Centrally acting anticholinesterases


Galantamine, Rivastigmine

 [For donepezil see separate monograph]


  Issues for Surgery


Potential deterioration in cognitive function if omitted.

Interaction with neuromuscular blocking drugs (NMBDs) if continued (see Interaction(s) with Common Anaesthetic Agents).


  Advice in the Perioperative period


Elective surgery

Stop 24 hours before operation1.

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 / sugammadex1
  • Consider use of remifentanil infusion

Post-operative advice

Restart as soon as possible post-operatively1.

If recovering from gastrointestinal or bladder surgery seek specialist advice before restarting (see Further Information).


  Interaction(s) 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 inhibition1, 2, 3.

Suxamethonium
Galantamine and rivastigmine are expected to prolong the effects of suxamethonium through their inhibition of acetylcholine metabolism1, 2, 3, 4, 5, 6.

Bradycardia

Galantamine and rivastigmine can increase the risk of bradycardia when used concomitantly with the following2: -

  • alfentanil, fentanyl or remifentanil
  • cisatracurium
  • neostigmine


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


None2, 3, 4, 5, 6.


  Further Information


Temporary discontinuation

The manufacturers of galantamine advise there is no rebound effect after abrupt discontinuation of treatment in preparation of surgery6. The manufacturers of rivastigmine also advise that temporary discontinuation before surgery can be considered4, 5.

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 obstruction2, 6, 7. The manufacturer is not able to provide any recommendations on when galantamine can safely be restarted in this situation7; 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 surgery4, 5.

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 risk1.


  References


  1. Alcorn, S and Foo, I. Perioperative management of patients with dementia. BJA Education. 2017; 17(3):94-98
  2. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 5th June 2019]
  3. Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 5th June 2019]
  4. 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]
  5. 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]
  6. 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]
  7. Shire Pharmaceuticals Limited. Personal communication with Shire Medical Information. 14/06/2019.