Perioperative Management of Skyrizi (Risankizumab)
Yes, you should stop Skyrizi before elective surgery by timing the procedure to occur when the next dose is due, effectively creating a medication-free interval of approximately 12 weeks (one dosing cycle).
Recommended Approach for Biologics Before Surgery
Timing of Discontinuation
For biologics like Skyrizi, plan surgery to occur after the next dose is due rather than actively stopping the medication 1. This means scheduling your surgery at week 13 or later if your last dose was at week 0, since Skyrizi is dosed every 12 weeks after loading doses 2.
The 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline conditionally recommends withholding all biologics prior to surgery and planning the surgery after the next dose is due for patients with inflammatory arthritis undergoing joint replacement 1.
While this guideline specifically addresses rheumatologic conditions and joint surgery, the principle of allowing biologics to clear before elective surgery applies broadly to minimize infection risk 1.
Rationale Based on Drug Characteristics
The "four half-lives rule" provides additional context: Older British Association of Dermatologists guidelines recommended discontinuing biologics at least four half-lives prior to major surgery 1. For medications with long half-lives like ustekinumab (similar IL-23 inhibitor), this translated to 12 weeks 1.
Risankizumab has a similar mechanism and dosing schedule to ustekinumab, suggesting comparable perioperative considerations 2.
Planning surgery when drug levels are lowest (at the end of the dosing cycle) reduces theoretical infection risk while avoiding active medication discontinuation that could trigger disease flare 1.
Type of Surgery Matters
Major vs. Minor Surgery
The recommendations above apply primarily to major elective surgery where infection risk is substantial 1.
For minor procedures with low infection risk, continuing Skyrizi may be reasonable, though this should be discussed with both your dermatologist and surgeon 1.
Evidence from Inflammatory Bowel Disease Surgery
Recent data from Crohn's disease surgery shows that continuing biologics (anti-TNF, vedolizumab, ustekinumab) does not increase postoperative complications 1, 3.
However, this evidence may not fully apply to Skyrizi since risankizumab is an IL-23 inhibitor with different immunologic effects than the studied medications 1, 3.
When to Resume After Surgery
Restart Skyrizi once the surgical wound shows evidence of healing, typically around 14 days postoperatively 1.
Specific criteria for resumption include: sutures/staples removed, no significant swelling or erythema, no drainage, and no ongoing infection at any site 1.
This typically means waiting at least 2 weeks, but potentially longer if wound healing is delayed 1.
Important Caveats and Pitfalls
Risk-Benefit Considerations
Patients with severe, difficult-to-control psoriasis may experience significant disease flare if Skyrizi is withheld for 12+ weeks 1. In such cases, you and your physicians might decide the risk of disease flare outweighs the theoretical infection risk 1.
Patients with history of severe or recurrent infections or prior surgical site infections should be particularly cautious about continuing biologics perioperatively 1.
Urgent Surgery
- If you require urgent or emergency surgery, there may not be time to wait for medication clearance 1. The surgery should proceed as needed, with heightened vigilance for postoperative infection 1.
Communication is Critical
Ensure both your dermatologist and surgeon are aware of your Skyrizi use and coordinate the timing together 1.
Do not independently stop Skyrizi without discussing with your dermatologist, as abrupt discontinuation could trigger severe psoriasis flare 3.
Evidence Quality Note
The direct evidence for risankizumab specifically in the perioperative setting is limited 2. The recommendations are extrapolated from guidelines for other biologics in inflammatory conditions, particularly the high-quality 2022 ACR/AAHKS guideline for rheumatologic surgery 1. The principle of timing surgery at the end of a dosing cycle represents a balanced approach that minimizes both infection risk and disease flare risk 1.