Issues for surgery
Risk of increased urinary frequency, urgency and urge incontinence if omitted.
Risk of QT-interval prolongation if continued (see Interactions with common anaesthetic agents and Interactions with other common medicines used in the perioperative period).
Advice in the perioperative period
Elective and emergency surgery
Continue.
Post-operative advice
Restart post-operatively when next dose due.
Review if patient develops reduced gastrointestinal motility (e.g. ileus) post-operatively.
Review appropriateness of continuing treatment if patient develops post-operative delirium.
Patients undergoing overactive bladder surgery
Review the need for tolterodine post-operatively.
Interactions with common anaesthetic agents
Antimuscarinic action
Antimuscarinic action may be additive with agents that also have antimuscarinic effects such as atropine and glycopyrronium.
QT-interval prolongation
Tolterodine prolongs the QT-interval. Co-administration with other medicines known to prolong the QT-interval must be based on careful assessment of the potential risks and benefits for each patient.
Anaesthetic agents that may be used in the perioperative period that are known to, or predicted to, prolong the QT-interval include:
- desflurane, isoflurane, sevoflurane – avoid for tolterodine; for solifenacin*
- thiopental (theoretical)**
*monitor ECG if concurrent use unavoidable; if risk factors for QT-prolongation are also present (increasing age, female sex, cardiac disease, and some metabolic disturbances e.g. hypokalaemia) use greater caution
**monitor ECG with concurrent use if risk factors for QT-prolongation are also present (increasing age, female sex, cardiac disease, and some metabolic disturbances e.g. hypokalaemia)
Whilst QT-interval prolongation has not been observed in patients taking fesoterodine the manufacturers advise caution with concomitant administration of medicines known to prolong the QT-interval.
Interactions with other common medicines used in the perioperative period
Prokinetics
Due to the effect of antimuscarinics on gastro-intestinal motility the effectiveness of prokinetic agents e.g. metoclopramide may be reduced.
Antimuscarinic action
Also see QT-interval prolongation below.
Antimuscarinic action may be additive with antiemetics that also have antimuscarinic effects such as cyclizine, haloperidol, levomepromazine or prochlorperazine.
Nefopam
Antimuscarinic action may be additive with nefopam which also has antimuscarinic effects.
Antimicrobials
Also see QT-interval prolongation below.
Clarithromycin (and to a lesser extent erythromycin) is predicted to increase the exposure of tolterodine.
Whilst single surgical prophylactic doses should not pose a problem, consult product literature if continued post-operative treatment necessary as depending on the antimuscarinic concomitant use may be contraindicated or require dose reduction or monitoring for adverse effects.
Hypokalaemia
Dexamethasone and hydrocortisone may cause hypokalaemia (potentially increasing the risk of torsades de pointes with tolterodine) – monitor potassium levels. If hypokalaemia occurs, corrective action should be taken and QT-interval monitored.
QT-interval prolongation
Tolterodine prolongs the QT-interval and post-marketing. Co-administration of tolterodine with medicines known to prolong the QT-interval must be based on a careful assessment of the potential risks and benefits for each patient since the risk of torsade de pointes may increase.
Medicines that may be used in the perioperative period that are known to prolong the QT-interval include:
- ciprofloxacin*
- clarithromycin – avoid with tolterodine, for solifenacin see Antimicrobials above
- domperidone – avoid
- droperidol – avoid with tolterodine, for solifenacin*
- erythromycin (particularly intravenous) – not recommended with tolterodine, for solifenacin see Antimicrobials above
- granisetron – avoid with tolterodine if risk factors, for solifenacin*
- haloperidol – avoid with tolterodine, for solifenacin if concurrent use unavoidable monitor ECG for all patients (risk further increased if risk factors present)
- loperamide*
- ondansetron – avoid with tolterodine, for solifenacin*
- prochlorperazine (theoretical risk)*
*monitor ECG with concurrent use if risk factors for QT-interval prolongation also present (increasing age, female sex, cardiac disease, and some metabolic disturbances e.g. hypokalaemia)
Further information
Intraoperative Floppy Iris Syndrome (IFIS)
For combination products containing tamsulosin see Alpha-adrenoceptor blockers drug records.
References
Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://about.medicinescomplete.com [Accessed on 3rd February 2021]
Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://about.medicinescomplete.com [Accessed on 3rd February 2021]
Summary of Product Characteristics – Detrusitol® (tolterodine)XL 4mg. Upjohn UK Limited. Accessed via www.medicines.org.uk 06/11/2020 [date of revision of the text September 2020]text April 2020]