Flupenthixol and Elective Surgery: No Routine Discontinuation Required
Flupenthixol (a typical antipsychotic, NOT a selective serotonin reuptake inhibitor) does not require routine discontinuation before elective surgery, as there are no established guidelines recommending its perioperative cessation. The question contains a critical error in drug classification—flupenthixol is a thioxanthene antipsychotic, not an SSRI.
Critical Clarification on Drug Classification
- Flupenthixol is a typical (first-generation) antipsychotic belonging to the thioxanthene class, with dopamine D2 receptor antagonism as its primary mechanism of action
- The question incorrectly identifies it as an SSRI; this misclassification would lead to inappropriate perioperative management
- Unlike SSRIs, flupenthixol does not significantly affect platelet serotonin reuptake or increase surgical bleeding risk
Evidence-Based Perioperative Management
No Guideline Support for Discontinuation
- None of the major perioperative guidelines (American College of Chest Physicians, ACC/AHA, or other surgical societies) recommend discontinuing typical antipsychotics before elective surgery 1
- The available perioperative guidelines focus on anticoagulants, antiplatelet agents, cardiac medications, and specific metabolic drugs (SGLT2 inhibitors, phentermine), but do not address antipsychotic discontinuation 1, 2, 3
Contrast with Medications Requiring Discontinuation
For context, medications that DO require preoperative discontinuation include:
- Phentermine (sympathomimetic): Must be stopped at least 4 days before procedures requiring anesthesia due to hyperadrenergic effects and paradoxical refractory hypotension 2
- SGLT2 inhibitors: Should be withheld 3-4 days before surgery to reduce perioperative metabolic acidosis risk 1, 3
- SSRIs (the actual drug class mentioned in error): May increase bleeding risk, with some evidence suggesting consideration of 2-week discontinuation in high-bleeding-risk patients 4, 5
SSRI Perioperative Management (For Comparison)
Since the question references SSRIs, here is the actual evidence for this drug class:
Bleeding Risk Evidence
- SSRIs increase intraoperative blood loss by approximately 95 mL (95% CI: 9-181 mL) in orthopedic surgery, though this is clinically modest 6
- Current SSRI use increases risk of re-operation for bleeding after breast cancer surgery (adjusted RR = 2.3; 95% CI: 1.4-3.9) 7
- SSRIs increase red blood cell transfusion requirements in CABG surgery (OR = 1.15; 95% CI: 1.06-1.26), but do not increase mortality (OR = 1.03; 95% CI: 0.90-1.17) 8
SSRI Discontinuation Considerations
- Physicians may consider planned discontinuation of SSRIs 2 weeks before surgery in patients with high bleeding risk who are in the stable phase of depression 4, 5
- Discontinuation must be weighed against risks of SSRI discontinuation syndrome, symptom recrudescence, or depressive relapse 4, 5
- Alternative strategy: Switch to non-serotonergic antidepressants (bupropion or mirtazapine) if discontinuation is required 4
Practical Recommendations for Flupenthixol
Continue Through Perioperative Period
- Maintain flupenthixol through the perioperative period unless specific contraindications exist (e.g., severe hypotension, QTc prolongation concerns with specific anesthetic agents)
- Monitor for potential drug interactions with anesthetic agents, particularly regarding QTc prolongation and extrapyramidal effects
- Ensure adequate hydration and blood pressure management, as typical antipsychotics can cause orthostatic hypotension
Common Pitfalls to Avoid
- Do not confuse flupenthixol with SSRIs—this misclassification could lead to unnecessary medication discontinuation and psychiatric destabilization
- Do not routinely discontinue antipsychotics before surgery unless there is a specific anesthetic concern identified by the anesthesiology team
- Abrupt discontinuation of antipsychotics can precipitate psychotic relapse, which poses greater perioperative risk than continuing the medication