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
Author
Care Group Approval
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Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 1 of 26
BNF Class / Drug group
(examples)
Risk
Use pre-op. when NBM
Alternative post-op if unable to
take po medication
1. GASTRO-INTESTINAL
1.1 Antacids
Reduce risk of acid aspiration.
(e.g. co-magaldrox,
GavisconR)
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
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
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 2 of 26
Management
NB increased risk of C.
difficile associated with
PPI’s
BNF Class / Drug group
(examples)
Risk
Use pre-op. when NBM
Alternative post-op if unable to
take po medication
Management
2. CARDIOVASCULAR
2.1 Digoxin
Increased toxicity with
suxamethonium
Arrhythmias
Continue.
2.2 Diuretics
-thiazide and loop
(e.g. bendroflumethiazide,
furosemide)
Diuretics - potassium
sparing
(e.g. amiloride,
spironolactone)
Arrhythmias
Prolonged N/M block
Hypokalaemia may provoke paralytic
ileus
Tissue damage
Reduced kidney perfusion
Hyperkalaemia
2.3 Antiarrhythmics
To prevent relapse of arrhythmia
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

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.
i.v. diuretics
(max rate for furosemide =
4mg/min)
Monitor digoxin level
and K+. Level checked
6-8hrs after dose.
Add potassium to fluids where
needed.
Monitor U+E’s
Use i.v. alternative within same
class with ECG monitoring
ECG monitoring.
Monitor U+E’s.
Hypokalaemia can
predispose to digoxin
toxicity
Some antiarrhythmics prolong the
duration of action of non depolarising
neuromuscular blockers
2.4 Beta blockers
(e.g. atenolol, propranolol)
Hypotension
Bradycardia
Bronchospasm
Continue- improves c/v stability. Betablockers should not be discontinued
abruptly in the peri-operative period.
Rebound if withdrawn.
In post-thyroidectomy, dose may be
gradually tapered to zero.
Author
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Date of Approval
Date of Review
Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
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Give alternative i.v. beta-blocker
(rarely needed) or GTN patch if
patient symptomatic
Monitor BP, fluids,U+E’s
Omit if bradycardic
Monitor BP and pulse
BNF Class / Drug group
(examples)
Risk
Use pre-op. when NBM
Alternative post-op if unable to
take po medication
2.5.1 Vasodilators (e.g.
hydralazine)
Reflex tachycardia
Hypotension.
Continue
2.5.2 Central-acting antihypertensives
(e.g. clonidine,
methyldopa)
2.5.4 Alpha blockers
(e.g. doxazosin)
Hypotension
Rebound hypertension if withdrawnhypertensive crisis with one missed dose.
Continue.
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
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.
GTN patch or, if BP remains high,
alternative i.v. antihypertensive
agent / i.v. diuretic.
If Prescribed for heart failure +/or MI
continue as per the European Society of
Cardiology guidelines and discuss with the
anaesthetist.
Some ACE inhibitors absorbed s/l,
e.g. captopril
2.5.5.1 ACE inhibitors
(e.g.
short-acting :captopril
long-acting: lisinopril)
2.5.5.2 Angiotensin II
antagonists
(e.g. losartan)
Hypotension (risk increases if volume
depleted, be aware if substantial fluid
shifts or bleeding is anticipated). Perioperative ACEI’s carry a risk of
hypotension under anaesthesia, in
particular following induction and
concomitant beta-blocker use.
Renal failure
Reduced cerebral blood flow
i.v. alternatives available
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
Author
Care Group Approval
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Date of Approval
Date of Review
Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 4 of 26
Management
Monitor BP and pulse
Monitor BP
Monitor BP
If for urinary retention
then should discontinue
post TURP
Monitor BP and U+E’s.
Caution NSAIDS.
Resume cautiously postoperatively as long as
the patient is not
hypotensive and has
normal renal function.
BNF Class / Drug group
(examples)
Risk
Use pre-op. when NBM
Alternative post-op if unable to
take po medication
Management
For patients on combination products such
as ACEI / AIIRA with diuretic or ACEI / AIIRA
with calcium channel blocker discuss with
the anaesthetist
2.5.5.3 Renin inhibitors
(e.g. aliskiren)
2.6.1 Nitrates
Hypotension can occur in patients
with marked volume depletion.
Hypotension
Continue
2.6.2 Calcium antagonists
Hypotension
Bradycardia(verapamil)
Additive effect with enflurane,
halothane
Continue
--diltiazem,
- verapamil
-dihydropyridines
(nifedipine, amlodipine)
2.6.3 K+ channel
activators (e.g. nicorandil)
Additive effect with isoflurane
Hypotension
Author
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Continue
Topical, buccal, sublingual and iv
forms available.
GTN patch or, if BP remains high,
alternative i.v. antihypertensive
agent.
Avoid sublingual nifedipine
capsules (associated with
increased risk of stroke)
Monitor BP
Alternative anti-anginals (see
nitrates)
Monitor BP
Refer to Trust Oral Anticoagulant
Guidelines LINK / Anticoagulation
guidelines for Neuraxial procedures LINK
2.8 AnticoagulantsParenteral
Heparin, LMWH,
Fondaparinux (see SPC
re dose, timing, duration
etc)
Vitamin K antagonists
-Oral Anticoagulants
(e.g. warfarin)
Continue
Haemorrhagic risk if continued.
Risk of peri-operative
thromboembolism if stopped
Refer to Trust Oral Anticoagulant
Guidelines. LINK
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 5 of 26
See oral anticoagulant guidelines
Monitor BP and pulse
For information
regarding epidural
analgesic infusions and
anticoagulants see the
CDDFT policy for the
management of Epidural
Analgesia Infusions
INR, platelet counts (>5
days of heparin)
Check BNF for
interacting drugs.
BNF Class / Drug group
(examples)
Direct thrombin inhibitors
– Dabigatran
Risk
Haemorrhagic risk
No antidote for rapid reversal in
emergencies
Refer also to
Anticoagulation
guidelines for Neuraxial
procedures. LINK
Use pre-op. when NBM
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
Alternative post-op if unable to
take po medication
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
Management
Normal/near-normal
aPTT or thrombin time
on morning of surgery;
renal function
(Cockcroft-Gault
estimation of CrCl)
When restarting, give 0-2 hours
before next dose of LMWH would
have been due.
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.
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 6 of 26
Normal/near-normal
aPTT or thrombin time
on morning of surgery;
renal function
(Cockcroft-Gault
estimation of CrCl
BNF Class / Drug group
(examples)
2.9 Antiplatelets
Risk
-Aspirin
Haemorrhagic risk. Depends on
surgery and / or choice of
anaesthesia, i.e. epidural
-platelet P2Y12 receptor
blockers
(e.g. clopidogrel,
prasugrel, ticagrelor and
ticlopidine)
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.
Dipyridamole
Haemorrhagic risk when used in
combination with aspirin, warfarin or
clopidogrel
Use pre-op. when NBM
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
As above consider balance between
bleeding risk and thrombotic risk.
If used a sole agent, does not need to be
stopped.
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 7 of 26
Alternative post-op if unable to
take po medication
Management
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.
BNF Class / Drug group
(examples)
Risk
Use pre-op. when NBM
Alternative post-op if unable to
take po medication
Management
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
Myopathy and rhabdomyolysis
(numerous factors increase risk e.g.
impaired renal function after major
surgery, multiple drug use during
anaesthesia)
Niacin and fibric acid
derivatives
Myopathy and rhabdomyolysis (risk
increases in combination with statins)
Bile squestrants
May interfere with absorption of
medications required perioperatively
Ezetimibe
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 cardioprotection therefore continue but check CK
post-op and monitor for signs of muscle
toxicity
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
Stop evening before surgery
i.v. available.
Check levels pre-operatively.
Theophylline level
Continue
Nebulised therapy if unable to use
inhalers post-op
NB: post op analgesia
and post op pain may
mask signs of
myopathy.
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
3. RESPIRATORY
Theophylline
Inhaled bronchodilator
therapy
Narrow therapeutic range leading to
increased risk of toxicity.
Check for interacting drugs.
4. CNS
Author
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Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 8 of 26
BNF Class / Drug group
(examples)
Risk
4.1 Benzodiazepines
(e.g. diazepam,
temazepam)
4.1 Hypnotics
(e.g. Zopiclone, zolpidem)
4.2 Antipsychotics
(e.g. haloperidol,
clozapine, olanzapine)
Tolerance
Additive effects
Withdrawal syndrome
Additive effects
Withdrawal syndrome
Sedation
Arrhythmias
4.2.3 Lithium
Prolongs N/M blockade
Toxicity
4.3.1 TCAs
(e.g. amitriptyline,
doselupin)
4.3.2 MAOIs
-‘old type’, e.g. phenelzine
- ‘new’ type, e.g.
moclobemide
Increase effect of exogenous
catecholamines e.g. adrenaline
resulting in arrhythmias, hypotension
Hypertension, hyperthermia,
convulsions, coma with opioids esp.
pethidine, and sympathomimetics.
Can be fatal.
4.3.3 SSRIs
(e.g. citalopram,
fluoxetine)
Interactions may cause Serotonin
syndrome (agitation, coma,
tachycardia, hypertension, fever,
myoclonus), eg pethidine,
pentazocine, tramadol
Author
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Protocol Number
Use pre-op. when NBM
Alternative post-op if unable to
take po medication
Management
Continue
i.v. and rectal forms if necessary.
May need lower/higher
doses for sedation
Continue
i.v. and rectal alternatives
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.
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.
i.v. alternatives available
May need lower/higher
doses for sedation
U+E’s,
FBC (clozapine)
Continue. Avoid pro-arrhythmic anaesthetic
agents. Use reduced doses of
sympathomimetic agents.
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
Continue- Fluoxetine has an extended halflive so can be omitted for 24-48 hours.
Discontinuation of some SSRIs can
precipitate withdrawal syndrome (especially
paroxetine and venlafaxine), therefore
withholding not advised.
Extended half-lives so can be
omitted for few days.
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 9 of 26
Haloperidol +/- lorazepam in some
cases
Check Lithium levels
preassessment, monitor
fluids and U+E’s.
Avoid NSAIDs.
Care with drug
interactions
Liquids available
Caution when initiating
interacting agents
BNF Class / Drug group
(examples)
4.3.4 Antidepressants,
Other (e.g. mirtazapine,
duloxetine)
4.4 Psychostimulants
(methylphenidate)
4.5.1 Anti-obesity drugs
acting on the GI tract
(Orlistat)
4.7.2 Opioids
Risk
Use pre-op. when NBM
Alternative post-op if unable to
take po medication
Management
Continue
Hypertension, arrhythmias, reduced
seizure threshold
Withhold on day of surgery
Involuntary bowel movement during
admission/ under anaesthesia
Stop when NBM
Hypotension, respiratory depression
Continue, anaesthetist and pain team must
be informed especially in patients on
substance misuse program.
Consult specialist
psychiatrist
Other routes available including
topical, IV, Liquids, SL
Consult pain team upon
admission for
management of acute
on chronic pain
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.
-Continue L-dopa (sinemet/ madopar) as
abrupt withdrawal can lead to neuroleptic
malignant syndrome.
-Dopamine agonists (pramipexole/
ropinerole) should be continued with
-NG L-Dopa- can convert
Sinemet/Madopar to Madopar
Dispersible
AntiemeticsDomperidone PR or NG
before parkinsons meds,
if required. Avoid
Consider referral to pain team at preassessment for patients on buprenorphine
as may need switching by primary care
prior to admission. See also LINK
4.8. Anticonvulsants
Induce hepatic enzymes(phenytoin,
barbiturates, carbamazepine)
Anaesthetics may depress hepatic
drug elimination.
Resistance to non-depolarising
muscle relaxants.
4.9 Anti-parkinsonian
drugs
Neuroleptic malignant syndrome,
Arrhythmias, Hypertension (L-dopa)
Symptoms exacerbated by some
antiemetics.
Author
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Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 10 of 26
BNF Class / Drug group
(examples)
Risk
Selegiline/ rasagiline + pethidine can
cause hyperpyrexia and CNS toxicity
4.10 Alcohol & nicotine
e.g. acamprosate,
disulfiram, varenicline
Abrupt withdrawal of varenicline
leads to risk of relapse, depression,
insomnia
Use pre-op. when NBM
Alternative post-op if unable to
take po medication
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.
-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.
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
5. ANTIBIOTICS, ANTIVIRALS & ANTIFUNGALS
5.1 / 5.2
Antibiotics & antifungals
5.3 Antivirals used for HIV
Author
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Date of Approval
Date of Review
Protocol Number
Consult Microbiology
Continue
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 11 of 26
Restart immediately post-op
otherwise may lead to decline in
patient’s mental function
Management
metoclopramide and
prochlorperazine
Discuss with
Specialist Parkinson’s
team
BNF Class / Drug group
(examples)
Risk
Use pre-op. when NBM
Alternative post-op if unable to
take po medication
Management depends on usual insulin
regime.
Consult Diabetes Specialist Team for
specific advice.
Continue taking as normal prior to
admission. Once NBM then omit dose
(pioglitazone may be continued).
Recommence once normal eating resumed.
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_are
Management
6. ENDOCRINE
6.1.1 Insulin
Increased risk of post-op infection.
Altered requirements
6.1 Oral hypoglycaemics
(e.g. gliclazide,
rosiglitazone, metformin,
repaglinide, sitagliptin,
exenetide)
Peri-operative hypoglycaemia
Lactic acidosis (metformin)
6.2.1 Levothyroxine
Impaired stress reaction if
hypothyroid
6.2.2 Anti-thyroid drugs
(e.g. carbimazole)
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.
6.4 Hormone replacement
therapy +
SERMS(Raloxifene)
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
www.diabetes.nhs.uk/our_work_areas/inpatient_care/
as/inpatient_care/
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.
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
Restart after discharge as for COC.
Ensure adequate
thrombo-prophylaxis
prescribed
Continue
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.
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.
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 12 of 26
BNF Class / Drug group
(examples)
6.4.1.2 High dose
progestogens ( eg used
for menstrual disorders)
6.6.2 Bisphosphonates
(alendronic acid,
risedronate)
Risk
Use pre-op. when NBM
Alternative post-op if unable to
take po medication
Increased risk of DVT/PE in major
surgery
Discontinue 4 weeks prior to major surgery.
Oesophageal irritation
Omit on morning of surgery, If due on
morning of surgery advise patient to take
day before.
Restart with first menses that occur
at least 2 weeks after discharge
providing patient fully mobile
Recommence when patient is able
to sit upright and is drinking free
fluids.
Management
7. OBSTETRICS, GYNAECEOLOGY AND URINARY-TRACT DISORDERS
7.3 Combined oral
contraceptive (COC)
(oestrogen containing)
VTE and Hormonal
Contraception RCOG
guideline 2010
7.3 Progestogen only
contraceptives (includes
injectables, IUD &
implants)
7.4.2 Drugs for urinary
frequency (oxybutynin,
solifenacin)
7.4.5 Drugs for erectile
dysfunction
(sildenafil, tadenafil)
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)
No added risk of thrombo-embolic
risk (see OCP/HRT protocol appendix 2)
Discontinue 4 weeks prior to major surgery
where immobilisation is expected and all
lower limb surgery.
Restart with first menses that occur
at least 2 weeks after discharge
providing patient is fully mobilised
However, consider risks of unplanned
pregnancy.
Progestogen-only pill is suitable alternative.
Continue
Continue
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
8.3.4 Tamoxifen
Discuss with specialist
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
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 13 of 26
If discontinued, restart at least 4
weeks post-operatively providing
patient fully mobile
If decision is to continue
ensure adequate
thromboprophylaxis
BNF Class / Drug group
(examples)
Risk
9.1 Iron
Use pre-op. when NBM
Alternative post-op if unable to
take po medication
Management
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
10.1.3 DMARDS and
immunosuppressants
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
Methotrexate
Elderly/frail/co-morbidities/RI : stop ONE
week pre-op. Can continue in otherwise
healthy individuals.
pr preps available
U+E’s
Restart as soon as possible once
wound healed and providing renal
function stable.
U+E’s. Caution with
NSAIDs.
Sulfasalazine / Azathioprine
Withold day of surgery
Hydroxochloroquine / Lefluonimide
Continue as normal
10.1.3 Cytokine inhibitors
e.g Adalimumab,
Inflixamab, Anakinra,
Etanercept
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Increase risk of infection
Impaired wound healing
NB: if using for any other condition, e.g.
haematological or post-transplantation, then
the advice of the relevant specialist must be
obtained
Withold prior to major surgical procedures.
Risk/ benefits must be discussed with
specialist.
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 14 of 26
Treatment may be restarted once
wound healing is satisfactory and
no sign of infection.
BNF Class / Drug group
(examples)
Risk
Use pre-op. when NBM
Alternative post-op if unable to
take po medication
General guidance stop 3-5 x half life (T1/2):
 Adalimumab stop at 45 days
 Etanercept stop 9 days
 Infliximab stop 24 days
10.2 Neuromuscular
Disordersanticholinesterases e.g.
neostigmine,
pyridostigmine
Respiratory complications,
cholinergic crisis
Discuss with anaesthetist- manage
according to severity of disease and type of
surgery
11. TOPICAL EYE PREPS
Steroids, pilocarpine,
beta-blockers (timolol)
Bradycardia due to systemic
absorption (beta- blockers)
Continue
Flu like symptoms
Advise patients to avoid having vaccination
within 7 days pre-op
14 VACCINES
Flu vaccine
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 15 of 26
IV pyridostigmine available. Dose
adjustment required
Management
References
Actavis Pharma. Bisphosphonates prior to surgery. Personal communication accessed 27th July 2012
Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and perioperative care. JAMA 2001; 286(2): 208-216
Anon. Drugs in the peri-operative period: 2 – Corticosteroids and therapy for diabetes mellitus. Drug Therapeutic Bull 1999;
37: 68-70
Anon. Drugs in the peri-operative period: 3 – Hormonal contraceptives and hormone replacement therapy. Drug Therapeutic
Bull 1999; 37: 78-80
Anon. Drugs in the peri-operative period: 4 – Cardiovascular drugs. Drug Therapeutic Bull 1999; 37: 89-92
Anon. Drugs in the peri-operative period: Stopping or continuing drugs around surgery. Drug Therapeutic Bull 1999; 37: 2-74
Anon. Surgery and long-term medication. Drug Therapeutic Bull 1984 ; 22(19) : 73-76
Anon. Surgery patients at risk for herb-anaesthesia interactions. Lancet 1999 ; 354 :1362
Anon. Use of herbal medicines could pose risk to patients undergoing surgery. Pharm J 2001; 267: 79
Auerbach AD, Goldman L. Beta-blockers and reduction of cardiac events in noncardiac surgery: scientific review. JAMA 2002
; 287 (11) : 1435-1444.
Burger W, Chemnitimus JM, Kneissl GD, Rucker G. Low dose aspirin for secondary prevention – cardiovascular risks after its
perioperative withdrawal versus bleeding risks with its continuation- review and meta-analysis. Journal of internal Medicine 2005
;257: 399-414
Cardone, A et al. Perioperative evaluation of Myesthenia Gravis. Ann. Ital. Chir. 2007; 78: 359-365
Carpenter MT, West SG, Vogelgesang SA, Casey Jones DE. Postoperative joint infections in rheumatoid arthritis patients on
methotrexate therapy. Orthopedics 1996; 19(3):207-10
Castanheira L, Fresco P, Macedo AF. Guidelines for the management of chronic medication in the perioperative period:
systematic review and formal consensus. Journal of Clinical Pharmacy and Therapeutics (2011) 36, 446–467
Chakravarty K,McDonald H, Pullar T et al. BSR/BHPR guideline for disease modifying anti-rheumatic drug (DMARD) terapy in
consultation with the British Association of Dermatologists 2008. www.rheumatology.org.uk/resources/guidelines (last
accessed April 2013)
Ding T, Leckingham J, Luqmaru R et al. BSR and BHPR rheumatoid arthritis guidelines on safety of anti-TNF therapies 2010.
www.rheumatology.org.uk/resources/guidelines (last accessed April 2013)
Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American College of Chest
Physicians Evidence Based Clinical Practice Guidelines (8th Edition). Chest 2008;133:299S
Duthie DJR, Montgomery JN, Spence AA, Nimmo WS. Concurrent drug therapy in patients undergoing surgery. Anaesthesia
1987 ; 42 : 305-306
European Society of Cardiology (ESC) guidelines for pre-operative cardiac risk assessment and peri-operative cardiac
management in non-cardiac surgery. European Heart Journal (2009) 30, 2769-2812.
Fleisher LA, Beckman JA, Brown KA. ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. Circulation 2007; 116; 418-499
Fugh-Berman A. Herb-drug interactions. Lancet 2000 ; 355 :134-138
Kennedy JM, van Rij AM, Spears GF, Pettigrew RA, Tucker IG. Polypharmacy in a general surgical unit and consequences of
drug withdrawal. Br J Clin Pharmacol 2000; 49(4): 353-62
Goh L, Jewell T, Laversuch C, Samant A. Should anti-TNF therapy be discontinued in rheumatoid arthritis patients
undergoing elective orthopaedic surgery? A systematic review of the evidence. Rheumatol Int 2012; 32 (1):5-13.
Merli, GJ, Bell, RD. Perioperative care of the surgical patient with neurologic disease. www.uptodate.com 2012
Miller J, Warren A. Nil-by-mouth needs defining. Hosp Pharm Prac 1994 ; 4(2) :53-54
Muluk V, Macpherson DS. Perioperative Medication Management. www.uptodate.com 2012
Mushtaq S, Goodman S, Scanzello C. Peri-operative management of Biologic Agents used in the treatment of Rheumatoid
Arthritis. American Journal of Therapeutics 2011; 18(5):426-434
NHS Diabetes. Management of Adults with Diabetes undergoing surgery and elective procedures: improving standards. April
2011 www.diabetes.nhs.uk/our_work_areas/inpatient_care/
Nielsen JD, Holm-Nielsen A, Jespersen J, Vinther CC, Settgast IW, Gram J. The effect of low-dose acetylsalicylic acid on
bleeding after transurethral prostatectomy- a prospective, randomized, double-blind, placebo-controlled study. Scand J Urol
Nephrol 2000; 34(3):194-198
RCN Rheumatology Biologics Working Party. Assessing, managing and monitoring biologic therapies for inflammatory
arthritis. Guidance for Rheumatology practitioners 2nd edition 2009.
Rispler DT, Sara J. The impact of complementary and alternative treatment modalities on the care of orthopaedic patients. J
Am Acad Orthop Surg 2011; 19(10):634-643
Rosenman DJ, McDonald FS, Ebbert JO, et al. Clinical consequence of withholding versus administering renin-angiotensinaldosterone system antagonists in the preoperative period. J Hosp Med 2008; 3:319
Royal College of Obstetricians and Gynaecologists Guideline No 40 Venous Thromboembolism and Hormonal
Contraception.July 2010
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Page 16 of 26
Salem M, Tainish RE, Bromberg J, Loriaux DL, Chernow B. Perioperative glucocorticoid coverage. A reassessment 42 years
after emergence of a problem. Ann Surg 1994; 219 : 416-425
Schouten O, Hoeks SE, Gijs MJM et al. Effect of statin withdrawal on frequency of cardiac events after vascular surgery.
American Journal of Cardiology 2007; 100(2): 316-320
Scottish Intercollegiate Guideline Network (SIGN) Guidelines. Prophylaxis of Venous Thromboembolism. Guideline 62, October
2002.
Sear JW, Higham H. Issues in the perioperative manangement of the elderly patient with cardiovascular disease. Drugs and
Ageing 2002; 19(6) : 429-451
Shammash JB, Trost JC, Gold JM, et al. Perioperativebeta-blocker withdrawal and mortality in vascular surgical patients. Am
Heart J 2001;141:148
SPC Dabigatran. Accessed Oct 2012.
SPC Rivaroxaban. Accessed Oct 2012
Stafford Smith M, Muir H, Hall R. Perioperative management of drug therapy : clinical considerations. Drugs 1996; 51(2) : 238259
Steuer A, Keat AC. Perioperative use of methotrexate- a survey of clinical practice in UK. Br J Rheum 1997; 36: 1009-1011
Straube S, Derry S, McQuay H and Moore R :Effect of pre-operative Cox 2 Selective NSAIDS (Coxibs) on post-operative
outcomes: A systematic review of Randomized studies. Acta Anaestesiol Scand 2005:49:601-613
Thromboembolic Risk Factors (THRIFT) Consensus Group. Risk of prophylaxis for venous thromboembolism in hospital
patients. BMJ 1992 ; 305 :567-574
Wijeysundera DN, BeattieWS. Calcium channel blockersfor reducing cardiac morbidity after non cardiac surgery: a metaanalysis. Anesth Analg 2003; 97:634
Wysokinski WE, McBane RD. Periprocedural Bridging Mangement of Anticoagulation. Circulation 2012;126: 486-90.
The following guidelines were consulted:
Royal Cornwall Hospitals NHS Trust. Pre-Operative Assessment Guidelines. November 2010
Whittington Hospital NHS Trust. Nil by mouth perioperative medicine use guideline. January 2012.
Worcestershire Acute Hospitals NHS Trust. Nil by mouth and peri-operative medicines use guideline. Accessed on 12.09.12
This policy refers to the following CDDFT policies and procedures:
County Durham and Darlington Foundation NHS Trust. Oral Anticoagulation with warfarin- adult patient management guidelines.
January 2013. County Durham and Darlington Foundation NHS Trust.
http://intranet/sites/policiesandprocedures/Published%20Documents/Oral%20anticoagulation%20with%20warfarin%20%20adult%20patient%20management%20guidelines.pdf
County Durham and Darlington Foundation NHS Trust. Anticoagulation guidelines for Neuraxial procedures (2010)
http://intranet/Directorates/CCG/SD/Anaes/Joint%20Dept%20Guidelines/Regional/Anticoagulation%20and%20Neuraxial%20CDDFT.pdf
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 17 of 26
Appendix 1: Herbal and homeopathic medicines
The use of herbal and homeopathic medications in the UK is becoming increasingly popular. It is vital that these medications
are
listed during the medicines reconciliation process as many may interfere with or have an effect on surgical procedures.
The following list is intended as a guide only, however it is advised that ALL herbal/ homeopathic medicines be stopped
TWO WEEKS prior to elective surgery
Medication
Risk
5-HTP
Agnus Castus
Has serotinergic properties; treat as an SSRI. Caution with pethidine use.
Pro-oestrogenic; could increase thrombus risk. Dopamine agonist; Treat as haloperidol clozapine or
sulpiride
Clinical evidence of hypotensive effects. Clinical research suggests hypoglycaemic effects
Immunomodulating properties; Possible increased risk of infection and poor wound healing. Prooestrogenic; could increase thrombus risk. Clinical research suggests hypoglycaemic effects
Clinical research suggests hypoglycaemic effects
Clinical research suggests hypoglycaemic effects
Preliminary evidence of hypotensive effects
Pro-oestrogenic; could increase thrombus risk. Sympathomimetic; can cause hypertension,
tachycardia and arrhythmias
Anticholinesterase action; bradycardia, hypotension, bronchoconstriction.
Clinical evidence of hypotensive effects
Clinical evidence of hypotensive effects
Clinical research suggests hypoglycaemic effects
Mineralocorticoid effect; could increase blood pressure
Antiplatelet effect; increases bleeding risk
Clinical research suggests hypoglycaemic effects
Stimulant. Structurally related to phenylephrine, it can predispose the patient to stroke, myocardial
infarction, arrhythmia from tachycardia and hypertension. May interact with MAOIs. Omit a minimum
of 24hours pre-op.
Pro-oestrogenic; could increase thrombus risk
Large quantities of caffeine in black tea can have antiplatelet effects; increased bleeding risk
Agrimony
Alfalfa
Aloes/Aloe vera
Alpha-lipoic acid
Andrographis
Aniseed
Arnica
Asafoetida
Avens
Banaba
Bayberry
Bilberry
Bitter melon
Bitter orange
Black Cohosh
Black tea
(concentrated
tablets)
Blue Cohosh
Boldo
Boneset
Broom
Burdock
Butterbur
Calamus
Calendula
Capsicum
Cat's Claw
Celery
Centaury
Chamomile
Chondroitin
Clove
Coenzyme Q10
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Theoretical hypertensive effects
Anticoagulation effect; increased risk of bleeding. Can potentiate the effects of warfarin.
Immunomodulating properties; Possible increased risk of infection and poor wound healing
Hypertensive; potential to raise blood pressure
Potential cardiac depressant activity
Clinical research suggests hypoglycaemic effects
Clinical evidence of hypotensive effects
Clinical evidence of hypotensive effects. Theoretical catecholamine activity. Potentiates barbiturate
sleeping time
Immunomodulating properties; Possible increased risk of infection and poor wound healing
Sympathomimetic; can cause hypertension, tachycardia and arrhythmias
Antiplatelet effect; increases bleeding risk. Clinical evidence of hypotensive effects
Immunomodulating properties;
Possible increased risk of infection and poor wound healing
Clinical research suggests hypoglycaemic effects Sedatives effect
Sedative effect
Immunomodulating properties; Possible increased risk of infection and poor wound healing. Mild
sedative effects; could potentiate anaesthetics
Anticoagulation effect; increased risk of bleeding. Can potentiate the effects of warfarin. Chondroitin
also affects blood sugar control
Antiplatelet effect; increases bleeding risk
Clinical research suggesting modest hypotensive effects
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 18 of 26
Cola nut
Coltsfoot
Corn Silk
Couchgrass
Cowslip
Damiana
Dandelion
Danshen
Devil's Claw
Dong quai
Drosera
Echinacea
Elecampane
Ephedra
Epimedium
Eucalyptus
Fenugreek
Feverfew
Fucus
Fumitory
Garlic
Ginger
Ginkgo
Ginseng
(American,
Eleutherococcus
and
Panax)
Glucomannan
Glucosamine
Golden Seal
Greater
Celandine
Green tea
(concentrated)
Guarana
Gymnema
Hawthorn
Hops
Horehound
Horse chestnut
Horseradish
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Stimulant. Increased risk of tachycardia and hypertension.
Vasopressor activity causes hypertension
Clinical evidence of hypotensive effects. Clinical research suggests hypoglycaemic effects
Sedative effect
Initially causes hypotension, then later hypertension
Clinical research suggests hypoglycaemic effects
Clinical research suggests hypoglycaemic effects
Anticoagulation effect; increased risk of bleeding. Can potentiate the effects of warfarin
Clinical research suggests hypoglycaemic effects. Clinical evidence of hypotensive effects
Anticoagulation effect; increased risk of bleeding. Can potentiate the effects of warfarin
Immunomodulating properties; Possible increased risk of infection and poor wound healing
Possible increased risk of infection and poor wound healing
Clinical research suggests hypoglycaemic effects. Sedative effect. Clinical evidence of hypotensive
effects
Stimulant: Is a source of ephedrine, pseudoephedrine, and phenylpropanolamine. Can cause
tachycardia and hypertension with spontaneous adverse events including stroke, myocardial
infarction,QT interval prolongation and arrhythmia.
Also known to inhibit complement pathway
Preliminary evidence of hypotensive effects
Clinical research suggests hypoglycaemic effects
Anticholinesterase action; bradycardia, hypotension, bronchoconstriction. Anticoagulation effect;
increased risk of bleeding.
Can potentiate the effects of warfarin. Clinical research suggests hypoglycaemic effects
Antiplatelet effect; increases bleeding risk
Anticoagulation effect; increased risk of bleeding.
Potential hypotensive effects, Both hyper- and hypothyroidism reported with continued use
Clinical evidence of hypotensive effects
Antiplatelet effect; increases bleeding risk. Also have hypotensive properties. Clinical research
suggests hypoglycaemic effects
Antiplatelet effect; increases bleeding risk. Clinical research suggests hypoglycaemic effects. Also
has hypotensive properties
Pro-oestrogenic; could increase thrombus risk. MAOI activity. Antiplatelet effect; increases bleeding
risk
Immunomodulating properties; Possible increased risk of infection and poor wound healing.
Has erratic blood glucose control in patients reporting both hyper- and hypoglycaemic control
CNS depressant and stimulant
Pro-oestrogenic; could increase thrombus risk Antiplatelet effects; increases bleeding risk
Also has erratic blood pressure altering properties, causing both hyper- and hypo-tension in
patients.
MAOI potentiation, suspected phenelzine interaction
Clinical research suggesting hypoglycaemic effects
Anticoagulation effect; increased risk of bleeding. Can potentiate the effects of warfarin and can
also affect blood sugar control
Potential hypotensive effects, Heparin antagonist, Sedative effect
Immunomodulating properties; Possible increased risk of infection and poor wound healing
Large quantities of caffeine in green tea can have antiplatelet effects; increased bleeding risk.It can
also be a stimulant in large quantities.
Antiplatelet effects; increases bleeding risk. Also a known stimulant; increases risk of tachycardia,
hypertension and arrhythmias.
Clinical research suggests hypoglycaemic effects
Clinical evidence of hypotensive effects.CNS depressant; potentiates barbiturate sleeping time
Mild sedative effects ( usually used in combination with other sedative products). Could potentiate
anaesthetics.
White Vasodilator properties; lowers blood pressure
Active constituents thought to have antiplatelet activity; increases bleeding risk.Clinical evidence of
hypotensive effects
Clinical evidence of hypotensive effects. Peroxidase stimulates synthesis of arachidonic acid
metabolites
Both hyper- and hypo thyroidism reported with continued use
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 19 of 26
Hydrocotyl
Jamaica
Java Tea
Juniper
Kava
L-arginine
Lavender
Lemon balm
Liquorice
L-tryptophan
Marshmallow
Maté
Melatonin
Mistletoe
Motherwort
Myrrh
Nettle
Parsley
Passionflower
Plantain
Pleurisy Root
Pokeroot
Policosanol
Prickly Ash
Prickly pear
cactus
Red Clover
Resveratrol
Rosemary
Sage
SAMe
Saw Palmetto
Scullcap
Senega
Shepherd's Purse
Squill
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Hyperglycaemic effect and Sedative effect
Dogwood Sedative effect
Clinical evidence of hypotensive effects. Clinical research suggests hypoglycaemic effects
Clinical evidence of hypotensive effects. Clinical research suggests hypoglycaemic effects
Additive effects with benzodiazepines increasing sedation; also linked to numerous reports of
hepatotoxicity
Possible dopamine antagonist effects. Treat as haloperidol clozapine or sulpiride.
Clinical research suggesting modest hypotensive effects
Mild sedative effects; additive effects with CNS depressants and anaesthetics.
Clinical research suggesting sedative effects. Could potentiate anaesthetics
Mineralocorticoid effect; could increase blood pressure. Pro-oestrogenic; could increase thrombus
risk, Antiplatelet effect; increases bleeding risk.
Also has a laxative effect similar to senna. Particularly important to withdraw prior to bowel surgery.
Clinical research showing sedative effects; documented reports of additive effects with CNS
depressants and anaesthetics.
Also has serotinergic properties; treat as an SSRI. Caution with pethidine.
Clinical research suggests hypoglycaemic effects
Stimulant. Increased risk of tachycardia and hypertension
Clinical research suggesting sedative effects; can potentiate anaesthetics.
Seek anaesthetic advice if prescribed by a clinician (especially in children).
Clinical evidence of hypotensive effects. Promotes coagulation and has Immunomodulating
properties; Possible increased risk of infection and poor wound healing
Oxytocic properties
Clinical research suggests hypoglycaemic effects
Clinical evidence of hypotensive effects. CNS depression, in vivo. Clinical research suggests
hypoglycaemic effects, Anticholinesterase action; bradycardia, hypotension, bronchoconstriction.
Sympathomimetic; can cause hypertension, tachycardia and arrhythmias
Mild sedative effects; animal models suggest additive effects with CNS depressants
Clinical evidence of hypotensive effects
Sympathomimetic; can cause hypertension, tachycardia and arrhythmias.
Pro-oestrogenic; could increase thrombus risk
Clinical evidence of hypotensive effects
Possible antiplatelet effect (based on anecdotal evidence). May increase bleeding risk
Clinical evidence of hypotensive effects
Clinical research suggesting hypoglycaemic effects
Pro-oestrogenic; could increase thrombus risk
Possible antiplatelet effect (based on in vitro data). May increase bleeding risk
Hyperglycaemic effect
Potential hypotensive effects Sedative effect. Clinical research suggests hypoglycaemic effects
Has serotinergic properties; treat as an SSRI. Caution with pethidine use.
Immuno -modulating properties; Possible increased risk of infection and poor wound healing. Both
oestrogenic and anti-androgenic properties. Possible antiplatelet effect (based on anecdotal
evidence). May increase bleeding risk
Reputed action
CNS depressant, Clinical research suggests hypoglycaemic effects
Potentiates barbiturate sleeping time. Anticholinesterase action; bradycardia, hypotension,
bronchoconstriction
Clinical evidence of hypotensive effects
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 20 of 26
Appendix 2 : Guidelines on the use of Oral Contraceptives and Hormone Replacement Therapy in
the Peri-operative Period
Progesterone-only Preparations
There is no evidence of increased risk of venous thromboembolism in the peri-operative period and these
preparations should not be stopped.
Combined Oral Contraceptives (COC)

Minor surgery (excluding leg surgery)
Women should continue taking the COC.

Major Surgery or Leg Surgery
There is known to be a small absolute risk of post-operative venous thromboembolism in COC users
(estimated to be 0.96% for users compared with 0.5% for non-users).
Whenever possible the surgeon should discuss the possible risk with the patient at least six weeks before
elective surgery.
The risk of thromboembolism should be balanced against the possibility of unwanted pregnancy if the pill
were to be stopped without adequate alternative contraception
If the patient states that she wishes to continue the COC, she should then receive the recommended
thromboprophylaxis.
If the patient does want to stop the COC, she should do so at least four weeks before surgery. There is no
proven benefit in stopping nearer to surgery. The patient should be referred back to her GP or Family
Planning Clinic to arrange alternative contraception.
Whichever peri-operative approach is chosen, a careful record should be made in the case notes that
potential advantages and disadvantages have been discussed with the woman.
In any cases (trauma or elective) where the patient is admitted still taking the COC, it should be prescribed
on the drug chart and NOT be discontinued. The patient should then receive the recommended
thromboprophylaxis.
Hormone Replacement Therapy (HRT)
Taking HRT is likely to increase the risk of post-operative thromboembolism, but this additional risk has
not been well quantified.
In general, there appears to be no need to advise patients to discontinue HRT before surgery if there are
no predisposing factors for thromboembolism , e.g. personal or family history of DVT or PE, severe
varicose veins, obesity or prolonged bed-rest.
If there are predisposing risk factors, it may be prudent to review the need for HRT as the risks may
exceed the benefits. Any patient wishing to stop, should do so at least four weeks before surgery and be
referred back to her GP.
The possible increased risk should be explained to the patient and the decision documented.
Patients continuing with HRT should have their medication prescribed on the drug chart and receive the
recommended thromboprophylaxis. Such prophylaxis is unnecessary with minor surgery.
In any cases (trauma or elective) where the patient is admitted still taking HRT, it should be
prescribed on the drug chart and NOT be discontinued. The patient should then receive the
recommended thromboprophylaxis.
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 21 of 26
Appendix 3 :
Acute management of Parkinson’s Disease patients with compromised
swallow or nil by mouth
RISK OF DEATH IF MEDICATION IS OMITTED
If timely Parkinson’s medication is not given this can lead to patients being unable to swallow (risk of
aspiration), unable to speak, unable to move, increased risk of falls, increased care needs, pain and
distress. At the worst it could develop into neuroleptic malignant syndrome, Parkinson’s Hyperpyrexia,
Dopamine Agonist Withdrawl syndrome or even death.
Introduction
Parkinson’s disease is a progressive disabling neurological disorder, resulting from the degeneration of
dopamine producing neurones in the substantia nigra.
The cardinal signs being
1) Bradykinesia - slowness of movement
2) Rigidity - increased muscle tone, may be asymmetrical or limited to certain muscle groups
3) Tremor – 30% of patients have no evidence of tremor
Parkinson’s disease is predominantly a movement disorder, but which also is associated with many other
non-motor function such as anxiety disorders, depression, excessive daytime sleepiness, dementia,
apathy etc.
This document is a guide for those patients that are admitted to hospital and are either nil by mouth or
unable to swallow. It can be used in the first 48 hours; however advice should be taken from the patient’s
own specialist (Dr or Parkinsons Disease Nurse Specialist) as soon as possible.
On presentation to services
1. Check drug history – the following sources can be used:
 Family/ carer
 Medication brought in
 Consultant or Movement Disorder Nurse Specialist team letter in notes
 Residential/nursing home
 GP
 Community pharmacist
 Community nurse
2. Doses must be checked carefully.
3. Timings of medication ARE VERY IMPORTANT - Regimes are individual, it is therefore essential
to give at patient’s times not ward drug round times.
4. Obtain medication ASAP. This is classed as a critical medication and must be ordered as such.
a. Acute areas/wards hold a standard stock of commonly used Parkinson’s medications; these
include AMU and emergency drug cupboard. Also Ward 52 Rachel could you investigate
b. Patient’s own supply of medication.
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 22 of 26
5. DO NOT STOP PARKINSON’S MEDICATION!
6. If on Duodopa, Apomorphine or Rotigotine patch, continue as prescribed.
1. Unable to swallow (includes nil by mouth)
For patients who are unable to swallow or are nil by mouth, see appropriate section below:
Consider:
1) Speech and language therapist (S.A.L.T.) - a.s.a.p
2) Nasogastric tube - (consent)
2. Advice regarding Levodopa products
There is no conversion from Levodopa to a Dopamine Agonist. As a minimum a 2mg Rotigotine patch
should be used if no NG tube in place. A review should then be done by the Specialist team as soon
as possible.
Medication which may be given via N.G tube as follows:
Brand Name
Sinemet
Generic Name
Co-careldopa
Alternative
Madopar Dispersible
Madopar
Co-beneldopa
Madopar Dispersible
Stalevo
Levodopa/carbidopa/entacapone Madopar Dispersible
Dose
Convert ‘like to
like’ as a
minimum
3. Antiemetics
Use Domperidone; this should be by suppository 30 mg bd or liquid 10 - 20mg tds via N.G. tube given
prior to Parkinsons medication. This should be used for short term only, following MHRA
recommendations. An alternative would be Cyclizine or Ondansetron.
4. Medication which may be safely omitted until able to swallow

C.O.M.T. Inhibitors - Entacapone / Tolcapone

M.A.O.B. Inhibitors - Selegiline/ Rasagiline / Zelapar

Amantadine (Symmetrel)
5. Dopamine Agonist advice
Brand Name
Advice
Rotigotine patch
Continue
Apomorphine s/c
Continue. Use familiar pump if unsure of Apo-go pump. DO NOT STOP!!
(injection or infusion) (24hr helpline: 08448801327) contact Movement Disorder Nurse team
Pramipexole
Maintain same dose, crush tablets **
Pramipexole PR
Convert to standard dose Pramipexole TDS and crush as above
(slow release)
Ropinirole
Maintain same dose, crush tablets **
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 23 of 26
Ropinirole XL
(slow release)
Pergolide
Cabergoline
Bromocriptine
Convert to standard dose Ropinirole TDS and crush as above
Maintain same dose, crush tablets **
Maintain same dose, crush tablets **
Maintain same dose, crush tablets **
** Unlicensed use. Crushing of tablets should only be considered for short term use, i.e. first 48 hours of admission until the
patient can be reviewed by a specialist, for prolonged use or if crushing tablets blocks the N.G. tube see alternatives in this
pathway.
6. Switch guidelines Only to be used under instruction from Movement Disorder Team.
01325743000
Suggested conversions for oral dopamine agonist doses to equivalent patch treatment
Pramipexole*
88 mcgs BASE tds
(125 mcgs SALT tds)
Pramipexole PR*
(slow release)
260 mcgs BASE od
(375 mcgs SALT od)
180 mcgs BASE tds
(250mcgs SALT tds)
350 mcgs BASE tds
(500 mcgs SALT tds)
530 mcgs BASE tds
(750 mcgs SALT tds)
700 mcgs BASE tds
(1mg tds)
880mcg BASE tds
(1.25mg SALT tds)
520 mcgs BASE od
(750miCS SALT od)
1.05mg BASE od
(1.5mg SALT od)
1.57mg BASE od
(2.25mg SALT od)
2.1 mg BASE od
(3mg SALT od)
2.62mg BASE od
(3.75mg SALT od)
Ropinirole
Ropinirole XL
(slow release)
Rotigotine
Patch
Starter pack
2mg /24 hrs
1mg tds
4mg od
4mg/24 hrs
2mg tds
6mg od
6mg/24 hrs
3mg tds
8mg od
4mg tds
12mg od
8mg/24 hrs
10-12mg /24
hrs
14mg/24 hrs
6mg tds
16mg od
*Pramipexole doses are expressed as base (salt).
Less frequently used dopamine agonists. Now very rarely used but patient’s may still be admitted on
these drugs. Contact Movement Disorder team as above for advice.
Cabergoline
Pergolide
Change to Rotigotine Patch
0.5 mg od
125microgram tds
2mg od
1mg od
250microgram tds
4mg od
2mg od
500microgram tds
6mg od
3mg od
750microgram tds
8mg od
7. Apomorphine
Apomorphine is a potent D1 and D2 dopamine agonist. It can only be administered by intermittent
subcutaneous injections, or continuous subcutaneous infusion.
Patient already on apomorphine:
 Continue on same dose, use alternative pump if necessary
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 24 of 26

Patient, Carer or family are well trained in the use of an APO-GO pump and are a good resource,
if Movement disorder team are unavailable.

(24hr helpline: 08448801327) or contact Movement Disorder Nurse Specialist
Patient not already on apomorphine:
 Do not start without discussion with specialist consultant.

It is important to give Domperidone 30mg suppository bd (minimum 24 hours prior to
administering Apomorphine) and then continue, to avoid vomiting.

If patient on levodopa 400 mg daily or above or Duodopa has been discontinued then commence
Apomorphine 2mgs/hr over 12 hours (daytime).

If on an oral Dopamine Agonist and Levodopa, and have symptoms of rigidity and/or tremor
severe may need to consider increasing Apomorphine within first 12 hours to 3 mgs per hour over
12 hours (daytime).

For patients with overnight symptoms, bolus doses may be given as per the current daytime rate
via subcutaneous pen injector.
Always monitor Blood pressure regularly- clinical decision.
Change infusion line every 12 hours. Massage site prior insertion of needle and after removal. Use a
different insertion/injection site each time (see information pack).
Duodopa -continue as prescribed. For advice contact 24 hour helpline on 0800-458 4410
Movement Disorder Nurse Specialist team contact details:
Alison Rose: 01325743000, Mobile 07980729862,
Louise Cochrane: 01325743000, Mobile 07980726532,
Liz Taylor: 01325743000, Mobile 07967202353
References:
British National Formulary No: 62, 2011
Summary of Product Characteristics for individual products: www.medicines.org.uk
This document has been adapted by Alison Rose, Movement Disorder Nurse Specialist, in June 2012.
Acknowledgements
Many thanks to the below:
This document was originally produced by North West Parkinson’s Disease Nurse Specialist’s in
collaboration with pharmacists with a specialist interest in P.D. It was then adapted for use by Sue Lord,
Pharmacist, for Betsi Cadwaldr University Health Board. Date of production March 2011.
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 25 of 26
Appendix 4 : Summary of drugs requiring withdrawal prior to major surgery
This sheet is intended as a summary of the guidelines for the management of drug therapy in the
perioperative period. They relate to MAJOR surgery only. For further guidance please refer to the full
guidance or contact Pharmacy.
4-6 weeks pre-op
2 weeks pre-op
1 week pre-op
4 – 6 days pre-op
2 days pre-op
12 – 24 hrs pre-op
Day of op
Author
Care Group Approval
Trust Approval
Date of Approval
Date of Review
Protocol Number
Combined oral contraceptive
Hormone replacement therapy
SERMs, e.g. raloxifene
Tamoxifen / anastrazole if prescribed for primary prevention /
anovulatory infertility.
Continue in women with history of breast cancer.
High dose progestogens
Adalimumab
Infliximab
MAOIS depending on anaesthetic technique (except reversible
MAOIs, i.e. moclobemide). Refer to anaesthetist and discuss with
psychiatry if to be stopped.
ALL herbal preparations
Fish oil supplements
Glucosamine
Etanercept
Aspirin (only if high bleeding risk)
P2Y12 blockers (e.g. clopidogrel, ticagrelor). Check risk with
cardiologist.
Methotrexate. Check Consultant preference.
Oral anticoagulants, e.g. warfarin, dabigatran, rivaroxaban.
Refer to specific guidance.
Metformin prior to angiograms / angioplasty
Long-acting NSAIDs, e.g. piroxicam
Ephedra
Dipyridamole
Lithium (or continue with close monitoring)
Donepezil, rivastigmine, galantamine (inform anaesthetist)
Reversible MAOIs (moclobemide) depending on anaesthetic technique.
Drugs for erectile dysfunction
Clozapine (12hrs pre-op)
Theophyline (evening pre-op)
Short-acting NSAIDs, e.g. diclofenac, ibuprofen
(does not include COX 2 inhibitors , e.g.celecoxib)
Antispasmodics , e.g. mebeverine
Diuretics (ONLY if used for HYPERTENSION ALONE)
ACEI/A2RAs (ONLY if used for HYPERTENSION ALONE)
Sulfasalazine
Azathioprine
Methylphenidate
Bisphosphonates
COX 2 inhibitors , e.g.celecoxib
Oral hypoglycaemics stop once NBM
Orlistat once NBM
Created by Lynne Harris 2008. Updated by Andrew Parker, Lynsey Stephenson & Michelle Thornton
Review of existing guidance co-ordinated through email consultation
Clinical Standards & Therapeutics Committee
Page 26 of 26