What are the guidelines for managing infliximab (chimeric monoclonal antibody against tumor necrosis factor alpha) therapy in patients undergoing surgery?

Management of Infliximab Therapy in Patients Undergoing Surgery

For patients undergoing elective surgery who are on infliximab therapy, withhold infliximab prior to surgery and plan the surgery at the end of the dosing cycle (8 weeks for standard dosing), which is typically during week 9 after the last dose. 1

Timing of Infliximab Discontinuation Before Surgery

Rheumatologic Conditions

• Rheumatoid Arthritis (RA), Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA), and Juvenile Idiopathic Arthritis (JIA):
  • Withhold infliximab before surgery and schedule the procedure after the next dose is due 1
  • For standard infliximab dosing (every 8 weeks), plan surgery during week 9 1
  • This timing allows drug levels to be at their lowest point, potentially reducing infection risk

Inflammatory Bowel Disease

• Similar principles apply for patients with Crohn's disease or ulcerative colitis
• Schedule elective surgery at the end of the dosing cycle

Special Considerations

Urgent/Emergency Surgery

• In cases where surgery cannot be delayed (e.g., emergency colectomy for acute severe ulcerative colitis):
  • Proceed with surgery regardless of timing of last infliximab dose 1
  • Recognize that recent infliximab administration may increase postoperative complication risk in some settings 2

Disease Severity and Control

• Patients with severe disease or difficult-to-control symptoms may consider continuing infliximab if:
  • Pain relief from surgery outweighs potential infection risk
  • Disease control would be significantly compromised by medication interruption 1

Postoperative Medication Resumption

• Resume infliximab once:

  • Wound shows evidence of healing
  • Sutures/staples are removed
  • No significant swelling, erythema, or drainage is present
  • No ongoing infection at surgical or non-surgical sites
  • This typically occurs approximately 14 days after surgery 1

• Recent evidence suggests better outcomes in patients who restart infliximab within 4 weeks after surgery compared to later resumption 1

Risk Assessment

Factors That May Warrant Longer Withholding Periods

• History of severe or recurrent infections
• Prior prosthetic joint infection
• Immunocompromised status

Evidence on Infection Risk

• The evidence regarding infection risk with perioperative infliximab is mixed:
  • Some studies show increased risk of postoperative complications, particularly in ulcerative colitis patients undergoing proctocolectomy 2
  • Other meta-analyses found no significant increase in overall complications or infection rates in patients with Crohn's disease or ulcerative colitis 3, 4
  • A recent study in elderly RA patients found no association between timing of infliximab infusion and post-operative infection or mortality risk 5

Practical Algorithm for Perioperative Infliximab Management

1. Elective Surgery Planning:

   • Schedule surgery at the end of the dosing cycle (week 9 for standard 8-week dosing)
   • Last dose should be given at least 4-8 weeks before surgery

2. Risk Stratification:

   • Higher risk: History of infections, complex surgery, multiple comorbidities
   • Lower risk: Otherwise healthy, minor surgical procedures

3. Postoperative Resumption:

   • Resume at approximately 14 days post-surgery if wound healing is adequate
   • Consider earlier resumption (within 4 weeks) in patients with high risk of disease flare
   • Consider delayed resumption in patients with postoperative complications or infection

4. Monitoring:

   • Watch for signs of infection: fever, increased pain, purulent drainage
   • Monitor for disease flare during medication interruption

By following these guidelines, clinicians can balance the risks of surgical site infections against the risk of disease flares when managing patients on infliximab therapy who require surgery.