Antimuscarinics (Inhaled and Nebulised)

Aclidinium (Eklira®), Glycopyrronium (Seebri®), Ipratropium (Atrovent®, Inhalvent®, Ipravent®), Tiotropium (Acopair®, Braltus®, Spiriva®, Tiogiva®), Umeclidinium (Incruse®)

Combination products include Anoro®, Bevespi®, Combiprasal®, Combivent®, Duaklir®, Enerzair®, Ipramol®, Spiolto®, Trelegy®, Trimbow®, Ultibro®, Yanimo® but this list is not intended to be exhaustive

  Issues for Surgery

For asthma and chronic obstructive pulmonary disease (COPD) – increased risk of exacerbation if omitted.

  Advice in the Perioperative period

Elective and Emergency Surgery
Continue (including combination products). 

There are numerous inhaled preparations which contain antimuscarinics, either as single agents or in combination products with corticosteroids and / or beta agonists – all of these can be continued pre-operatively.  Check active ingredients of currently available preparations in British National Formulary and see also Corticosteroids (Inhaled, Nebulised and Intranasal) monograph and Long-acting Beta₂ Adrenoceptor Agonists monograph and Short-acting Beta₂ Adrenoceptor Agonists monograph if applicable.

Advise patients who are prescribed regular inhaled antimuscarinics but do not usually take them regularly to do so pre-operatively to optimise breathing prior to anaesthesia.

Confirm the inhaler brand, device, and strength with the patient.

Post-operative Advice
Restart post-operatively as soon as next dose is due.

If patients are unable to resume their usual inhaled medication post-operatively consider nebulised ipratropium if clinically appropriate.

  Interaction(s) with Common Anaesthetic Agents

Antimuscarinic action
Antimuscarinic action may be additive with agents that also have antimuscarinic effects such as atropine and glycopyrronium^{1, 2}.  Concomitant administration of inhaled antimuscarinics with other medication known to have antimuscarinic effects has not been studied and is therefore not recommended by the manufacturers^{3, 4, 5, 6, 7}; however, in practice monitor patient for adverse effects.

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

Antimuscarinic action
Antiemetics
Antimuscarinic action may be additive with antiemetics that also have antimuscarinic effects such as cyclizine, haloperidol, levomepromazine or prochlorperazine^{1, 2}.

Nefopam
Antimuscarinic action may be additive with nefopam which also has antimuscarinic effects^{1, 2}.

Concomitant administration of inhaled antimuscarinics with other medication known to have antimuscarinic effects has not been studied and is therefore not recommended by the manufacturers^{3, 4, 5, 6, 7}; however, in practice monitor patient for adverse effects.

  Further Information

None relevant.

  References

1. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://about.medicinescomplete.com [Accessed on 4^th February 2021]
2. Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://about.medicinescomplete.com [Accessed on 4^th February 2021]
3. Summary of Product Characteristics – Eklira® (aclidinium) Genuair 322 micrograms inhalation powder. AstraZeneca UK Limited. Accessed via www.medicines.org.uk 04/02/2021 [date of revision of the text November 2019]
4. Summary of Product Characteristics – Atrovent® (ipratropium) Inhaler CFC-Free.  Boehringer Ingelheim Limited. Accessed via www.medicines.org.uk 04/02/2021 [date of revision of the text February 2018]
5. Summary of Product Characteristics – Seebri® (glycopyrronium) Breezhaler 44 micrograms inhalation powder, hard capsules. Novartis Pharmaceuticals UK Ltd. Accessed via www.medicines.org.uk 04/02/2021 [date of revision of the text December 2019]
6. Summary of Product Characteristics – Spiriva® 18 microgram inhalation powder, hard capsule (aclidinium) Genuair 322 micrograms inhalation powder. Boehringer Ingelheim Limited. Accessed via www.medicines.org.uk 04/02/2021 [date of revision of the text January 2019]
7. Summary of Product Characteristics – Incruse® (umeclidinium) Ellipta 55 micrograms inhalation powder, pre-dispensed. GlaxoSmithKline UK. Accessed via www.medicines.org.uk 04/02/2021 [date of revision of the text September 2019]