Should desvenlafaxine (serotonin-norepinephrine reuptake inhibitor) be continued in the preoperative (pre-op) period?

Perioperative Management of Desvenlafaxine

Desvenlafaxine should be continued during the preoperative period to prevent withdrawal symptoms and maintain patient stability.

Rationale for Continuing Desvenlafaxine

• Desvenlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI) used for treating major depressive disorder and other conditions 1
• Discontinuation of antidepressants preoperatively has been associated with:
  • Deterioration of depressive symptoms (20% vs 5% when continued) 2
  • Increased incidence of delirium or confusion (30% vs 13% when continued) 2
  • Withdrawal symptoms that typically begin within days of discontinuation 3, 4

Withdrawal Considerations

• Abrupt discontinuation of desvenlafaxine can lead to significant withdrawal symptoms including:
  • Dizziness, nausea, headache, irritability, diarrhea, anxiety, abnormal dreams, fatigue, and hyperhidrosis 4
  • Symptoms can occur even with gradual tapering 3
  • Discontinuation symptoms are dose-dependent, with higher doses (200-400mg) showing more significant withdrawal effects 4

Clinical Practice Guidelines

• Current perioperative medication management guidelines support continuing antidepressants through the perioperative period 5
• The Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement specifically recommends continuing buprenorphine (another medication affecting neurotransmitters) perioperatively 6
• The Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory emphasizes that medications with withdrawal potential should be continued perioperatively 6

Management Algorithm

1. Preoperative Period:

   • Continue desvenlafaxine at the patient's regular dose through the day of surgery 2
   • Ensure the anesthesiologist is aware of the patient's desvenlafaxine use 5
   • If the patient cannot take oral medications temporarily, be aware that missing even a few doses may lead to withdrawal symptoms 3, 4

2. Intraoperative Considerations:

   • No specific dose adjustments are needed for anesthesia when continuing desvenlafaxine 2
   • Unlike sympathomimetic medications (e.g., phentermine) that require discontinuation before surgery, desvenlafaxine does not pose significant cardiovascular risks during anesthesia 7, 2

3. Postoperative Period:

   • Resume the patient's regular desvenlafaxine dosing as soon as oral intake is possible 5
   • Monitor for signs of serotonin syndrome if other serotonergic medications are used postoperatively 6
   • Be vigilant for potential withdrawal symptoms if doses are missed 4

Common Pitfalls and Caveats

• Avoid discontinuation before surgery: Unlike some medications that require preoperative discontinuation, stopping desvenlafaxine can lead to withdrawal and psychiatric decompensation 2, 3
• Distinguish from medications requiring discontinuation: Unlike sympathomimetics (e.g., phentermine) or medications affecting platelet function, desvenlafaxine does not need to be stopped 7
• Consider alternative administration routes: If the patient cannot take oral medications postoperatively for an extended period, consult psychiatry for alternative management strategies 5
• Monitor for drug interactions: Be aware of potential interactions with other perioperative medications, particularly those with serotonergic effects 6