) - Risk of arrhythmias if discontinued.

Thyroid hormones

e.g. Levothyroxine Continue (6; 12)



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4.7 BNF Chapter 7: Genito-urinary system


Drugs for urinary incontinence

e.g. Duloxetine, Oxybutinin, Solifenacin,

Fesoterodine, Tolterodine

Continue (5) - Alternative formulations: Oxybutinin liquid.

Drugs for urinary retention

e.g. Alfuzosin, Tamsulosin Continue (5) - Withhold if hypotensive.

Dutasteride &Finasteride Continue (5)

Contraceptives – COC

e.g. Mercilon®, Loestrin®, Marvelon®,

Yasmin®, Cilest®, Microgynon®

Discontinue 4-6 weeks prior to

surgery (3; 4; 25; 27; 28)

- Increased risk of VTE with COC.


- Patient must be advised to use alternative methods of contraception.

- Restart at the first menses occurring at least two weeks after full ambulation. (3)

- A Progestogen-only contraceptive may be offered as an alternative in the interim

and the Oestrogen-containing contraceptive restarted after full mobilisation.

Contraceptives – POP

- Desogestrel

(Cerazette®,Aizea®, Cerelle®, Nacrez®)

Noriday® Micronor®, Norgeston®

Continue (3; 28; 29)

- Low risk of VTE with POP.

- As per manufacturer recommendation, consider discontinuation in case of long-

term immobilisation for the following: Noriday® to be discontinued 4 weeks

prior to surgery (30); Micronor® and Norgeston® to be discontinued 6 weeks prior

to surgery (31; 32).

- If discontinued, patient must be advised to use alternative methods of

contraception and ensure appropriate VTE prophylaxis is prescribed. Restart two



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weeks post-op and full ambulation.

Levonorgestrel intrauterine system

Progestogen-only implant Continue (3; 28; 33)

4.8 BNF Chapter 8: Malignant disease


Immunosuppressants

e.g. Azathioprine, Mycophenolate,

Ciclosporin, Tacrolimus, Sirolimus

Continue (5; 4; 6)

- CONSULT PATIENT’S TRANSPLANT SPECIALIST.

- Must seek advice from the relevant specialist before withholding any

immunosuppressant therapy

- Seek advice if levels need to be monitored during peri-operative period.

- Risk of rejection with omitted doses.

- Sirolimus is associated with poor wound healing.

DMARDs

e.g. Methotrexate Consult rheumatologist (34)

- CONSULT PATIENT’S RHEUMATOLOGIST.

- Continue peri-operatively whenever possible to maintain control of the

condition. (34; 35; 36)

- Discontinuation should occur only after a case-based discussion between the

rheumatologist and surgeon, considering the risks and benefits and taking into

account patient characteristics and planned procedure.

- If the patient is on multiple DMARD therapy or the surgeon prefers to withhold,

stop Methotrexate one week prior to surgery and restart a week after, provided

there is no evidence of infection and renal function is assessed. If GFR is less than

30ml/min, discuss with rheumatologist/anaesthetist.



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- Avoid use with Nitrous oxide – increases antifolate effect of Methotrexate (14).

- Can affect inflammatory response and increase the risk of infection.

- Risk of toxicity due to potential renal insufficiency secondary to peri-op related

hypovolaemia

- Continue Folic acid as usual.

Anti-oestrogens

e.g. Tamoxifen

Dependent on indication:

- Anovulatory infertility:

Withhold at least 6 weeks

before surgery (37)

- Breast cancer: Continue

- Increased risk of VTE.

- Ensure appropriate VTE prophylaxis is prescribed as a risk reducing measure.

- If stopped, restart when fully mobile.

4.9 BNF Chapter 9: Blood and Nutrition


Erythropoietins

e.g. Darbepoetin, Epoetin Continue (5)

Oral iron

e.g. Ferrous sulphate, Ferrous fumarate Continue (5) - Alternative formulations: Ferrous fumarate liquid.

Drugs in megaloblastic anaemia

e.g. Cyanocobalamin, Folic acid Continue (5) - Alternative formulations: Folic acid liquid.

Oral rehydration salts

e.g. Dioralyte®, Electrolade® Continue (5)



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Minerals and Vitamins

Forceval®, Ketovite®

Calcium

e.g. Calcichew ®, Adcal®, Cacit®

Vitamin D

e.g. Alfacalcidol, ProD3®, Calcichew D3®,

Adcal D3®, Accrete D3®

Phosphate binding agents

e.g. Lanthanum, Sevelamer

Zinc, Ascorbic acid, Pyridoxine, Thiamine,

Vitamin B Co- Strong

Continue (5)

- Prescribed supplements may be continued.

- Assess individual components of OTC bought supplements.

- See 4.11 (Herbal products)

4.10 BNF Chapter 10: Musculoskeletal System


Cytokine modulators - TNFα inhibitors

e.g. Adalimumab (Humira®), Certolizumab

(Cimzia®), Etanercept (Enbrel®),

Golimumab (Simponi®),

Infliximab(Remicade®)

Consider discontinuing at least one

treatment interval prior to surgery (34; 35; 36)

- CONSULT PATIENT’S RHEUMATOLOGIST.

- Discontinuation should occur only after a case-based discussion between

rheumatologist and surgeon, considering the risks and benefits and taking into

account patient characteristics and planned procedure.

- Limited safety experience.

- Increase risk of infection and delayed wound healing – closely monitor post-op.

Gout medications

e.g. Colchicine, Allopurinol Continue (5)



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Anticholinesterases

e.g. Neostigmine, Pyridostigmine Continue (4; 5; 7)

- INFORM ANAESTHETIST – may request to withhold on morning of surgery.

- Anticholinesterases prolong effects of depolarising neuromuscular blockers e.g.

Suxamethonium.

Nocturnal leg cramps

e.g. Quinine Continue (5)

Skeletal muscle relaxants

e.g. Baclofen, Tizanidine Continue (5) - Alternative formulations: Baclofen liquid.

NSAIDs – short acting

e.g. Ibuprofen, Diclofenac

Withhold 24 hours

prior to surgery (4; 5) - Assess pain control and liaise with pain team if required.

- Monitor renal function.

- Restart when risk of bleeding no longer significant.

NSAIDs – long acting

e.g. Naproxen

Withhold 72 hours

prior to surgery (4; 5)

COX-2 Inhibitors

e.g. Celecoxib, Eterocoxib

Withhold 2-3 days prior to surgery

(5)



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4.11 Herbal and Homeopathic Medicinal Products

Herbal and homeopathic medications can mistakenly be perceived as ‘safe’ because they are ‘natural’

and as a result, patients may not disclose they may be taking these. If a patient visits the pre-

admissions clinic within 2 weeks of their procedure date, it is essential to acquire an accurate history,

specifically about herbal products, during pre-assessment. In this case, patients should be asked to

bring a list of their herbal medications or any other dietary supplements to pre-assessment to ensure

the history is verified and be informed to discontinue these immediately. (38; 39; 40; 13)

Discontinue all herbal and homeopathic medicinal products

TWO weeks prior to surgery (38; 39)

Although there is lack of safety information on herbal products, they may potentially cause

cardiovascular, endocrine, hepatic, renal, coagulation, sedative and withdrawal complications in the

peri-operative period. Some complications of common herbal medicinal products are highlighted

below (38; 39; 40; 41). Note that this list is not exhaustive.

Herbal product Common indications Additional information;

Possible side effects/interactions

Echinacea

- To improve the immune system

- Prophylaxis and treatment of viral,

bacterial and fungal infections

- Potentially hepatotoxic

- Potential for immunosuppression with

long-term use

Ephedra/

Ma Huang

- To increase energy

- To promote weight loss

- Treat respiratory conditions e.g.

asthma, bronchitis

- Enhanced sympathomimetic activity as

contains alkaloids such as ephedrine and

pseudoephedrine

- Can cause MI and stroke from

hypertension and tachycardia

- Can cause arrhythmias with halothane

- Life-threatening interaction with MAOI



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Herbal product Common indications Additional information

Possible side effects/interactions

Garlic

- To reduce atherosclerosis

- To treat hypertension

- Hyperlipidaemia

- Increased bleeding risk due to its anti-

platelet activity

Ginger

- As an anti-inflammatory

- As an anti-emetic

- Can cause hypoglycaemia


platelet activity

Gingko

- To prevent effects of ageing

- Memory enhancement

- To increase energy

- To improve stress

- Erectile dysfunction

- Appetite stimulant

- Tinnitus and Vertigo


platelet activity

Ginseng

- Memory enhancement

- To improve stress

- Appetite stimulant

- Bleeding disorders

- Cancer

- Has mild sympathomimetic effect


platelet activity

- Can cause hypoglycaemia

Kava - Anxiolytic

- Sedative

- Can potentiate sedative effects of

anaesthetic agents

St. John’s Wort - Antidepressant

- Anxiolytic

- Potent cytochrome P450 enzyme inducer

therefore increases metabolism of drugs

e.g. lidocaine, alfentanil and midazolam


anaesthetic agents

Valerian - Anxiolytic

- Hypnotic/Sedative

- Risk of withdrawal syndrome if abruptly

stopped – may require slow tapering prior

to surgery


anaesthetic agents



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5. Monitoring and the effectiveness of this policy

Adherence to this policy will be routinely monitored by the pre-assessment pharmacist.

The following monitoring activities will be carried out in relation to this policy:

- Audit the advice given to patients in line with the policy

- Monitor incident report forms and cancellations related to medication related reasons to highlight

areas of training and deviation from the policy recommendations.



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Appendix 1: Diabetic medications (42)

For all diabetic medications - Day before surgery: Take as normal

- After surgery: Restart medication when eating and drinking normally.

* In patients having major surgery and are likely to miss more than one meal, or there is likely to be

significant blood loss, metformin should be omitted on the morning of surgery and resumed when renal

function is satisfactory and the patient is eating and drinking normally.

* The radiology department must advise their patients on whether to continue or discontinue their

metformin, particularly where contrast media might be used.

Medication Day of surgery

Patient for AM surgery Patient for PM surgery

Acarbose Omit morning dose if NBM - Take morning dose if eating breakfast

- Omit lunchtime dose

Meglitinide e.g. Repaglinide or Nateglinide

Omit morning dose if NBM - Take morning dose if eating breakfast

- Omit lunchtime dose

Metformin, Metformin MR ** - If taken once daily/twice daily, take as normal* - If taken once daily/twice daily, take as normal*

- If taken three times daily, omit lunchtime dose - If taken three times daily, omit lunchtime dose

Sulphonylurea

e.g. Glibenclamide , Glipizide, Gliclazide, Gliclazide MR, Glimepiride, Gliquidone

- If taken once daily in the morning, omit am dose

- If taken twice daily, omit am dose

- If taken once daily in the morning, omit am dose

- If taken twice daily, omit both am and pm doses

Thiazolidinedione e.g. Pioglitazone

Take as normal Take as normal

DPP IV inhibitor e.g. Sitagliptin, Vildagliptin, Saxagliptin, Linagliptin

Omit morning dose Omit morning dose

GLP-1 analogue e.g. Exenatide, Liraglutide, Lixisenatide

Omit on day of surgery Omit on day of surgery

SGLT2 inhibitors e.g. Dapagliflozin, Canagliflozin, Empagliflozin

Seek advice from patient’s diabetic specialist team on peri-operative management.



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Insulin Day of surgery


Once Daily (evening)

Long-acting insulin:

Lantus®/Glargine, Levemir/Detemir® , Hypurin Bovine Lente®,Hypurin Bovine PZ1®

Intermediate-acting insulin:

Insulatard® , Insuman Basal® , Humulin I® , Hypurin Bovine Isophane®,Hypurin

Porcine Isophane®

No dose adjustment necessary. No dose adjustment necessary.

Evening dose can be given as usual if

eating and drinking post-surgery.

Evening dose can be given as usual if

eating and drinking post-surgery.

Once Daily (morning)

Long-acting insulin:

Lantus®/Glargine or Levemir/Detemir® , Hypurin Bovine Lente®,Hypurin Bovine PZ1®

Intermediate-acting insulin:

Insulatard® , Insuman Basal® , Humulin I® , Hypurin Bovine Isophane®, Hypurin

Porcine Isophane®

Take normal morning dose*. Take normal morning dose*.

Check blood glucose on admission. Check blood glucose on admission.

Twice daily

Pre-Mixed Insulins:

Humalog Mix 25®, Humalog Mix 50® Novomix 30®,Insuman Comb 15®, Insuman

Comb 25®, Insuman Comb 50®, Humulin M3®, Hypurin Porcine 30/70 Mix®

Twice daily:

Lantus®/Glargine, Levemir/Detemir® , Hypurin Bovine Lente®, Hypurin Bovine PZ1®

Halve the usual morning dose. Halve the usual morning dose.

Check blood glucose on admission.

Resume normal insulin dose with

evening meal.


Resume normal insulin dose with

evening meal.



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Insulin Day of surgery


3, 4 or 5 injections daily

(+/- long-acting insulin or pre-mixed insulin)

Rapid-acting insulin:

Novorapid®, Humalog®, Apidra®

Short-acting insulin:

Actrapid®, Humulin S®, Insuman Rapid® , Hypurin Bovine Neutral®,

Hypurin Porcine Neutral®

- Omit morning dose of rapid-acting or short-

acting insulin if no breakfast is eaten.

- Take usual morning dose of rapid-acting or

short-acting insulin.

- Omit lunchtime dose of rapid-acting or


- Omit lunchtime dose of rapid-acting or


- If normally take long acting basal insulin in

the morning, take normal morning dose.


Resume normal insulin with evening meal. - If normally take pre-mixed insulin, halve the

usual morning dose.


Resume normal insulin with evening meal.

* Some units would recommend reduction of usual dose of long acting insulin by one third, particularly in Type 2 diabetic patients taking regular snacks during the day, and

patient reports that capillary blood glucose regularly drops by ≥ 2mmol/l overnight

For all insulin therapy:

- Day before surgery: No dose change

- After surgery: Restart insulin when eating and drinking normally



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Appendix 2: Glossary of Terms

BP Blood Pressure

COC Combined Oral Contraceptive

COX-2 Cyclo-Oxygenase-2

DMARD Disease-Modifying Anti-Rheumatic Drug

DPP IV Dipeptidylpeptidase-4

GLP-1 Glucagon-like peptide-1

H2 Histamine 2 receptor

HRT Hormone Replacement Therapy

IV Intravenous

MAOI Monoamine Oxidase Inhibitor

MI Myocardial Infarction

N&V Nausea and Vomiting

NBM Nil By Mouth

NSAIDs Non-Steroidal Anti Inflammatory Drugs

OTC Over the Counter

POP Progestogen-Only Pill

SGLT2 Sodium-Glucose co-transporter 2

SSRI Selective Serotonin Re-uptake Inhibitor

TCA Tricyclic Antidepressant

TNFα Tumour Necrosis Factor Alpha

U&E Urea and Electrolytes

VTE Venous Thromboembolism



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Appendix 3: Other linked trust policies and guidelines

1. Royal National Orthopaedic Hospital NHS Trust. Fasting Policy. May 2012. Version 1

2. Royal National Orthopaedic Hospital NHS Trust. The Medicines Policy (MP05) – Medicines

Reconciliation.

3. Royal National Orthopaedic Hospital NHS Trust. Adult Diabetes Policy. October 2014. Version 3



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Appendix 4: Extra sources of information and support

1. Royal National Orthopaedic Hospital NHS Trust. Fasting Policy. May 2012. Version 1.

2. Royal National Orthopaedic Hospital NHS Trust. The Medicines Policy (MP05) - Medicines

Reconciliation .

3. Rahman, M and Beattie, J. Medication in the peri-operative period. The Pharmaceutical Journal, 6

March 2004. 272:287-289.

4. Drugs in the peri-operative period: Stopping or continuing drugs around surgery. Drug and

Therapeutics Bulletin. 8, 1999, Vol. 37, 62-64.

5. Royal Brompton & Harefiled NHS Foundation Trust. Guideline for the perioperative management of

medicines and herbal medicinals in adult surgical patients. January 2013.

6. Joint Formulary Committee. Surgery and long term medication. British National Formulary. London :

BMJ Group and Pharmaceutical Press, September 2015 - March 2016 70 ed.

7. Blood, S. Medication considerations before surgery. The Pharmaceutical Journal, 1 Feb 2012. Vol

288:179.

8. Summary of Product Characteristics Questran Light. Electronic Medicines Compedium. [Online] 28

March 2014. [Cited: 22 October 2015.] https://www.medicines.org.uk/emc/medicine/348.

9. Summary of Product Characteristics Creon 40000 capsules. Electronic Medicines Compedium.

[Online] 18 May 2015. [Cited: 22 October 2015.] https://www.medicines.org.uk/emc/medicine/11027.

10. Rahman, M and Beattie, J. Peri-operative medication in patients with cardiovascular disease. The

Pharmaceutical Journal, 2004. 272: 352-354.

11. Drugs in the peri-operative period: Cardiovascular drugs. Drug and Therapeutics Bulletin. 12, 1999,

Vol. 37, 89-92.

12. Nagelhout, J, Elisha, S and Waters, E. Update for Nurse Anaesthetists. Should I continue or

discontinue that medication. American Association of Nurse Anaesthetists Journal, February 2009.

77(1): 59-73.

13. Flynn, P and Sambhani, J. RNOH Pre-admissions Anaesthetist Consultants. December 2015.

14. Joint Formulary Committee. Appendix 1: Interactions. British National Formulary. London : BMJ

Group and Pharmaceutical Press, September 2014 - March 2015. 68 ed.

15. Stafford-Smith, M, Muir, H and Hall, R. Peri-operative management of drug therapy. Clinical

considerations. Drugs, Feb 1996. 51(2): 238-259.

16. Barker, R. RNOH Medical Liaison Consultant. January 2016.

17. Taylor, D, Paton, C and Kapur, S. The Maudsley Prescribing Guidelines. CRC Press, 2009. 10th ed.



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18. Sanofi Aventis. Personal Communication - Medicines Information. Praidel - pre and post-operative

use. 7th December 2015. Reference: 0023-3375.

19. McNally, S. RNOH Consultant Liaison Psychiatrist. January 2016.

20. UK Medicines Information. What is the risk of interaction between opioids and monoamine oxidase

inhibitors (MAOIs)? UKMI, April 2015. Q&A 192.5.

21. Bhalla, P. RNOH Pain Anaesthetist Consultant. January 2016.

22. Drugs in the peri-operative period: Corticosteroids and therapy for diabetes mellitus. Drug and


23. Summary of Product Characteristics Livial 2.5mg tablets. Electronic Medicines Compedium. [Online]

11 May 2015. [Cited: 7 December 2015.] https://www.medicines.org.uk/emc/medicine/8552.

24. Summary of Product Characteristics Ethinylestradiol Tablets BP 10 mcg, 50 mcg, 1 mg. Electronic

Medicines Compedium. [Online] 2 July 2015. [Cited: 7 December 2015.]

https://www.medicines.org.uk/emc/medicine/16780.

25. Drugs in the peri-operative period: Hormonal contraceptives and hormone replacement. Drug and


26. Summary of Product Characteristics Raloxifene 60 mg Film-coated Tablets. Electronic Medicines

Compedium. [Online] 25 March 2015. [Cited: 30 September 2015.]


27. Joint Formulary Committee. Contraceptives. British National Formulary. London : BMJ Group and

Pharmaceutical Press, September 2014 - March 2015. 68 ed.

28. Faculty of Sexual & Reproductive Healthcare/ Royal College of Obstetricians & Gynaecologists.

Venous Thromboembolism (VTE) and Hormonal Contraception. November 2014.

29. Summary of Product Characteristics Desogestrel 75 microgram Film-coated Tablets. Electronic

Medicines Compedium. [Online] 24 September 2015. [Cited: 23 October 2015.]


30. Summary of Product Characteristics Noriday Tablets. Electronic Medicines Compedium. [Online] 16

August 2010. [Cited: 11 September 2015.] http://www.medicines.org.uk/emc/medicine/1918.

31. Summary of Product Characteristics Micronor Oral Contraceptive Tablets. Electronic Medicines

Compedium. [Online] 20 April 2015. [Cited: 11 September 2015.]

http://www.medicines.org.uk/emc/medicine/911.

32. Summary of Product Characteristics Norgeston. Electronic Medicines Compedium. [Online] 17 April

2014. [Cited: 11 September 2015.] http://www.medicines.org.uk/emc/medicine/1834.

33. Faculty of Sexual & Reproductive Healthcare/ Royal College of Obstetricians & Gynaecologists.

Progestogen-only Implants Clinical Effectiveness Unit Guidance. February 2014.



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34. Cohen, H. RNOH Consultant Rheumatologist. January 2016.

35. Scanzello, C, et al. Perioperative Management of Medications Used in the Treatment of

Rheumatoid Arthritis. HSS Journal, 2006. 2: 141-147.

36. Scherrer, C, et al. Infection Risk After Orthopaedic Surgery in Patients With Inflammatory

Rheumatic Diseases Treated With Immunosuppressive Drugs. Arthritis Care & Research, American

College of Rheumatology, 2013. Vol.65, 12 (2032-2040).

37. Summary of Product Characteristics Tamoxifen 20mg Tablets. Electronic Medicines Compedium.

[Online] 28 August 2015. [Cited: 07 December 2015.]


38. UK Medicines Information. How should herbal medicines be managed in patients undergoing

surgery? UKMI, April 2015. Q&A 368.2.

39. Wong, A and Townley, SA. Continuing Education in Anaesthesia, Critical Care & Pain. Herbal

medicines and anaesthesia. 1, 2011, Vol. 11, 14-17.

40. Medicines Complete. Herbal Medicines . [Online] Pharmaceutical Press, 2015.

https://www.medicinescomplete.com/mc/herbals/current/index.htm.

41. Ang-Lee, MK, Moss, J and Yuan, CS. JAMA. Herbal Medicines and Perioperative Care. 2, 2001, Vol.

286, 208-216.

42. Royal National Orthopaedic Hospital NHS Trust. Adult Diabetes Policy. October 2014. Version 3.

43. Summary of Product Characteristics Fostair 100/6 inhalation solution. Electronic Medicines

Compedium. [Online] 23 September 2015. [Cited: 21 October 2015.]




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Appendix 5: Privacy Impact Assessment and Equality Analysis

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

Yes/No Comments

1. Does the policy/guidance affect one group less or more favourably than another on the basis of:

Race N

Ethnic origins (including gypsies and travellers) N

Nationality N

Gender N

Culture N

Religion or belief N

Sexual orientation including lesbian, gay and bisexual people

N

Age N

Disability - learning disabilities, physical disability, sensory impairment and mental health problems

N

2. Is there any evidence that some groups are affected differently?

N

3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

N

4. Is the impact of the policy/guidance likely to be negative?

N

5. If so can the impact be avoided? n/a

6. What alternatives are there to achieving the policy/guidance without the impact?

n/a

7. Can we reduce the impact by taking different action?

n/a

If you have identified a potential discriminatory impact of this procedural document, please refer it to

the Director of Human Resources and Corporate Affairs, together with any suggestions as to the action

required to avoid/reduce this impact.