What is the protocol for holding Tremfya (guselkumab) before surgery?

Protocol for Holding Tremfya (Guselkumab) Before Surgery

For patients taking Tremfya (guselkumab), the recommended protocol is to withhold the medication prior to surgery and plan the surgery after the next dose is due, which would be in week 9 for this medication that is typically administered every 8 weeks. 1

Rationale and Evidence Base

• The 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons (ACR/AAHKS) guidelines conditionally recommend withholding all biologics, including IL-23 inhibitors like Tremfya, prior to elective surgery 1
• This recommendation is based on the principle of planning surgery when active drug levels would be low, which occurs after the end of the dosing cycle 1
• For Tremfya, which is administered every 8 weeks, surgery should ideally be planned for week 9 (after the next scheduled dose would have been due) 1

Special Considerations

• The recommendation to withhold biologics is conditional rather than strong due to limited direct evidence, meaning individual factors may influence the decision 1
• Patients with severe symptoms from the operative joint may elect to have surgery within the dosing cycle if the anticipated pain relief outweighs the possible infection risk 1
• Patients whose disease has been difficult to control may consider continuing their medication rather than risk loss of disease control 1

Decision Algorithm

1. Standard approach: Withhold the scheduled Tremfya dose and plan surgery for week 9 (after the next dose would have been due) 1
2. For patients with severe joint symptoms: Consider earlier surgery if pain relief needs outweigh infection risk 1
3. For patients with difficult-to-control disease: Consider continuing medication if risk of disease flare outweighs surgical infection risk 1

Postoperative Management

• Restart Tremfya once the wound shows evidence of healing, sutures/staples are removed, there is no significant swelling, erythema, or drainage, and there is no ongoing infection 1
• This typically occurs around 14 days after surgery 1

Common Pitfalls to Avoid

• Failing to plan surgery timing in relation to the medication's dosing cycle 1
• Not considering individual patient factors such as disease severity and infection risk when making decisions about medication management 1
• Restarting medication too early before adequate wound healing has occurred 1