Holding Dupixent Before Orthopedic Surgery
There are no specific precautions or contraindications to holding dupilumab (Dupixent) for two weeks prior to orthopedic surgery, and this approach is reasonable based on current perioperative biologic management guidelines.
Key Recommendation
For patients on dupilumab undergoing orthopedic surgery, withhold the medication and schedule surgery after the next dose is due (approximately 2-3 weeks after the last dose). This aligns with the 2022 ACR/AAHKS guideline approach for biologic medications, which recommends planning surgery after the end of the dosing interval to minimize active drug levels while avoiding unnecessarily prolonged interruptions 1.
Rationale and Evidence
Biologic Timing Principles
The ACR/AAHKS guidelines for perioperative management of biologics demonstrate that:
- Short medication interruptions of approximately 1 dosing interval show no difference in postoperative outcomes compared to longer interruptions 1
- Planning surgery when active drug levels are low (after the dosing interval ends) is the preferred approach
- For medications dosed every 2 weeks (like dupilumab's standard regimen), surgery should ideally be planned for week 3 1
Dupilumab-Specific Considerations
Dupilumab has a standard dosing interval of 2 weeks (300 mg every 2 weeks for most indications) 2. Therefore:
- Holding for 2 weeks means surgery occurs right at the end of one dosing cycle
- This timing allows drug levels to decline while avoiding excessive treatment interruption
- The approach balances infection risk reduction with maintaining disease control
Important Caveats
Dupilumab is NOT an immunosuppressive biologic in the traditional sense - it is an IL-4 receptor alpha antagonist that modulates type 2 inflammation rather than broadly suppressing the immune system. The perioperative infection risk profile differs from TNF inhibitors or other immunosuppressants commonly addressed in orthopedic surgery guidelines.
The ACR/AAHKS guidelines specifically address rheumatic disease biologics (TNF inhibitors, IL-6 inhibitors, etc.) for total hip/knee arthroplasty 1. While dupilumab is not explicitly mentioned, the general principle of timing surgery after the dosing interval is reasonable to apply.
Practical Algorithm
Identify the patient's current dupilumab dosing schedule (typically every 2 weeks)
Schedule surgery 2-3 weeks after the last dose - this allows one full dosing interval to pass
Consider patient-specific factors:
- Severe, difficult-to-control atopic dermatitis may warrant continuing therapy through surgery (shared decision-making)
- History of recurrent infections or prior surgical site infections may warrant longer interruption
- Type of orthopedic procedure and infection risk profile
Plan for resumption: Restart dupilumab once the surgical wound shows evidence of healing, sutures/staples are removed, and there is no significant swelling, erythema, drainage, or infection - typically around 14 days post-surgery 1
Clinical Pitfalls to Avoid
- Do not unnecessarily prolong the interruption beyond 2-3 weeks - evidence shows longer interruptions provide no additional benefit and risk disease flare 1
- Do not continue dupilumab through surgery without consideration - while infection risk may be lower than traditional immunosuppressants, the prudent approach is to allow drug clearance
- Do not restart too early - wait for adequate wound healing markers before resuming 1
Bottom Line
Holding dupilumab for 2 weeks prior to orthopedic surgery is appropriate and aligns with evidence-based perioperative biologic management principles. Schedule surgery to occur 2-3 weeks after the last dose, and plan to restart approximately 2 weeks post-operatively once wound healing is confirmed.