Is it safe to proceed with urgent surgery, such as a tonsillectomy, in a patient who received their last dose of Dupixent (dupilumab) one week ago?

Dupixent and Urgent Surgery: Safety and Timing Considerations

It is safe to proceed with urgent surgery, including tonsillectomy, in a patient who received Dupixent (dupilumab) one week ago, as there are no specific contraindications to surgery based on dupilumab pharmacology or available clinical evidence.

Rationale for Proceeding with Surgery

Dupilumab Pharmacology and Surgical Risk

• Dupilumab is a monoclonal antibody targeting IL-4 receptor alpha that does not increase perioperative infection risk or impair wound healing based on its mechanism of action 1
• The drug has a half-life of approximately 1-2 weeks, meaning at one week post-dose, therapeutic levels remain present but this does not contraindicate urgent surgery 2
• Unlike traditional immunosuppressants (cyclosporine, azathioprine, mycophenolate), dupilumab does not broadly suppress immune function but rather modulates type-2 inflammatory pathways 1, 2

Absence of Perioperative Holding Requirements

• Current guidelines for perioperative management of biologic agents do not include dupilumab in medications requiring preoperative discontinuation 1
• The 2022 ACR/AAHKS guideline addresses TNF inhibitors, rituximab, and other biologics but does not list IL-4/IL-13 inhibitors as requiring surgical delays 1
• For elective surgery with other biologics, the recommendation is to schedule surgery after the next dose is due (not to delay urgent surgery) 1

Clinical Safety Profile

• Dupilumab's adverse event profile in clinical trials shows no increased risk of surgical complications, with the most common side effects being conjunctivitis, nasopharyngitis, and injection site reactions 3, 4, 2
• In trials involving over 700 patients, serious adverse events were rare and not related to wound healing or surgical complications 3, 4
• The drug does not affect coagulation, platelet function, or other parameters critical for surgical hemostasis 2

Specific Considerations for Tonsillectomy

Perioperative Steroid Use

• Intraoperative dexamethasone (0.5 mg/kg, maximum 8-25 mg) should be administered during tonsillectomy regardless of dupilumab use, as this is a strong recommendation for reducing postoperative nausea, vomiting, and pain 1
• The concurrent use of dupilumab and perioperative steroids is not contraindicated and may actually be complementary given their different mechanisms 1

Wound Healing and Infection Risk

• Tonsillectomy complications (hemorrhage, infection, poor oral intake) are not increased by type-2 cytokine inhibition 5
• Standard postoperative monitoring for bleeding, pain control, and oral intake applies regardless of dupilumab therapy 1, 5

Postoperative Dupilumab Management

Resuming Therapy

• Dupilumab can be resumed at the next scheduled dose (typically 2 weeks after the previous dose) without delay, as there is no evidence requiring extended interruption after surgery 1, 3
• The standard dosing of 300 mg every 2 weeks should be maintained for optimal disease control 1, 3
• Unlike anticoagulants or JAK inhibitors, dupilumab does not require dose adjustment or delayed resumption based on bleeding risk 1, 6, 7

Monitoring Considerations

• No additional laboratory monitoring beyond standard postoperative care is required for patients on dupilumab 1
• Watch for conjunctivitis symptoms postoperatively, as this is the most common dupilumab-related adverse event, though it does not affect surgical outcomes 1, 2

Key Clinical Pitfalls to Avoid

• Do not confuse dupilumab with traditional immunosuppressants (cyclosporine, azathioprine, methotrexate) that do require perioperative management 1
• Do not delay urgent surgery to allow for drug "washout" - there is no evidence supporting this practice for dupilumab 1, 2
• Do not withhold the next scheduled dupilumab dose postoperatively unless there are specific wound healing complications, which would be managed on a case-by-case basis 3

Urgent vs. Elective Surgery Distinction

• For truly urgent surgery (cannot be delayed without significant morbidity), proceed regardless of dupilumab timing 1
• For elective surgery in patients on dupilumab, no specific timing adjustments are required, unlike with other biologics where scheduling after the dosing interval is preferred 1
• The one-week interval since last dose provides no additional safety benefit compared to proceeding immediately if surgery is urgent 1, 2