Can a patient awaiting loop ileostomy take their nighttime dose of pregabalin (300mg) and methadone (2.5mg)?

Preoperative Administration of Pregabalin and Methadone Before Loop Ileostomy

Yes, both pregabalin 300mg and methadone 2.5mg should be continued on the night before loop ileostomy surgery. 1

Primary Recommendation

Patients on chronic opioid therapy, including methadone, should continue their regular doses on the morning of surgery and the night before. 1 The 2021 Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement explicitly recommends continuing opioid agonists, including methadone, perioperatively. 1

Specific Medication Considerations

Methadone (2.5mg)

• Continue the nighttime dose without modification. 1 This is a very low dose compared to typical maintenance dosing (80-120 mg/day for addiction treatment or 60-100 mg/day for pain management). 2, 3
• Abrupt discontinuation risks precipitating opioid withdrawal symptoms, which would complicate perioperative management. 4
• Patients on chronic methadone will require higher than usual opioid dosing postoperatively due to opioid tolerance. 1
• The long half-life of methadone (8-59 hours) means missing even one dose can lead to subtherapeutic levels during the critical perioperative period. 4

Pregabalin (300mg)

• Continue the nighttime dose. 5 While not explicitly addressed in perioperative guidelines for continuation, pregabalin has a short half-life of approximately 6 hours and is eliminated primarily unchanged in urine. 5
• Abrupt discontinuation of pregabalin can cause withdrawal symptoms including anxiety, insomnia, and increased pain sensitivity—all undesirable before surgery. 5
• Pregabalin can be taken with or without food, making administration straightforward even with NPO restrictions. 5

Critical Safety Considerations

QTc Prolongation Risk

• Obtain or review a recent ECG if not already done. 1, 4 Methadone can prolong the QTc interval, though at 2.5mg the risk is minimal compared to higher maintenance doses (≥120 mg/day). 1, 6
• The combination of methadone with other QTc-prolonging medications requires caution, but this low dose presents minimal risk. 4

Respiratory Depression

• The combination of pregabalin and methadone theoretically increases respiratory depression risk. 6 However, at these doses in a patient already tolerant to both medications, the risk is negligible. 1
• The greater risk is inadequate postoperative pain control if these medications are discontinued, as the patient will have established tolerance. 1

Perioperative Management Algorithm

Night Before Surgery:

• Administer pregabalin 300mg at usual time 5
• Administer methadone 2.5mg at usual time 1, 4

Morning of Surgery:

• Continue both medications with a small sip of water per anesthesia protocol 1
• Inform anesthesia team of chronic opioid and pregabalin use 1

Postoperative Planning:

• Anticipate need for higher opioid doses than standard protocols due to tolerance 1
• Resume regular pregabalin and methadone schedule as soon as oral intake permitted 1
• Consider multimodal analgesia with non-opioid adjuncts 1

Common Pitfalls to Avoid

• Do not hold these medications "to be safe"—this creates greater perioperative risk through withdrawal and inadequate pain control. 1
• Do not assume standard postoperative opioid doses will be adequate—patients on chronic opioids require individualized, often higher dosing. 1
• Do not confuse this low-dose methadone (2.5mg) with high-dose maintenance therapy—the safety concerns about QTc prolongation and drug interactions are dose-dependent. 1, 6, 4
• Avoid abrupt discontinuation of pregabalin, which can worsen perioperative anxiety and pain. 5

Documentation Recommendations

• Document continuation of home medications in preoperative orders 1
• Alert surgical and anesthesia teams to chronic opioid use for appropriate perioperative pain planning 1
• Ensure postoperative orders include resumption of home pregabalin and methadone regimen 1