Resuming Enbrel (Etanercept) After Cephalomedullary Nail for Intertrochanteric Hip Fracture
Etanercept should be restarted once the surgical wound shows evidence of healing, all sutures/staples are out, there is no significant swelling, erythema, or drainage, and there is no clinical evidence of non-surgical site infections, which typically occurs around 14 days after surgery. 1
Rationale for Timing of Biologic Restart
The decision to restart biologic therapy like Enbrel (etanercept) after orthopedic surgery should be based on careful evaluation of:
- Wound healing status - evidence of proper healing 1
- Absence of sutures/staples 1
- Resolution of significant swelling, erythema, or drainage 1
- No clinical evidence of surgical or non-surgical site infections 1
This typically corresponds to approximately 14 days post-surgery, which is when wound closure is generally achieved following procedures like cephalomedullary nailing for intertrochanteric hip fractures 1.
Clinical Considerations
Factors That May Influence Timing
- History of prior severe infections may warrant longer withholding periods 1
- History of prosthetic joint infections may require extended medication withholding 1
- Wound healing complications would necessitate delaying restart of etanercept 1
Potential Complications of Delayed Restart
- Disease flares may occur if biologic therapy is withheld for extended periods 1
- In a Medicare dataset study, patients who restarted infliximab (another biologic) within 4 weeks after surgery had better outcomes than those who restarted later 1
Glucocorticoid Management
If the patient is also on glucocorticoids for rheumatoid arthritis:
- Continue the current daily dose of glucocorticoids rather than administering supraphysiologic "stress doses" 1
- This recommendation applies to patients receiving ≤16 mg/day prednisone or equivalent 1
- Higher glucocorticoid exposure is associated with increased risk of complications, including hyperglycemia 1
Common Pitfalls to Avoid
- Restarting biologics too early (before wound healing) may increase infection risk 1
- Delaying restart unnecessarily may lead to disease flares and worse outcomes 1
- Failure to monitor for signs of infection before restarting therapy 1
- Administering unnecessary supraphysiologic glucocorticoid doses perioperatively 1
Special Considerations for Cephalomedullary Nail Procedures
While the guidelines primarily address total hip and knee arthroplasty, the same principles apply to cephalomedullary nail procedures for intertrochanteric fractures:
- Cephalomedullary nailing is associated with minimal blood loss and lower infection rates compared to other techniques 2
- Patients with rheumatoid arthritis may have higher rates of complications after intertrochanteric fracture fixation, including avascular necrosis and nonunion 3
- Complete healing of intertrochanteric fractures with cephalomedullary nails typically occurs around 13.5 weeks 4
By following these evidence-based recommendations, you can optimize both fracture healing and rheumatoid arthritis management while minimizing infection risk and other complications.