The first stop for professional medicines advice

Making safe medicine choices during general anaesthesia and surgery in acute porphyria

Published
Topics: Cautions and contraindicationsNutritional and metabolic disordersPorphyria

Medicines listed as safe should preferably be used. However in a life-threatening situation no drug should be withheld from a patient with porphyria.

Contents
  1. General measures to take during the surgical period
  2. Choosing a medicine
    1. Induction agents
    2. Inhalation anaesthetics
    3. Local anaesthetics
    4. Neuromuscular blockers
    5. Analgesics – opiates
    6. Analgesics – NSAIDs
    7. Analgesics – other
    8. Sedatives
    9. Antiemetics
    10. Antihypotensives
    11. Antibiotics – aminoglycosides
    12. Antibiotics – carbapenems
    13. Antibiotics – cephalosporins
    14. Antibiotics – glycopeptides
    15. Antibiotics – penicillins
    16. Antibiotics – quinolones
    17. Antibiotics – other
    18. MRSA decolonisation
    19. Anticoagulants – parenteral
    20. Reversal agents
    21. Antimuscarinics
    22. Antiepileptics
    23. Miscellaneous
  3. Useful links

General measures to take during the surgical period

Fasting, stressful situations, pain and infection can trigger acute attacks in patients with acute porphyria, and measures to avoid these circumstances are advisable. General anaesthesia poses the greatest risk to people whose acute porphyria is or has been recently active. In addition to safe medicine choices for the anaesthesia itself, consideration should be given to the following to avoid provoking acute attacks:

  • Ensuring effective pre and post-operative analgesia to minimise stress and pain from procedure.
  • Ensuring any resulting infection(s) are treated aggressively to avoid post-operative porphyria complications.
  • Ensuring patients avoid a pre and post-operative starvation fasting (this can be avoided by ensuring the patient receives intravenous glucose infusions until able to resume an adequate diet).

Choosing a medicine

The list below provides safe and unsafe medicine options in acute porphyria (acute intermittent porphyria, aminolevulinate dehydratase deficiency porphyria, hereditary coproporphyria, variegate porphyria). In general, avoid unsafe options and choose a safe option instead. However, in a life-threatening emergency no medicine should be avoided.

Most medicines are safe in non-acute porphyria (congenital erythropoietic porphyria, erythropoietic protoporphyria or porphyria cutanea tarda) but there are some exceptions. Read the article What are the restrictions on prescribing for patients with non-acute porphyria? for more information.

Induction agents

Safe

Propofol (clinical safety has not been assessed for continuous use of this preparation)

Unsafe (avoid)

Esketamine
Etomidate
Ketamine
Thiopental

Inhalation anaesthetics

Safe

Desflurane
Enflurane
Isoflurane
Nitrous oxide
Sevoflurane

Unsafe (avoid)

Halothane

Local anaesthetics

Safe

Bupivacaine
Levobupivacaine
Lidocaine (use intravenous doses with caution)
Mepivacaine
Ropivacaine

Neuromuscular blockers

Safe

Atracurium
Cisatracurium
Mivacurium
Pancuronium
Rocuronium
Suxamethonium (depolarising)
Vecuronium

Analgesics – opiates

Safe

Alfentanil
Diamorphine
Fentanyl
Morphine
Nalbuphine
Oxycodone
Pethidine
Remifentanil
Tramadol

Analgesics – NSAIDs

Safe

Aspirin
Celecoxib
Dexibuprofen
Dexketoprofen
Diclofenac
Etoricoxib
Ibuprofen
Indometacin
Ketoprofen
Ketorolac
Meloxicam
Nabumetone
Naproxen
Parecoxib
Piroxicam
Tenoxicam

Unsafe (avoid)

Aceclofenac
Sulindac

Analgesics – other

Safe

Paracetamol

Unsafe (avoid)

Pentazocine

Sedatives

Safe

Chlorpromazine
Diazepam
Lorazepam
Midazolam (clinical safety has not been assessed for continuous use of this preparation)
Perphenazine
Prochlorperazine
Temazepam
Triazolam
Trifluoperazine

Unsafe (avoid)

Flunitrazepam
Nitrazepam

Antiemetics

Safe

Cyclizine
Domperidone
Granisetron
Metoclopramide
Ondansetron
Prochlorperazine

Antihypotensives

Safe

Adrenaline (epinephrine)
Dopamine
Midodrine
Noradrenaline (norepinephrine)
Phenylephrine

Antibiotics – aminoglycosides

Safe

Amikacin
Gentamicin
Tobramycin

Antibiotics – carbapenems

Safe

Ertapenem
Imipenem
Meropenem
Meropenem with vaborbactam

Antibiotics – cephalosporins

Safe

Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime

Antibiotics – glycopeptides

Safe

Teicoplanin
Vancomycin

Antibiotics – penicillins

Safe

Amoxicillin
Ampicillin
Benzylpenicillin
Co-amoxiclav
Co-Fluampicil (Conflicting safety advice for flucloxacillin. Consider an alternative in high-risk patients. Contact UKPMIS for further advice)
Flucloxacillin (Conflicting safety advice for flucloxacillin. Consider an alternative in high-risk patients. Contact UKPMIS for further advice)
Phenoxymethylpenicillin
Tazocin (piperacillin with tazobactam)

Unsafe (avoid)

Mecillinam
Pivmecillinam

Antibiotics – quinolones

Safe

Ciprofloxacin
Levofloxacin
Moxifloxacin
Ofloxacin

Antibiotics – other

Safe

Metronidazole

Unsafe (avoid)

Clindamycin
Cotrimoxazole
Erythromycin
Nitrofurantoin
Rifampicin
Sulfadiazine
Sulfamethoxazole
Trimethoprim

MRSA decolonisation

Safe

Mupirocin 2% Topical
Skinsan

Anticoagulants – parenteral

Safe

Dalteparin
Enoxaparin
Fondaparinux
Heparin
Tinzaparin

Reversal agents

Safe

Flumazenil
Naloxone
Neostigmine
Sugammadex

Antimuscarinics

Safe

Atropine
Glycopyrronium

Antiepileptics

Safe

Levetiracetam

Unsafe (avoid)

Phenytoin
Sodium valproate
Valproic acid

Miscellaneous

Safe

Chlorphenamine
Dexamethasone
Dobutamine
Electrolytes
Hydrocortisone
Magnesium
Tranexamic acid
Trometamol

Unsafe (avoid)

Hydralazine

British and Irish Porphyria Network (BIPNET)
British Porphyria Association (BPA)
UK Porphyria Medicines Information Service (UKPMIS)