Issues for surgery
For suppression of transplant rejection – risk of rejection if omitted.
For rheumatology, dermatology and inflammatory bowel disease (IBD) conditions – risk of perioperative flare in disease activity if omitted (see Ciclosporin (Rheumatology, Dermatology and Gastroenterology) drug monograph).
Risk of post-operative infection if continued (see Further information).
Advice in the perioperative period
Elective surgery
Continue – the patient’s relevant specialist should be involved in the planning for surgery.
Emergency surgery
Continue – inform the patient’s relevant specialist at the earliest opportunity.
Post-operative advice
Restart treatment in the immediate post-operative period when next dose due. If the patient cannot take their usual oral medication post-operatively, their relevant specialist must be consulted for advice on an alternative medication, dose, route and frequency.
Monitor for signs of infection.
Monitor renal function and electrolytes. If renal function deteriorates post-operatively, the patient’s specialist should be consulted.
Due to the nature of these agents and the potential interactions that can occur, consult product literature prior to starting any medicines in the post-operative period.
Interactions with common anaesthetic agents
See Ciclosporin (Rheumatology, Dermatology and Gastroenterology) drug monograph
Interactions with other common medicines used in the perioperative period
See Ciclosporin (Rheumatology, Dermatology and Gastroenterology) drug monograph
Non-steroidal anti-inflammatory drugs (NSAIDs)
NSAIDs should be avoided due to the risk of adverse interactions (including nephrotoxicity).
Further information
Infection risk
Patients treated with immunosuppressants are at increased risk of opportunistic infections, fatal infections and sepsis. Patients should be monitored for neutropenia. Patients may not present with the typical signs and symptoms of infections (i.e. fever, leucocytosis). Microbiology advice may need to be sought when infections develop.
Plasma level monitoring
Plasma levels of ciclosporin must be kept within the indicated therapeutic range. The perioperative fluctuation of the plasma level of these two drugs should be strictly monitored. There is significant reduction of drug blood level by dilution with volume infusion or cardiopulmonary bypass in cardiac surgery.
References
Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 12th March 2019]
Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 7th April 2019]
Tacrolimus. In: Brayfield A (Ed), Martindale: The Complete Drug Reference. London: The Royal Pharmaceutical Society of Great Britain. http://www.medicinescomplete.com [Accessed 30th March 2019]
Brusich KT, Acan I. Anesthetic Considerations in Transplant Recipients for Nontransplant Surgery. Organ Donation and Transplantation – Current Status and Future Challenges. 2018. Accessed via www.intechopen.com 08/08/19