What are the recommendations for managing mycophenolate (an immunosuppressant medication) in patients undergoing surgery?

Perioperative Management of Mycophenolate in Surgical Patients

For patients taking mycophenolate who are undergoing surgery, management should be based on the underlying disease severity, with mycophenolate being continued through surgery in severe SLE patients and withheld for one week prior to surgery in non-severe SLE patients. 1

Disease-Specific Recommendations

Severe SLE

• Continue mycophenolate mofetil at the current dose throughout the perioperative period 1
• Rationale: The risk of organ damage from SLE flare outweighs infection risk
• This recommendation is based on indirect evidence from organ transplant patients where continuing anti-rejection therapy during surgery is standard practice 1
• Decisions should involve consultation with the patient's rheumatologist

Non-Severe SLE

• Withhold mycophenolate mofetil for 1 week prior to surgery 1
• Restart 3-5 days after surgery if there are no wound healing complications or infection 1
• Rationale: The morbidity of prosthetic joint infection may be more severe than a flare in non-severe SLE 1
• This allows partial return of immune function before surgery

Medication Restart Protocol

• For all patients who had mycophenolate withheld, restart only when:
  • Wound shows evidence of healing (typically ~14 days)
  • All sutures/staples are removed
  • No significant swelling, erythema, or drainage is present
  • No clinical evidence of surgical or non-surgical site infections 1

Rationale and Mechanisms

Mycophenolate mofetil works by:

• Inhibiting inosine monophosphate dehydrogenase, a key enzyme in purine synthesis 2
• Causing lymphocyte-selective immunosuppression 3
• Affecting both T and B cell function 4

The immunosuppressive effects increase infection risk, particularly:

• Cytomegalovirus infections 4
• Other opportunistic infections
• Surgical site infections

Important Clinical Considerations

1. Monitoring after restart: Watch for signs of:

   • Wound healing complications
   • Infection (surgical site and elsewhere)
   • Disease flare

2. Common adverse effects to monitor:

   • Gastrointestinal effects (especially diarrhea) 3
   • Hematological toxicity (leukopenia) 5
   • Increased susceptibility to infections 4

3. Pitfalls to avoid:

   • Abrupt discontinuation in severe SLE patients can trigger disease flares
   • Restarting too early in non-severe SLE patients may increase infection risk
   • Failing to adjust dosing schedule if gastrointestinal side effects occur (consider spreading total daily dose over more than two doses) 3

Updated Recommendations (2022)

The 2022 American College of Rheumatology guidelines maintain the same recommendations for mycophenolate management during surgery as the 2017 guidelines, reinforcing the approach of continuing mycophenolate in severe SLE and withholding for one week in non-severe SLE 1.

This disease-severity based approach to perioperative mycophenolate management balances the risks of infection against the risks of disease flare, prioritizing patient outcomes in terms of morbidity, mortality, and quality of life.