Alpha2-Adrenoceptor Agonists


Apraclonidine (Iopidine®), Brimonidine (Alphagan®)

  Issues for Surgery


For primary open-angle glaucoma (topical) – increased risk of deterioration in eyesight if omitted for a prolonged period.


  Advice in the Perioperative period


Elective and Emergency Surgery

Continue including the following combination products (unless the patient is undergoing ophthalmology surgery and the Ophthalmologist requests for them to be withheld): -

Confirm with patient if drops are prescribed for left eye, right eye or both eyes. Encourage correct application technique to reduce systemic absorption (see Further Information)


Post-operative Advice
Restart post-operatively when next dose is due (unless the patient has undergone ophthalmology surgery and the Ophthalmologist requests for them to be withheld).


   Interaction(s) with Common Anaesthetic Agents



Systemic absorption is likely to be low after ocular administration of apraclonidine or brimonidine, however, given the actions of oral clonidine the possibility of CNS depression, bradycardia or hypotension cannot be excluded 1, 2, 3, 4 (see Centrally Acting Antihypertensives monograph). There is also a theoretical risk that systemic sympathomimetics may reduce the efficacy of alpha2-adrenoceptor agonists 4

For combination products containing beta-blockers
Systemic absorption can follow topical application of beta-blockers to the eyes 3 – the advice and cautions as listed for systemic beta-blockers should be considered (see Beta-adrenoceptor Blockers (Beta-Blockers) (Systemic and Topical) monograph).


  Interaction(s) with other Common Medicines used in the Perioperative Period



Systemic absorption is likely to be low after ocular administration of apraclonidine or brimonidine, however, given the actions of oral clonidine the possibility of CNS depression or hypotension cannot be excluded 1, 2, 3, 4 (see Centrally Acting Antihypertensives monograph).

Non-Steroidal Anti-inflammatory Drugs (NSAIDs)
The intraocular pressure lowering effect of brimonidine eye drops might be reduced by oral indomethacin. Other NSAIDs might, to a lesser or greater extent, interact similarly 4. Whilst short term use post-operatively should not pose a problem, if long term use is necessary discuss with an Ophthalmologist. 

For combination products containing beta-blockers
Systemic absorption can follow topical application of beta-blockers to the eyes 3  – the advice and cautions as listed for systemic beta-blockers should be considered (see Beta-adrenoceptor Blockers (Beta-Blockers) (Systemic and Topical) monograph).


  Further Information



Systemic Absorption
Nasolacrimal occlusion or gently closing the eyelid is recommended following ocular administration of any medication to reduce systemic absorption 1, 2.


  References


  1. Summary of Product Characteristics – IOPIDINE® (apraclonidine) 5mg/ml Eye Drops, Solution. Novartis Pharmaceuticals UK Ltd. Accessed via www.medicines.org.uk 05/02/2021 [date of revision of the text January 2021]
  2. Summary of Product Characteristics – Alphagan® (brimonidine). Allergan Ltd. Accessed via www.medicines.org.uk05/02/2021 [date of revision of the text September 2020]
  3. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 5th February 2021]
  4. Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 5th February 2021]