What are the anesthesia considerations for a patient taking Emgality (galcanezumab), Skyrizi (risankizumab), Imitrex (sumatriptan), Topamax (topiramate), and Kenalog (triamcinolone)?

Anesthesia Implications of Emgality, Skyrizi, Imitrex, Topamax, and Kenalog

Emgality (Galcanezumab)

Continue Emgality through the perioperative period without interruption, as CGRP antagonists are free of cardiovascular adverse effects and pose minimal anesthetic risk. 1

• No preoperative discontinuation required: Galcanezumab is a calcitonin gene-related peptide (CGRP) receptor antagonist monoclonal antibody that lacks cardiovascular adverse effects, making it safe to continue perioperatively 1

• Key perioperative monitoring considerations:

  • Monitor for hypertension development or worsening of pre-existing hypertension, particularly within the first 7 days of dosing, though this is more relevant for chronic dosing than acute perioperative management 2
  • Watch for signs of Raynaud's phenomenon, especially in patients with pre-existing vascular disease, though symptom onset typically occurs after a median of 71 days 2
  • Be prepared for potential hypersensitivity reactions including dyspnea, urticaria, rash, anaphylaxis, or angioedema, which can occur days after administration and may be prolonged 2

• Drug interaction profile: No significant interactions with anesthetic agents, opioids, or other perioperative medications 1

Skyrizi (Risankizumab)

Continue Skyrizi through the perioperative period, as this IL-23 inhibitor has no known anesthetic interactions and does not require perioperative discontinuation.

• No specific anesthetic concerns: Risankizumab is an interleukin-23 inhibitor used for psoriasis with no documented interactions with anesthetic agents 3

• General immunosuppression considerations: While not requiring discontinuation, be aware of potential increased infection risk in the surgical site, though this is a surgical rather than anesthetic concern

Imitrex (Sumatriptan)

Hold Imitrex on the day of surgery due to theoretical risks of serotonin syndrome and drug-drug interactions with perioperative medications, but continue it up until the day before surgery. 1

• Preoperative management: Take preoperatively but hold on the day of operation 1

• Rationale for holding:

  • Theoretical risk of serotonin syndrome when combined with opioids (fentanyl, sufentanil, tramadol) commonly used perioperatively 1
  • Sumatriptan is metabolized by monoamine oxidase A, CYP3A4, CYP2D6, and CYP1A2, creating potential for drug-drug interactions with anesthetic agents 1
  • Case reports exist of triptans being used to treat preoperative headaches with subsequent uneventful general anesthesia, but consensus favors avoidance on the day of surgery 1

• Alternative management: Use alternative acute headache treatment if needed on the day of surgery 1

• Drug interaction with Topamax: At topiramate dosages of 200 mg/day, there is no or little pharmacokinetic interaction with sumatriptan 4

Topamax (Topiramate)

Continue Topamax through the perioperative period including the day of surgery, as abrupt discontinuation risks seizures, but be prepared for enhanced CNS depression and potential metabolic acidosis.

• Continue perioperatively: Do not discontinue topiramate preoperatively due to seizure risk with abrupt withdrawal

• Key anesthetic considerations:

  • Enhanced CNS depression: Topiramate potentiates the effects of general anesthetics, benzodiazepines, and opioids, requiring careful titration and potentially reduced dosing of anesthetic agents 1
  • Metabolic acidosis: Topiramate can cause non-anion gap metabolic acidosis; check baseline electrolytes and acid-base status preoperatively
  • Reduced anesthetic requirements: Patients may require lower doses of volatile anesthetics and sedatives due to synergistic GABA-ergic effects

• Pharmacokinetic profile:

  • Long half-life (19-25 hours in monotherapy), which is shortened to approximately 10-12 hours when co-administered with enzyme-inducing drugs 4
  • Predominantly renal elimination (renal clearance 10-20 mL/min), making it less susceptible to drug interactions from enzyme inhibition 4
  • Linear pharmacokinetics over the dose range 100-800 mg 4

• Drug interactions:

  • If patient is on concomitant phenytoin or carbamazepine, topiramate clearance is increased 2-fold with a 50% shorter half-life 4
  • At dosages of 200 mg/day, topiramate exhibits minimal pharmacokinetic interactions with most CNS-active drugs 4

Kenalog (Triamcinolone)

Continue Kenalog through the perioperative period, but consider stress-dose corticosteroid supplementation if the patient has been on chronic systemic corticosteroid therapy or has received multiple recent injections.

• HPA axis suppression risk:

  • Assess for hypothalamic-pituitary-adrenal (HPA) axis suppression if patient has received multiple injections or high doses
  • Consider stress-dose corticosteroids (hydrocortisone 100 mg IV at induction, then 50 mg IV q8h for 24 hours) for major surgery if chronic suppressive therapy is suspected
  • Single intra-articular or soft tissue injections typically do not require supplementation

• Wound healing considerations: Chronic corticosteroid use may impair wound healing, though this is primarily a surgical concern

• Glucose management: Monitor blood glucose closely perioperatively, as corticosteroids cause hyperglycemia

• No direct anesthetic drug interactions: Triamcinolone does not interact with anesthetic agents directly

Summary Algorithm

Medication-specific perioperative management:

• Continue without modification: Emgality, Skyrizi, Topamax, Kenalog 1, 2
• Hold day of surgery only: Imitrex 1
• Enhanced monitoring: Blood pressure (Emgality), CNS depression (Topamax), glucose (Kenalog)
• Dose adjustments: Reduce anesthetic agent doses when using Topamax due to synergistic CNS depression 1