Q:  Interaction of Anesthesia & BP Meds

 
Dear Dr. Phelps,

A friend of mine who is on maintenance doses of bi-polar meds, (i.e. abilify, lamictal, cymbalta, neurontin), needs to undergo a spinal decompression for stenosis.  The surgeons say that her continuation of the meds during surgery will be a "problem".  What are they talking about?  I can find nothing on the internet that suggests that there is a problem involving the interaction of bipolar meds with anaesthesia.  Are they worried that she will "act out" after surgery and destroy their work?  Do they simply want to rule out any possible, however unlikely, interaction by discontinuing the meds during surgery?

I would appreciate any enlightenment.

Very truly yours,


Dear Mr. Q. --

I see what you mean. I'm not sure what their concern is. It may be that the anesthesiologist is doing a great job and is looking in detail at these medications in terms of what kind of modifications to make in her or his usual approach. Or it could be that the surgeons are simply worried about what kind of a patient they think they are dealing with on a basis of this medication list. To my knowledge there is nothing there which would affect the tissues upon which the surgeons will be operating, or wound repair, or such things. They may well know something I don't, however.

Taking the medications one at a time and trying to think of any problems they might present (this list is not exhaustive, and I may be missing something): first, Aripiprazole (let us all wage war against using the trade name for this medication as otherwise we will continue to see these cutesy names for subsequent medications). As this medication has effects on the neurotransmitter dopamine, there might be some reason to wonder about levels of muscle tension after surgery, but probably only if there was excess muscle tension even before surgery.

Lamictal must not be omitted for more than three days (some would say four, a few five) else it must be restarted again from scratch with the usual step-by-step dose increases. However, most people miss only 24 hours of medications for surgery, often less, rarely more.

Cymbalta is a new medication, relatively, so perhaps there is something here that I am not familiar with. Neurontin has been around quite a while and distinguished itself as having little propensity for interactions with other medications, as you probably discovered. Both of these medications are used for people with chronic pain, and this might be one of the things that the surgeons are seeing as a "red flag": they might be concerned about postoperative pain, and perhaps about the percentage likelihood of a good and complete response to the surgery. Overall, I think this is the most likely among my speculations, but all of them are just that.

I hope things go smoothly, in all respects.

Dr. Phelps



Published July, 2007