Does Remicade (Infliximab) affect bone healing in patients undergoing surgery?

Effect of Infliximab (Remicade) on Bone Healing in Surgery

Infliximab should be withheld prior to surgery and scheduled at the end of the dosing cycle (typically during week 9 for standard 8-week dosing) to minimize potential negative effects on bone healing and reduce infection risk.

Mechanism and Concerns

Infliximab, a TNF-α inhibitor, may theoretically interfere with bone healing through its effects on inflammatory pathways that are important in the early phases of fracture repair. In vitro studies have shown that infliximab can inhibit osteoblast proliferation 1, which could potentially impair bone formation and healing following surgical procedures.

Evidence-Based Recommendations for Perioperative Management

Pre-Operative Management

• Timing of Surgery: Schedule elective surgery at the end of the infliximab dosing cycle (week 9 for standard 8-week dosing) 2
• Medication Withholding: For patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, or juvenile idiopathic arthritis, withhold infliximab prior to surgery 3
• Risk Assessment: Consider individual patient factors including:
  • Severity of underlying disease
  • History of infections
  • Complexity of planned surgery
  • Bone healing requirements of the procedure

Special Considerations

• For patients with severe disease where control would be significantly compromised, the benefits of continuing therapy may outweigh risks 2
• In emergency surgeries where delay is not possible, proceed with surgery regardless of timing of last infliximab dose 2

Post-Operative Management

• Resume infliximab once:
  • Wound shows evidence of healing
  • Sutures/staples are removed
  • No significant swelling, erythema, or drainage is present
  • No ongoing non-surgical site infection exists
  • Typically approximately 14 days after surgery 3, 2

Potential Complications to Monitor

Wound Healing and Infection

• Studies suggest that continuing biologic DMARDs perioperatively may be associated with a non-significant increase in surgical site infections (OR 1.11) and wound complications (OR 2.16) 4
• Patients on leflunomide have shown significantly higher rates of wound healing complications (40.6%) compared to those on methotrexate (13.6%) 5, suggesting careful monitoring is needed with all immunosuppressive medications

Bone Healing Concerns

• Limited evidence specifically addressing bone healing with infliximab exists, but in vitro studies indicate potential inhibition of osteoblast proliferation 1
• For spine surgery specifically, there may be concerns about fusion rates and wound healing when DMARDs are continued perioperatively 6

Balancing Risks

The decision to withhold infliximab must balance:

1. Risk of impaired bone healing and surgical site infection
2. Risk of disease flare (continuing biologics is associated with significantly lower risk of disease flares, OR 0.22) 4

Clinical Algorithm for Decision-Making

1. For elective orthopedic surgery requiring bone healing:

   • Withhold infliximab and schedule surgery at the end of dosing cycle
   • Consider surgical complexity and bone healing requirements

2. For urgent/emergency surgery:

   • Proceed regardless of timing of last dose
   • Consider prophylactic antibiotics and enhanced wound monitoring

3. For patients with severe, difficult-to-control disease:

   • Weigh benefits of disease control against potential surgical risks
   • Consider consultation with rheumatology for perioperative management plan

4. For all patients:

   • Resume infliximab approximately 14 days post-surgery when wound healing is evident
   • Monitor closely for signs of delayed healing or infection

This approach aligns with current American College of Rheumatology recommendations while accounting for the potential effects of infliximab on bone healing processes.