The Safety of Elective Surgery with Concurrent Use of Immunosuppressants

Abstract

While providing superior benefits for a cadre of diverse diseases, the prevalence of Immunosuppressive use often brings to question possible additional risks caused by these therapies in the setting of surgical procedures. Specifically, is the risk of impaired wound healing or increased chance of infection worth avoiding the possible side effects associated with temporary cessation during the perioperative period. The appropriate use of immunosuppressants (IS) during elective surgery has been debated extensively with conflicting results, through the current body of literature. Herein, we aim to provide a comprehensive, yet streamlined, overview of the common IS medications that surgeons are likely to encounter in practice in a wide variety of patients. This discussion includes an overview of the pharmacology and use of eight of the common IS medications: azathioprine, cyclosporine, hydroxychloroquine, infliximab, leflunomide, methotrexate, methylprednisolone, and mercaptopurine.

Operative management of colonic diverticular disease in the setting of immunosuppression: A systematic review and meta-analysis

“…51,52 While preoperative optimization and heightened postoperative care may help minimize the risk of operating on immunosuppressed patients, ultimately the underlying cause of the immunosuppression is paramount to perioperative risk. 25,53 Immunosuppressed patients are heterogenous and thus, differences in postoperative outcomes can be expected. Patients receiving immunosuppressive therapy following transplantation have up to a 22-fold increased risk of postoperative mortality as compared to the general population undergoing surgery for diverticular disease.…”

Practical Guidance in Perioperative Management of Immunosuppressive Therapy for Rheumatology Patients Undergoing Elective Surgery

“…Table 1 summarizes management recommendations for rheumatology patients during the perioperative period of elective surgeries for common immunosuppressants marketed in Canada. 3,[5][6][7][8][9][10][11][12][13][14] Canadian recommendations have been prioritized as much as possible (in Table 1, see the recommendations originating from reference 3). The information in this table applies only to rheumatology patients and does not cover other populations, such as transplant patients, who may be at risk of organ rejection if immunosuppressive therapy is stopped temporarily.…”

“…Hold for 2 × t 1/2 (28 days) of infection, and wound healing is (SC/IV), satisfactory Nr-Ax SpA (SC), Contaminated/dirty surgery 3,5 : psoriatic arthritis (SC/IV), Hold for 5 × t 1/2 (70 days) rheumatoid arthritis (SC/IV) All surgeries, option 2 10 Hold for 28 days Total hip and total knee arthroplasty 9 Total hip and total knee arthroplasty 9 Schedule surgery at the end of the Restart at least 14 days after surgery, dosing interval (during week 5 or 9) when there is no evidence of infection, and wound healing is satisfactory Hydroxychloroquine 200-400 mg PO daily 40 days All surgeries 6,7,10,11 9 Total hip and total knee arthroplasty 9 Schedule surgery at the end of the Restart at least 14 days after surgery, dosing interval (during week 5, 7, or 9) when there is no evidence of infection, and wound healing is satisfactory continued on page 222 9 Total hip and total knee arthroplasty 9 Schedule surgery at the end of the Restart at least 14 days after surgery, dosing interval (during week 13) when there is no evidence of infection, and wound healing is satisfactory ER = extended release, IM = intramuscular, IR = immediate release, IV = intravenous, nr-Ax SpA = nonradiographic axial spondyloarthritis, PO = by mouth (oral), SC = subcutaneous, SLE = systemic lupus erythematosus. *Decision should always be individualized on the basis of clinical judgment and assessment of clinical factors.…”

“…Because clinical data and guidelines are few, there is a need for further research to develop a standardized approach for optimizing perioperative care of these patients. 6,7…”

“…Hence, a risk-benefit assessment for each patient is warranted. 6,7 This article aims to provide guidance to clinical practitioners for the perioperative management of rheumatology patients who are receiving immunosuppressive therapy and for whom elective surgery is planned. This guidance is a collection of recommendations from national rheumatology associations and other groups of rheumatology specialists.…”