Issues for surgery
Potential deterioration in cognitive function if omitted.
Interaction with neuromuscular blocking drugs (NMBDs) if continued (see Interactions with common anaesthetic agents).
Advice in the perioperative period
Elective surgery
Stop 24 hours before operation.
Emergency surgery
If possible, delay surgery by 24 hours so that elective surgery advice can be followed. If delaying surgery is not possible, ideally avoid NMBDs.
If NMBDs are required – monitor blockade.
Consider use of rocuronium / sugammadex.
Consider use of remifentanil infusion.
Post-operative advice
Restart as soon as possible post-operatively.
If recovering from gastrointestinal or bladder surgery seek specialist advice before restarting (see Further information).
Interactions with common anaesthetic agents
Neuromuscular blocking drugs (NMBDs)
Non-depolarising NMBDs
Galantamine and rivastigmine are expected to antagonise the effect of non-depolarising NMBDs; larger doses may be required to achieve satisfactory paralysis. Neostigmine may be ineffective as a reversal agent due to the pre-existing level of cholinesterase inhibition.
Suxamethonium
Galantamine and rivastigmine are expected to prolong the effects of suxamethonium through their inhibition of acetylcholine metabolism.
Bradycardia
Galantamine and rivastigmine can increase the risk of bradycardia when used concomitantly with the following:
- alfentanil, fentanyl or remifentanil
- neostigmine
- propofol
- suxamethonium (see also Neuromuscular blocking drugs above).
Interactions with other common medicines used in the perioperative period
None.
Further information
Temporary discontinuation
The manufacturers of galantamine advise there is no rebound effect after abrupt discontinuation of treatment in preparation of surgery. The manufacturers of rivastigmine also advise that temporary discontinuation before surgery can be considered.
Gastrointestinal or bladder surgery
The manufacturer advises that due to its cholinergic action galantamine is not recommended in patients with gastrointestinal obstruction or urinary outflow obstruction or in patients recovering from gastrointestinal or bladder surgery as it may exacerbate or induce this obstruction. The manufacturer is not able to provide any recommendations on when galantamine can safely be restarted in this situation; seek advice from patient’s specialist and monitor patient closely for obstruction. Rivastigmine is also cautioned in urinary obstruction although no specific recommendations are made with respect to gastrointestinal or bladder surgery.
Delirium
Patients with dementia are at increased risk of developing post-operative delirium. Avoiding medications with anticholinergic side-effects e.g. cyclizine can minimise this risk.
References
Alcorn, S and Foo, I. Perioperative management of patients with dementia. BJA Education. 2017; 17(3):94-98
Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 5th June 2019]
Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 5th June 2019]
Summary of Product Characteristics – Exelon®(rivastigmine) transdermal patch. Novartis Pharmaceuticals UK Limited. Accessed via www.medicines.org.uk 05/06/2019 [date of revision of the text April 2018]
Summary of Product Characteristics – Nimvastid® (rivastigmine) hard capsules. Consilient Health Ltd. Accessed via www.medicines.org.uk 05/06/2019 [date of revision of the text December 2015]
Summary of Product Characteristics – Reminyl X® (galantamine) prolonged release capsules. Shire Pharmaceuticals Limited. Accessed via www.medicines.org.uk 05/06/2019 [date of revision of the text July 2017]
Shire Pharmaceuticals Limited. Personal communication with Shire Medical Information. 14/06/2019.