Prehabilitation: a global movement in perioperative care
Since the 1990s, the development of fast-track surgery and Enhanced Recovery After Surgery (ERAS) protocols has demonstrated that multimodal perioperative interventions can reduce complications, shorten hospital stays, and accelerate recovery [1, 2]. Building on these principles, prehabilitation has emerged as a complementary strategy, extending from diagnosis to surgery to enhance patients’ functional capacity and physiological reserve through exercise, nutrition, psychological preparation, respiratory training, and medical optimization [3–5]. Evidence confirms that prehabilitation improves perioperative function, independence, and recovery, while reducing complications [6–10].
However, its implementation remains uneven worldwide. Programs often focus on exercise and nutrition while neglecting medical optimization, even though medication safety is crucial for perioperative stability. Many surgical patients are older adults with multimorbidity and polypharmacy [11–14], and perioperative medication errors, such as omissions or drug–drug interactions, are major risk factors for adverse outcomes [15–20].
Globally, prehabilitation aligns priorities to prevent complications and enhance patient-centered care; however, pharmacists’ contributions remain under-recognized. Neither the ERAS Society guidelines [2] nor the U.S. perioperative surgical home model [21] clearly define the role of pharmacists. As the surgical population ages and the incidence of chronic diseases increases [11, 22], integrating pharmacotherapeutic expertise into surgical practice becomes imperative.
As this manuscript is a commentary and call to action, our aim is to emphasize the strategic opportunity to recognize medication optimization as a core component of prehabilitation rather than to prescribe operational protocols. Conceptually, expanding prehabilitation to include structured approaches, such as MTM, has the potential for pharmacists to contribute meaningfully to perioperative safety and readiness.
Why pharmacists matter in prehabilitation
The current medical community has entered an evidence-based era. However, evidence supporting perioperative medication therapy remains limited. Many recommendations are based on low or very low levels of evidence, and some interventions are not addressed by existing guidelines.
Pharmacists’ expertise lies at the intersection of medication therapy, patient education, and inter-professional collaboration, addressing the issue of insufficient evidence for surgical medications to a large extent. Within prehabilitation, this expertise directly mitigates key perioperative risks. Nevertheless, in most international prehabilitation frameworks, pharmacists are viewed as peripheral contributors rather than as core members of the multidisciplinary team.
As this manuscript is a commentary, our aim is to highlight these strategic gaps and advocate for a stronger conceptual recognition of the importance of pharmacists in prehabilitation.
Polypharmacy and chronic disease management
Older surgical patients commonly present with multimorbidity and polypharmacy. In China, nearly one-third of surgical patients are aged ≥ 65 years, and more than two-thirds of older adults have at least one chronic disease, with over one-third living with two or more conditions [11, 22]. Polypharmacy not only increases the risk of drug-related adverse events, but is also linked to higher postoperative complication rates, particularly when ten or more medications are used concurrently [13, 14, 19].
Surgical wards consistently report higher medication error rates than medical services do [15–18]. These findings demonstrate the need for systematic medication reconciliation, deprescribing when appropriate, and the optimization of chronic therapies as integral components of prehabilitation programs. Pharmacists are uniquely qualified to deliver these interventions, drawing on established MTM frameworks that reduce drug-related problems (DRPs) and healthcare costs [23].
Although detailed implementation models vary by institution, the conceptual alignment between pharmacists’ skills and the needs of this high-risk population highlight their strategic value in prehabilitation.
Nutrition optimization and drug–nutrition interactions
Nutritional optimization is a cornerstone of prehabilitation programs. Perioperative malnutrition is associated with poor outcomes, including increased complications and delayed recovery [24–27]. Guidelines from the European Society for Clinical Nutrition and Metabolism (ESPEN) emphasize early enteral nutrition as a priority for surgical patients [26].
Pharmacists play an important role in nutritional support in China [28, 29] and globally [30, 31], helping to prevent drug–nutrition interactions and customize supplementation. For instance, proton pump inhibitors can impair micronutrient absorption, whereas certain chemotherapeutic agents can exacerbate malnutrition [32, 33]. Pharmacist-led monitoring and adjustment of these therapies can enhance the effectiveness of nutritional intervention.
Conceptually, this highlights another domain in which medication expertise supports the broader goals of prehabilitation.
Anemia detection and management
Preoperative anemia is prevalent and is strongly associated with adverse outcomes, including infection, cardiovascular events, and increased transfusion requirements [34–38]. International consensus statements recommend routine screening and correction of anemia before surgery [35, 39]. Pharmacists contribute to anemia management by coordinating iron supplementation, ensuring adherence, and monitoring the treatment response [40–43].
The International Pharmaceutical Federation (FIP) has explicitly called for expanded pharmacist roles in iron deficiency anemia care [43]. Integrating anemia management into pharmacist-led MTM during prehabilitation directly addressed one of the most preventable surgical risk factors. While operational pathways differ across health systems, the conceptual inclusion of pharmacists in anemia optimization aligns naturally with the emphasis on risk reduction in prehabilitation.
Pain management and opioid stewardship
Although pain management is not always considered part of prehabilitation, initiating multimodal analgesia before surgery can reduce postoperative pain and opioid consumption [44, 45]. Pharmacists optimize analgesic regimens, prevent harmful drug–drug interactions (e.g., NSAIDs with anticoagulants), and educate patients on the safe use of opioids [20]. In regions facing opioid misuse, pharmacists’ involvement in perioperative pain management strategies supports the broader public health goal of rational opioid stewardship.
These conceptual contributions reinforce the potential value of pharmacists in the absence of specific analgesic protocols.
Patient education and engagement
Patient education, a core component of MTM, has profound implications for prehabilitation. Studies have shown that well-informed patients experience less postoperative pain and require fewer analgesics [46–48]. Pharmacists’ ability to explain complex medication regimens, reinforce adherence, address patient concerns, reduce anxiety, and foster active engagement in the recovery process.
These strengths provide a conceptual rationale for pharmacists to contribute more prominently to patient preparation in prehabilitation pathways.
In summary, these contributions illustrate that pharmacists are not adjuncts to surgical teams but are essential partners in addressing the fundamental domains of prehabilitation: medication optimization, chronic disease management, nutrition, anemia, pain, and education. Pharmacist inclusion ensures that prehabilitation extends beyond physical training and diet to encompass the safe and effective use of medicines, which is foundational for holistic perioperative care.
China’s experience: surgical pharmacy and MTM as a case study
While international discussions of prehabilitation often focus on exercise and nutrition, China has taken decisive steps to formalize the pharmacist’s role in surgical care through the establishment of surgical pharmacy as a distinct professional discipline. In 2015, Zheng et al. [49–51] from the Guangdong Pharmaceutical Association (GDPA) first proposed the position of a surgical pharmacist, envisioning a surgical care model in which surgeons, anesthesiologists, and pharmacists share complementary responsibilities: surgeons perform operations, anesthesiologists provide anesthesia, and pharmacists manage medication therapy.
This concept evolved further in 2020, when the GDPA developed a dedicated knowledge framework for surgical pharmacists that differed from conventional clinical pharmacies. The distinction lies in the unique pathophysiological features of surgical versus internal medicine conditions, which require different pharmacotherapeutic strategies even for similar clinical manifestations [51–53]. In recognition of these efforts, the FIP awarded its Seal of Quality to the GDPA Surgical Pharmacy Program, acknowledging the growing legitimacy and international relevance of the field [54].
Guangdong pioneered the introduction of MTM in hospital practice. Originally developed in the United States under Medicare Part D in the early 2000s, MTM has demonstrated benefits in reducing medication errors, improving adherence, and lowering healthcare costs [23]. Recognizing its potential, the GDPA translated and disseminated MTM training materials in 2018 [23] and subsequently promoted pharmacist-managed outpatient clinics based on the MTM model [55, 56].
By 2021, these clinics were formally incorporated into China’s national health service standards [57], marking a milestone in localizing international pharmacy service models.
To overcome the lack of independent prescribing authority for pharmacists in China, the GDPA adapted the Collaborative Drug Therapy Management (CDTM) model from the U.S. This protocol-based framework authorizes pharmacists to initiate, refill, modify, or discontinue medications under physician-approved agreements [58]. Within the prehabilitation context, this structure enables pharmacists to deliver comprehensive care encompassing medication reconciliation, management of polypharmacy and chronic diseases, anemia correction, nutritional optimization, and patient education.
While the operationalization of these services varies across institutions, China’s experience demonstrates the feasibility of expanding pharmacists’ roles through structured and collaborative models.
These innovations demonstrate how regional leadership can align with global pharmaceutical initiatives. Rather than serving as a prescriptive template, China’s example illustrates how professional organizations can catalyze the recognition of new pharmacy roles, adapt international models such as MTM/CDTM to local regulatory conditions, and build momentum toward broader perioperative pharmacist integration. This model may serve as a practical template for other countries in which pharmacists face similar legislative or structural barriers to independent prescriptions.
Finally, China’s experience illustrates the importance of professional leadership. The GDPA has acted as a catalyst by uniting experts, developing training programs, and advocating for policy reform. Such organizational engagement demonstrates how strategic leadership can elevate pharmacists from peripheral participants to conceptual recognized members of surgical care teams, laying the foundation for future empirical and implementation work.
Global lessons and opportunities
China’s experience demonstrates how surgical pharmacy services and MTM can be institutionalized, even within a system in which pharmacists lack independent prescribing authority. However, the relevance of these innovations has extended beyond China’s borders. Globally, health systems are confronting an aging surgical population, rising multimorbidity, polypharmacy, and escalating costs, all of which create an urgent need for structured medication optimization within prehabilitation.
These shared pressures highlight the strategic importance of recognizing pharmacists’ contributions to perioperative care, even if the specific implementation mechanisms differ across regions.
Comparing international models
In the United States, MTM has been embedded in Medicare Part D since 2006, providing a framework for pharmacist-led interventions to reduce DRPs and improve adherence [59]. Despite its proven success in chronic disease management, MTM remains concentrated in ambulatory care, with limited integration into surgical or perioperative settings. Expanding MTM into prehabilitation could leverage existing infrastructure to embed pharmacists more effectively in surgical optimization [60].
These examples offer conceptual insights rather than prescriptive models, illustrating how existing pharmacy services can be extended to provide perioperative support.
In Europe, the Enhanced Recovery After Surgery (ERAS) Society has issued evidence-based perioperative guidelines emphasizing multimodal analgesia, nutrition, and early mobilization; however, these guidelines do not consistently define the role of pharmacists. In contrast, the European Society for Clinical Nutrition and Metabolism (ESPEN) explicitly recognizes pharmacists as members of multidisciplinary nutrition support teams, highlighting the importance of their formal inclusion in perioperative protocols [26, 61]. This inconsistency further highlights the need to clearly articulate the role of pharmacists within prehabilitation frameworks.
In Australia, pharmacists are explicitly acknowledged in the context of opioid stewardship programs. The Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard, developed by the Australian Commission on Safety and Quality in Health Care, identifies pharmacists as key members of multidisciplinary stewardship teams [62].
International evidence, such as Shander et al. [63] further demonstrates pharmacists’ essential roles in transfusion safety and perioperative patient blood management (PBM), highlighting their importance in optimizing surgical outcomes.
In Canada, pharmacists have established roles in hospital opioid stewardship programs, such as the initiative at St. Paul’s Hospital in Vancouver, where clinical pharmacy specialists are embedded within stewardship teams [64]. At the system level, the National Advisory Committee on Blood and Blood Products’ Patient Blood Management Position Statement explicitly recognizes pharmacists as contributors to PBM activities [65].
Several provinces, most notably Ontario through the ONTraC program, have implemented preoperative anemia screening clinics to support PBM [66]. Although these clinics emphasize multidisciplinary collaboration among surgeons, anesthesiologists, hematologists, nurses, and coordinators, pharmacists are not explicitly identified as team members, and direct pharmacist involvement in anemia management clinics has not yet been widely reported. These variations highlight both the progress made and the unrealized potential for deeper pharmacy engagement.
Lessons from China for global practice
China’s model shows that the regulatory and structural barriers are significant. The CDTM framework illustrates how protocol-based prescribing can empower pharmacists without requiring immediate legislative reforms [58]. Similarly, the establishment of MTM-based outpatient clinics demonstrates how a chronic care model can be adapted for surgical patients [52, 53, 55–57].
Although local contexts vary, these experiences provide conceptual reference points for other countries where pharmacist participation in surgical care remains underdeveloped or fragmented.
Opportunities for international collaboration
The recognition of the GDPA Surgical Pharmacy Programme by FIP through the award of its Seal of Quality provides a global platform for standardizing competencies, sharing best practices, and advocating for pharmacist integration into surgical teams [54]. International organizations such as the American Society of Health-System Pharmacists (ASHP) and the European Society of Clinical Pharmacy (ESCP) can play a catalytic role in convening stakeholders and embedding pharmacist contributions into global prehabilitation and perioperative guidelines. Such collaboration can help move the field toward greater conceptual clarity regarding pharmacists’ roles, even before detailed implementation pathways are established.
The convergence of international experiences leads to a common conclusion: prehabilitation will not achieve its full potential without the structured involvement of pharmacists. China’s model offers proof of concept, while the U.S., European, and Commonwealth experiences provide complementary evidence. The next step is to link these parallel efforts into a coherent international movement—one that formally integrates pharmacists into surgical teams to shape the future of prehabilitation.
Call to action for global pharmacy practice
Prehabilitation is a major advance in perioperative medicine that integrates exercise, nutrition, psychological readiness, and medical optimization to prepare patients for surgery. However, systematic medication management remains underdeveloped. Pharmacists are uniquely equipped to address DRPs, polypharmacy, drug–nutrition interactions and enhance patient engagement.
Recognizing these capabilities at a conceptual and strategic level is essential for advancing the field.
China’s experience with surgical pharmacy, MTM, and CDTM demonstrates that pharmacists can be effectively integrated into prehabilitation pathways, even in systems with restricted prescribing rights [23, 49, 50, 52, 53, 55–58]. Internationally, ERAS and other prehabilitation frameworks can build on this model to close long-standing gaps in the optimization of medication. While operationalization will vary across health systems, these examples highlight the feasibility and value of elevating pharmacists’ roles within perioperative care.
Thus, global collaboration is essential. Professional societies, including the FIP, ASHP, ESCP, and national surgical associations, should define pharmacist competencies for prehabilitation and incorporate them into training and practice guidelines. Such consensus-building efforts can provide clarity on pharmacists’ conceptual roles while allowing health systems the flexibility to develop context-specific implementation models.
Health systems can adapt existing MTM infrastructure for surgical care and implement CDTM-style agreements in the absence of legislative reform. These approaches offer strategic pathways for expanding pharmacy services without requiring immediate regulatory overhaul.
Embedding pharmacists in prehabilitation teams will enhance safety, outcomes, and global visibility of clinical pharmacy, ensuring that prehabilitation becomes a truly multidisciplinary model for surgical readiness. As a commentary, our goal is to encourage dialogue, catalyze collaboration, and inspire the next steps toward fuller integration of pharmacists into prehabilitation research, policy, and practice.