Perioperative Management of Desvenlafaxine with Serotonin Syndrome Risk

Intraoperative Considerations

The American Society of Anesthesiologists recommends exercising heightened vigilance when combining desvenlafaxine with other serotonergic agents perioperatively, as this represents the primary safety concern, with a risk of serotonin syndrome 1, 2.
The Mayo Clinic advises avoiding or carefully monitoring concomitant use with serotonergic opioids, such as fentanyl, meperidine, methadone, tramadol, and tapentadol, to minimize the risk of serotonin syndrome 1, 2.
The American College of Clinical Pharmacology suggests monitoring for serotonin syndrome manifestations, including mental status changes, autonomic instability, neuromuscular symptoms, and gastrointestinal symptoms, when desvenlafaxine is combined with antiemetics with serotonergic activity, such as ondansetron, granisetron, and metoclopramide 2.

The American Psychiatric Association recommends resuming oral desvenlafaxine as soon as the patient can tolerate oral intake, and monitoring closely for emergence of withdrawal symptoms if any delay in resumption occurs, with a strength of evidence based on clinical experience and expert opinion 1.

The Society for Perioperative Assessment and Quality Improvement (SPAQI) recommends continuing medications like buprenorphine, which affect neurotransmitters, perioperatively, suggesting a similar approach may be applicable to desvenlafaxine 3
The Perioperative Pain and Addiction Interdisciplinary Network (PAIN) clinical practice advisory emphasizes that medications with withdrawal potential, such as desvenlafaxine, should be continued perioperatively 4, 5, 6

Unlike sympathomimetic medications, desvenlafaxine does not pose significant cardiovascular risks during anesthesia, and no specific dose adjustments are needed 7
The Mayo Clinic Proceedings suggests monitoring for signs of serotonin syndrome if other serotonergic medications are used postoperatively, highlighting the importance of careful medication management in patients on desvenlafaxine 8