Will buprenorphine (Subutex) affect anesthesia for an arterogram?

Management of Buprenorphine During Arterogram Procedures

Buprenorphine (Subutex) should be continued during arterogram procedures, as the medication can be safely maintained while anesthesia is administered, with appropriate adjustments by the anesthesia team. 1

Understanding Buprenorphine's Impact on Anesthesia

Buprenorphine is a partial mu-opioid receptor agonist that has unique pharmacological properties that require consideration during procedures requiring anesthesia:

• Buprenorphine has a high binding affinity for mu-opioid receptors and a long half-life, which initially raised concerns about potential interference with anesthetic agents 2
• Despite these concerns, current evidence supports continuing buprenorphine during procedures rather than discontinuing it 1
• The Society for Perioperative Assessment and Quality Improvement (SPAQI) recommends individualizing the approach based on the patient's daily dose, indication for treatment, and expected pain level 1

Recommendations for Arterogram Procedures

For patients undergoing arterograms specifically:

• Continue buprenorphine at the preoperative dose - this is particularly important for patients being treated for opioid use disorder to prevent relapse risk 1
• Inform the anesthesiologist about the patient's buprenorphine use - this allows for appropriate anesthetic planning and dosing adjustments 1
• Anticipate that full mu-opioid agonists can still be effective when used alongside buprenorphine, though potentially at higher doses 1, 3

Anesthetic Considerations

The anesthesia team should be aware of several key factors:

• Buprenorphine does not block the action of full mu-opioid agonists at clinically relevant doses, but rather can act synergistically 1
• For arterograms specifically, which typically involve moderate sedation rather than general anesthesia, buprenorphine's presence should not significantly impair the procedure 3
• Multiple drug interactions are possible, including potential QT-interval prolongation, so the anesthesiologist should be informed of all medications 1

Special Considerations

• Dose-dependent effects: If the patient is on a higher dose of buprenorphine (>12 mg daily), some practitioners may consider tapering to 12 mg daily over 2-3 days before elective procedures, though recent guidelines increasingly support maintaining the current dose 1
• Multimodal analgesia: The anesthesiologist may incorporate non-opioid adjuncts (NSAIDs, acetaminophen, local anesthetics) to optimize pain control during and after the procedure 3
• Avoid discontinuation: Stopping buprenorphine before procedures is no longer recommended as it can lead to withdrawal, increased pain sensitivity, and risk of relapse in patients with opioid use disorder 1

Common Pitfalls to Avoid

• Discontinuing buprenorphine unnecessarily: This outdated practice can lead to withdrawal symptoms and increased relapse risk 1
• Assuming opioid analgesia won't work: Full mu-opioid agonists can still provide effective analgesia in patients on buprenorphine 1
• Failing to communicate with the anesthesia team: The anesthesiologist needs to know about buprenorphine use to plan appropriate sedation strategies 1

In conclusion, for a patient starting buprenorphine who needs an arterogram, the medication should be continued with appropriate communication to the anesthesia team to ensure optimal procedural outcomes and patient safety.