Can mesalamine and mercaptopurine be continued if a patient (pt) needs surgery?

Perioperative Management of Mesalamine and Mercaptopurine in IBD Patients

Mercaptopurine can be safely continued during the perioperative period in patients with inflammatory bowel disease requiring surgery, while mesalamine offers limited benefit and can be discontinued if the patient is on other immunomodulatory therapy. 1

Perioperative Management of Immunomodulators

Mercaptopurine (Thiopurines)

• Mercaptopurine can be safely continued throughout the perioperative period without increasing the risk of postoperative complications 1
• Key pharmacokinetic considerations:
  • Thiopurines take up to 3 months to reach therapeutic levels
  • Elimination half-life is only 1-2 hours
  • Stopping immediately before surgery will not meaningfully impact complication risk
  • Can be safely restarted when oral intake resumes in the immediate postoperative period 1

Mesalamine (5-ASA)

• Mesalamine offers limited benefit in Crohn's disease management and can be discontinued perioperatively 1
• The AGA specifically recommends against using mesalamine for maintenance of surgically induced remission in Crohn's disease 1
• For patients starting biologic therapy, stopping mesalamine does not increase risk of adverse clinical outcomes 2
• If the patient is on mesalamine monotherapy without other immunomodulators, continuing it perioperatively is unlikely to increase surgical risk, but offers minimal benefit

Decision Algorithm for Perioperative Management

1. For mercaptopurine:

   • Continue throughout the perioperative period
   • Resume as soon as oral intake is established postoperatively
   • No dose adjustment necessary

2. For mesalamine:

   • If patient is on combination therapy with mercaptopurine or biologics: Consider discontinuing mesalamine as it provides minimal additional benefit 2
   • If patient is on mesalamine monotherapy: Can continue through surgery as it has no demonstrated adverse effect on surgical outcomes

Important Considerations and Caveats

• Steroid management is critical: If the patient is also on corticosteroids, prioritize tapering these medications before surgery whenever possible, as steroids significantly increase postoperative complication risk (OR 1.7 for infectious complications) 1

• Postoperative prophylaxis: After surgery, thiopurines like mercaptopurine are recommended as effective maintenance therapy to prevent disease recurrence 1, 3

• Monitoring recommendations: For patients continuing mercaptopurine:

  • Check full blood count within 4 weeks of surgery
  • Monitor for neutropenia, though profound neutropenia can develop rapidly 1

• Special populations: Mercaptopurine may be particularly beneficial in preventing relapse in patients with previous intestinal resections 4

The evidence strongly supports continuing mercaptopurine through the perioperative period, while mesalamine can be discontinued if the patient is already on other immunomodulatory therapy without compromising outcomes. This approach optimizes both surgical safety and long-term disease control.