What are the perioperative management guidelines for patients taking Tezepelumab (tezepelumab)?

Perioperative Management of Tezepelumab

Tezepelumab does not require specific perioperative withholding for elective surgery, as it is not addressed in current perioperative antirheumatic medication guidelines and lacks evidence of increased surgical infection risk.

Key Clinical Context

Tezepelumab is a human monoclonal antibody that blocks thymic stromal lymphopoietin (TSLP), approved for severe, uncontrolled asthma in patients aged 12 years and older 1. The standard dosing is 210 mg subcutaneously every 4 weeks 1.

Guideline-Based Approach

The 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guidelines for perioperative management of antirheumatic medications do not include tezepelumab in their recommendations, as these guidelines specifically address rheumatic diseases (RA, AS, PsA, JIA, SLE) undergoing total hip or knee arthroplasty 2.

Application of Biologic Principles

While tezepelumab is not explicitly covered, the ACR guidelines provide a framework for biologic agents used in inflammatory conditions:

• For biologics in rheumatic diseases: The ACR conditionally recommends withholding all biologic agents prior to surgery and planning surgery at the end of the dosing cycle 2
• Rationale: This approach minimizes drug effect at the time of surgery while limiting time off medication 2

Practical Timing Strategy

If applying biologic principles to tezepelumab (given every 4 weeks):

• Schedule elective surgery during week 5 (when the next dose would be due) 2
• This timing places surgery at the nadir of drug effect while avoiding prolonged medication interruption 2

Safety Profile Considerations

Tezepelumab demonstrates a favorable safety profile that may inform perioperative decision-making:

• Infection rates: In the 2-year DESTINATION extension study, adverse event incidence was 49.62 per 100 patient-years with tezepelumab versus 62.66 with placebo, and serious adverse events were 7.85 per 100 patient-years versus 12.45 with placebo 3
• No increased infection signal: Pooled analysis of PATHWAY and NAVIGATOR trials showed similar adverse event incidence between tezepelumab and placebo groups 4, 5
• These data suggest tezepelumab does not carry the same infection risk profile as traditional immunosuppressive biologics 3, 5

Postoperative Resumption

Following ACR guidance for biologic agents:

• Resume tezepelumab when the wound shows evidence of healing, sutures/staples are removed, there is no significant swelling/erythema/drainage, and no ongoing infection 2, 6
• This typically occurs around 14 days postoperatively 2, 6

Critical Caveats

Important limitations to consider:

• The ACR guidelines explicitly caution against extrapolation to procedures beyond total hip/knee arthroplasty until further data are available 2
• Tezepelumab is indicated for asthma, not rheumatic diseases, so direct guideline application requires clinical judgment 1
• Severe asthma control must be prioritized: Patients with poorly controlled asthma face significant perioperative respiratory risks that may outweigh theoretical infection concerns 5

Recommended Clinical Approach

For elective surgery in patients on tezepelumab:

1. Assess asthma control: Ensure optimal disease stability before proceeding with elective surgery 5
2. Coordinate timing: If withholding medication, schedule surgery at week 5 (end of dosing cycle) to minimize both drug effect and time off therapy 2
3. Alternative approach: Continue tezepelumab through surgery if asthma control is tenuous, given the lack of clear infection risk signal 3, 5
4. Communicate with surgical team: Ensure anesthesia and surgical teams are aware of the patient's severe asthma diagnosis and medication regimen 6
5. Resume therapy: Restart tezepelumab approximately 14 days postoperatively once wound healing is satisfactory 2

The decision to withhold versus continue tezepelumab perioperatively should prioritize maintaining asthma control, as respiratory complications from uncontrolled asthma likely pose greater perioperative morbidity risk than the theoretical infection risk from continuing this biologic agent 3, 5.