Issues for surgery
Risk of withdrawal if omitted (see Further information).
Risk of relapse of schizophrenia or bipolar disorder if omitted.
Advice in the perioperative period
Elective and emergency surgery
Continue.
Post-operative advice
If a long Nil by Mouth (NBM) period is anticipated, or if there are concerns regarding enteral absorption, advice on alternative preparations/routes should be sought from a psychiatrist.
Interactions wicommon anaesthetic agents
Central Nervous System (CNS) depression
Also see Interactions with other common medicines used in the perioperative period.
Cariprazine has CNS depressant effects which may be additive with other medicines that also have CNS depressant effects such as:
- benzodiazepines
- inhalational anaesthetics and intravenous anaesthetics
- local anaesthetics
- opioids
Consult British National Formulary for available drugs in each class.
Hypotension
With the exception of amisulpride, atypical antipsychotics can increase the risk of hypotension when used concomitantly with inhalational and intravenous anaesthetics.
Interactions with other common medicines used in the perioperative period
CNS Depression
Also see Interactions with common anaesthetic agents for information on opioids.
Atypical antipsychotics have CNS depressant effects which may be additive with antiemetics that also have CNS depressant effects such as cyclizine, droperidol and prochlorperazine.
Hypotension
With the exception of amisulpride, atypical antipsychotics can increase the risk of hypotension when used concomitantly with droperidol and prochlorperazine.
Antimicrobials
Macrolides
Clarithromycin is predicted to increase the exposure to cariprazine through inhibition of CYP3A4.
Myelosuppression
Concomitant use of atypical antipsychotics with the following can increase the risk of myelosuppression:
- co-trimoxazole
- linezolid
- trimethoprim
Whilst single surgical prophylactic doses should not pose a problem, monitor for side effects and consider reducing atypical antipsychotic dose if a prolonged course of clarithromycin or ciprofloxacin is required and monitor full blood count if a prolonged course of myelosuppressive medication is required.
Further information
Withdrawal
Abrupt withdrawal of cariprazine may result in symptoms including sweating, insomnia, tremor, anxiety, nausea and vomiting.
Venous thromboembolism (VTE)
Cases of VTE have been reported with antipsychotic drugs, although a causal relationship has not been established. Patients with schizophrenia often have acquired risk factors for VTE; identify any risk factors and consider if thromboprophylaxis is indicated post-operatively.
References
Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 20th August 2019]
Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 20th August 2019]
Summary of Product Characteristics – Sycrest® (cariprazine hydrochloride) 1.5mg hard capsules. Lundbeck Limited. Accessed via www.medicines.org.uk 20/08/2019 [date of revision of the text February 2018]