Anesthesia Considerations for Polypharmacy

Polypharmacy is common among surgical patients, particularly older adults and those with multiple chronic medical conditions. The use of multiple medications can increase the potential for drug interactions and alter a patient’s response to anesthetic agents. These effects may be more pronounced in older adults because age-related changes in renal and hepatic function can affect drug metabolism and elimination. A careful review of the patient’s medication regimen is therefore an important part of identifying potential interactions and developing a safe plan for anesthesia, especially for patients with polypharmacy (1).

Preoperative medication review involves more than documenting prescription drugs, over-the-counter medications, and supplements. The perioperative team should determine which therapies can be continued safely and which require temporary interruption. These decisions depend on the medication, the condition being treated, and the risks associated with either continuing or withholding therapy. Cardiovascular medications illustrate this distinction. Chronic beta-blocker therapy is generally continued because abrupt withdrawal can result in tachycardia, hypertension, and myocardial ischemia. In contrast, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers may be withheld before some procedures because continued therapy can increase the risk of intraoperative hypotension (2).

Psychotropic medications also require careful review before surgery. Antidepressants, antipsychotics, and benzodiazepines can affect anesthetic management through increased sedation, hypotension, and interactions with medications administered perioperatively. Benzodiazepines can have additive sedative effects when combined with anesthetic agents and opioids, which may increase the risk of excessive sedation and respiratory depression. Serotonergic antidepressants can contribute to serotonin toxicity when combined with certain serotonergic drugs, while some antipsychotics can prolong the QT interval and increase susceptibility to cardiac arrhythmias. Despite these concerns, most psychiatric medications are continued perioperatively because abrupt discontinuation can cause withdrawal or recurrence of psychiatric symptoms (3). Recognizing these effects before surgery can help guide the selection and dosing of perioperative medications and identify combinations that may require closer monitoring

Anticoagulant and antiplatelet medications require careful consideration because of their effect on perioperative bleeding risk. This is especially relevant for spinal or epidural anesthesia, where bleeding related to needle placement or an epidural catheter can result in a spinal or epidural hematoma. Although uncommon, these hematomas can compress neural structures and cause serious neurologic injury. The timing of anticoagulant interruption and resumption should therefore be considered before neuraxial anesthesia and depends in part on the specific medication and its duration of anticoagulant effect. However, withholding anticoagulation can also increase the risk of thrombosis (4). Management should therefore account for both the bleeding risk associated with continued therapy and the thrombotic risk created by interrupting it.

The perioperative management of polypharmacy requires attention to the clinical consequences of each medication during anesthesia and surgery. A drug that is appropriate to continue in one patient may warrant interruption in another depending on its indication, the planned procedure, and the risks created by either decision. For the anesthesiologist, a thorough medication review provides the basis for making these distinctions and adapting the anesthetic plan while preserving necessary chronic therapy.

References

Barnett SR. Polypharmacy and perioperative medications in the elderly. Anesthesiol Clin. 2009;27(3):. doi:10.1016/j.anclin.2009.07.004
Patel P, Whinney C. Perioperative Medication Management. Med Clin North Am. 2024;108(6):1135-1153. doi:10.1016/j.mcna.2024.05.002
Harbell MW, Dumitrascu C, Bettini L, Yu S, Thiele CM, Koyyalamudi V. Anesthetic Considerations for Patients on Psychotropic Drug Therapies. Neurol Int. 2021;13(4):640-658. Published 2021 Nov 29. doi:10.3390/neurolint13040062
Kopp SL, Vandermeulen E, McBane RD, Perlas A, Leffert L, Horlocker T. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition). Reg Anesth Pain Med. Published online October 17, 2025. doi:10.1136/rapm-2024-105766