Issues for surgery
For attention deficit hyperactivity disorder (ADHD) - risk of loss of symptom control if omitted.
Risk of serotonin syndrome if continued (see Interactions with common anaesthetic agents and Interactions with other common medicines used in the perioperative period).
Risk of perioperative hypertension if continued (see Further information).
Advice in the perioperative period
Elective surgery
Omit dose(s) on day of surgery - see Further information.
Ensure anaesthetist is aware patient is taking regular amfetamines.
Check heart rate and blood pressure pre-operatively – see Further information.
Emergency surgery
If patient has taken dose(s) on the day of surgery, inform anaesthetist – see Further information.
Post-operative advice
Restart post-operatively, when next dose due, once enteral intake resumes.
Monitor heart rate and blood pressure – see Further information.
Patients who have received Methylthioninium chloride (methylene blue)
Monitor for symptoms of CNS toxicity (see Interactions with common medicines used in the perioperative period and Further information).
Interactions with common anaesthetic agents
Inhalational anaesthetics
There is a risk of sudden blood pressure increase during surgery as both lisdexamfetamine and sevoflurane can cause hypertension. There is a recommendation that lisdexamfetamine use should be avoided for several days before surgery if sevoflurane use is necessary – see Further information.
Sympathomimetics
Lisdexamfetamine act as a noradrenaline reuptake inhibitor. Concomitant use of lisdexamfetamine with noradrenaline/norepinephrine and potentially other sympathomimetics may enhance the vasopressor effect of these medicines. Monitor blood pressure closely.
Opioids
CNS excitation (serotonin syndrome)
Serotonin syndrome has rarely occurred in association with use of amfetamines, when given in conjunction with other serotonergic drugs.
Some opioids act as weak serotonin reuptake inhibitors (SRIs) and can precipitate serotonin syndrome in conjunction with other serotonergic medication such as lisdexamfetamine. Symptoms of serotonin syndrome may occur if lisdexamfetamine is given concomitantly with:
- fentanyl
- methadone
- pentazocine
- pethidine
- tapentadol
- tramadol
Patients should be monitored closely, and the possibility of serotonin toxicity considered if patients experience altered mental state, autonomic dysfunction, or neuromuscular adverse effects with concomitant treatment.
Potentiation of analgesic effect
Lisdexamfetamine may potentiate the analgesic effects of some opioids. This increased analgesic effect may be beneficial perioperatively, although bear in mind lower than expected doses of opioids may be necessary.
QT-interval prolongation
Lisdexamfetamine has been shown to prolong the QT-interval in some patients. The manufacturer advises caution when administering lisdexamfetamine concurrently with drugs that prolong the QT-interval (e.g., desflurane, isoflurane, sevoflurane and possibly thiopental).
Interactions with other common medicines used in the perioperative period
CNS excitation (serotonin syndrome)
Opioids
See Interactions with common anaesthetic agents above.
Methylthioninium chloride (methylene blue)
Serotonergic symptoms may be possible in patients given methylthioninium chloride and lisdexamfetamine concurrently (see Further information).
Other medicines
There is an increased risk of developing serotonin syndrome when lisdexamfetamine is used concurrently with the following:
- granisetron
- ondansetron
- linezolid
Monitor patient for symptoms of serotonin syndrome such as fever, tremors, diarrhoea, and agitation. Concurrent treatment should be stopped if serotonin syndrome occurs.
Antiemetics
Prochlorperazine
The effects of lisdexamfetamine are opposed by some phenothiazines, and this reaction may occur with prochlorperazine if it is a class effect. Lisdexamfetamine is predicted to decrease the effects of prochlorperazine. If concurrent use is undertaken monitor for efficacy.
Haloperidol
Haloperidol inhibits the central stimulant effect of amfetamines; hence amfetamines might be less effective in those taking haloperidol.
QT-interval prolongation
Lisdexamfetamine has been shown to prolong the QT-interval in some patients. The manufacturer advises caution when administering lisdexamfetamine concurrently with drugs that prolong the QT-interval (e.g., domperidone, clarithromycin, ondansetron).
Further information
Sevoflurane and amfetamines
It is recommended that lisdexamfetamine use should be avoided several days prior to anaesthesia with sevoflurane due to the risk of pre-operative hypertensive crisis. If there is a clinical need for a patient to receive sevoflurane in preference to alternative anaesthesia, there needs to be clinical consideration of the risks associated with discontinuation of lisdexamfetamine therapy. Appropriate planning for elective surgery in conjunction with the patient, the specialist and anaesthetist should occur. There are no clear recommendations on the number of days lisdexamfetamine should be stopped prior to sevoflurane use and the decision of when to stop should form part of the planning discussions. Patients undergoing emergency surgery must not be given sevoflurane anaesthesia.
Hypertension
Stimulant medicines cause a modest increase in average blood pressure (about 2 – 4 mmHg) and average heart rate (about 3 – 6 bpm), and individuals may have larger increases. Caution is therefore required in patients administered any medication that is also likely to increase heart rate or blood pressure during the perioperative period.
Methylthioninium chloride (methylene blue)
Off label use of intravenous methylthioninium chloride a visualising agent, i.e., for parathyroid and thyroid surgery, should be carefully evaluated in view of the potential for CNS toxicity. If intravenous methylthioninium chloride cannot be avoided, the lowest possible dose should be used and the patient observed closely for CNS effects for up to 4 hours after administration.
References
Joint Formulary Committee. British National Formulary [online] London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 14th April 2023].
Summary of Product Characteristics – Elvanse® (lisdexamfetamine) 20mg Hard Capsules. Takeda UK Ltd. Accessed via www.medicines.org.uk 14/04/2023 [date of revision of the text November 2022].
Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicines.complete.com [Accessed on 22nd March 2023]
Summary of Product Characteristics – Sevoflurane 100% Inhalation Vapour, liquid. Piramal Critical Care Ltd. Accessed via www.medicines.org.uk 14/07/2023 [date of revision of the text November 2021]
MHRA Drug Safety Update. Methylthioninium chloride (methylene blue): update on central nervous system (CNS) toxicity. Volume 2, Issue 9, April 2009. Accessed via www.gov.uk 16/06/2023