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Crohn's Disease Forum » Ask the Experts » Should biologics such as Humira and Remicade be discontinued prior to surgery to reduce the chance of infection?


09-16-2013, 01:28 PM   #1
David
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Should biologics such as Humira and Remicade be discontinued prior to surgery to reduce the chance of infection?

Jennifer recently asked our panel of experts:
Should biologics such as Humira and Remicade be discontinued prior to surgery to reduce the chance of infection?
Dr. Walter A. Koltun, MD, FACS, FASCRS of the Penn State Hershey Inflammatory Bowel Disease Center took time out of his busy schedule to answer this question. A little about Dr. Koltun:


Dr. Koltun is the Director of the Hershey Penn State IBD Center, Chief of the Division of Colon and Rectal Surgery, and Professor of Surgery at the Penn State College of Medicine

In regards to the question, Dr. Koltun stated:

There is great controversy regarding this issue. Some surgeons feel strongly that being on these drugs at the time of surgery will increase complications, most significantly those associated with infection. There have been many studies looking at this question, but they all suffer from the same problem, namely that they all are retrospective (looking after the fact) and the patients are diverse and many other things are also taking place besides just getting these drugs and so the data is difficult to interpret. Specifically, if patients are on these drugs, they usually are sick and are having problems, so it may not be the drugs per se, but what the drugs represent, namely active, difficult to treat disease that worsens a personís risk for operative complications.

What is recognized and generally acknowledged is that if one operates on a healthy patient the complications are less that if you operate on a sick patient. So if someone is malnourished or anemic from their inflammatory bowel disease, then those are definitely factors that will worsen complications. In addition, Humira and Remicade suppress the immune system, so having more infections as a complication is definitely possible, but what is worse is being on more than one drug that compromises the immune system. The worst offender in this regard are steroids, or prednisone. If one is on not just 1 or 2, but 3 immune suppressants(for example prednisone, Remicade and Imuran) that gives a very high risk for operative complications especially infectious ones, like wound infection or leakage if the bowel is stitched together at the time of surgery.

If one is only on one immunosuppressant, I, as a surgeon would much prefer that to be Humira or Remicade rather than prednisone. Also, I often say it is better to operate on a healthy IBD patient on Humira or Remicade (or steroids for that matter) than a sick IBD patient NOT on these drugs. In other words, if discontinuing the drug will cause a flare of the disease, then keep the patient on the drug, whatever it is and do the surgery. If that one drug controlling the disease is Remicade, I will usually schedule the surgery about 4-6 weeks after the last dose of Remicade, so the level will be down around the time of surgery, but not so low as to cause a flare. Bottom line is to be as healthy as possible for the surgery and use the medications if those are necessary to achieve that.
Thank you to Dr. Koltun for his time and expertise!
09-16-2013, 03:57 PM   #2
DustyKat
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Thank you Dr. Koltun.
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09-24-2013, 04:32 PM   #3
DougUte
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That makes total sense to me. Thanks.
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