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James WA, Rosenberg AL, Wu JJ, Hsu S, Armstrong A, Wallace EB, Lee LW, Merola J, Schwartzman S, Gladman D, Liu C, Koo J, Hawkes JE, Reddy S, Prussick R, Yamauchi P, Lewitt M, Soung J, Weinberg J, Lebwohl M, Glick B, Kircik L, Desai S, Feldman SR, Zaino ML. Full Guidelines-From the Medical Board of the National Psoriasis Foundation: Perioperative management of systemic immunomodulatory agents in patients with psoriasis and psoriatic arthritis. J Am Acad Dermatol 2024; 91:251.e1-251.e11. [PMID: 38499181 DOI: 10.1016/j.jaad.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 02/06/2024] [Accepted: 03/05/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Systemic immunomodulatory agents are indicated in the treatment of moderate-to-severe plaque psoriasis and psoriatic arthritis. Perioperative use of these medications may increase the risk of surgical site infection (SSI) and complication. OBJECTIVE To evaluate the risk of SSI and complication in patients with chronic autoimmune inflammatory disease receiving immunomodulatory agents (tumor necrosis factor-alfa [TNF-α] inhibitors, interleukin [IL] 12/23 inhibitor, IL-17 inhibitors, IL-23 inhibitors, cytotoxic T-lymphocyte-associated antigen-4 costimulator, phosphodiesterase-4 inhibitor, Janus kinase inhibitors, tyrosine kinase 2 inhibitor, cyclosporine (CsA), and methotrexate [MTX]) undergoing surgery. METHODS We performed a search of the MEDLINE PubMed database of patients with chronic autoimmune inflammatory disease on immune therapy undergoing surgery. RESULTS We examined 48 new or previously unreviewed studies; the majority were retrospective studies in patients with rheumatoid arthritis and inflammatory bowel disease. CONCLUSION For low-risk procedures, TNF-α inhibitors, IL-17 inhibitors, IL-23 inhibitors, ustekinumab, abatacept, MTX, CsA, and apremilast can safely be continued. For intermediate- and high-risk surgery, MTX, CsA, apremilast, abatacept, IL-17 inhibitors, IL-23 inhibitors, and ustekinumab are likely safe to continue; however, a case-by-case approach is advised. Acitretin can be continued for any surgery. There is insufficient evidence to make firm recommendations on tofacitinib, upadacitinib, and deucravacitinib.
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Affiliation(s)
- Warren A James
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Angela L Rosenberg
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jashin J Wu
- Department of Dermatology, University of Miami Miller School of Medicine, Miami, Florida
| | - Sylvia Hsu
- Department of Dermatology, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - April Armstrong
- Department of Dermatology, Keck School of Medicine at University of Southern California, Los Angeles, California
| | | | - Lara Wine Lee
- Department of Dermatology, Medical University of South Carolina, Charleston, South Carolina
| | - Joseph Merola
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sergio Schwartzman
- Department of Dermatology, 72nd Street Medical Associates, New York, New York
| | - Dafna Gladman
- Department of Dermatology, University of Toronto, Toronto, Canada
| | - Clive Liu
- Department of Dermatology, Bellevue Dermatology, Bellevue, Washington
| | - John Koo
- Department of Dermatology, University of California, San Francisco Medical Center, San Francisco, California
| | - Jason E Hawkes
- Department of Dermatology, University of California, Davis, Rocklin, California
| | - Soumya Reddy
- Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Ron Prussick
- Department of Dermatology, Washington Dermatology Center, Frederick, Maryland
| | - Paul Yamauchi
- Department of Dermatology, Dermatology Institute & Skin Care Center, Santa Monica, California
| | - Michael Lewitt
- Department of Dermatology, Illinois Dermatology Institute, LLC, Chicago, Illinois
| | - Jennifer Soung
- Department of Dermatology, Southern California Dermatology, Santa Ana, California
| | - Jeffery Weinberg
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mark Lebwohl
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brad Glick
- Department of Dermatology, Glick Skin Institute, Margate, Florida
| | - Leon Kircik
- Department of Dermatology, Physicians Skin Care, Louisville, Kentucky
| | - Seemal Desai
- Department of Dermatology, Innovative Dermatology, Plano, Texas
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mallory L Zaino
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina.
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Syed H, Nadeem A, Gardinier D, Weekley K, Ribakow D, Lupe S, Bhat S, Holubar S, Cohen BL. Peri-Operative Optimization of Patients with Crohn's Disease. Curr Gastroenterol Rep 2024; 26:125-136. [PMID: 38421577 PMCID: PMC11081987 DOI: 10.1007/s11894-024-00925-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE OF REVIEW The management of patients with Crohn's disease (CD) undergoing surgery is complex and optimization of modifiable factors perioperatively can improve outcomes. This review focuses on the perioperative management of CD patients undergoing surgery, emphasizing the need for a multi-disciplinary approach. RECENT FINDINGS Research highlights the benefits of a comprehensive strategy, involving nutritional optimization, psychological assessment, and addressing septic complications before surgery. Despite many CD patients being on immune-suppressing medications, studies indicate that most of these medications are safe to use and should not delay surgery. However, a personalized approach for each case is needed. This review underscores the importance of multi-disciplinary team led peri-operative management of CD patients. We suggest that this can be done at a dedicated perioperative clinic for prehabilitation, with the potential to enhance outcomes for CD patients undergoing surgery.
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Affiliation(s)
- Hareem Syed
- Department of Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Ahmed Nadeem
- Department of Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - David Gardinier
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Kendra Weekley
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Dovid Ribakow
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Stephen Lupe
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Shubha Bhat
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Stefan Holubar
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Benjamin L Cohen
- Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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Masood N, Khalid M. Importance of age, complications, progression, and risk factors in Crohn's Disease management with biologics. Dig Liver Dis 2024; 56:214-215. [PMID: 37845153 DOI: 10.1016/j.dld.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 09/07/2023] [Accepted: 09/26/2023] [Indexed: 10/18/2023]
Affiliation(s)
- Nimra Masood
- Services Institute of Medical Sciences, Jail Road, Lahore, Pakistan.
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Li L, Jiang K, Lou D, Zhang M, Shi Y, Shen J, Fu X. Systematic Review and Meta-Analysis: Association between Preoperative Ustekinumab and Surgical Complications in Crohn's Disease Patients. Eur Surg Res 2023; 64:412-421. [PMID: 37598662 PMCID: PMC10733938 DOI: 10.1159/000533594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 08/09/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION The impact of ustekinumab (UST) therapy on surgical complications in patients with Crohn's disease (CD) remains controversial. The aim of this meta-analysis is to explore the link between these two. METHODS Databases (PubMed, Web of Science, Cochrane, and Springer Link) were searched until April 2022. Studies of CD patients who received UST and no UST prior to surgery (including no biological therapy, anti-tumor necrosis factor-α [anti-TNF-α] agent, and vedolizumab [VDZ]) were included. Primary outcomes included overall complications, infectious complications, and noninfectious complications. RESULTS Nine studies totaling 3,225 CD patients were enrolled; 332 patients received UST treatment. There was no evidence of difference in the overall complications (odds ratio [OR] = 0.84, p = 0.37, 95% confidence interval [CI] = [0.57-1.23], I2 = 40%) between CD patients who had UST treatment preoperatively and those who had no UST treatment. There was no evidence of a difference in infectious complications (OR = 1.15, p = 0.35, 95% CI = [0.86-1.53], I2 = 2%). Additionally, there was no significant evidence of difference between these groups in terms of noninfectious complications and death. Specifically, there was no evidence of difference in overall complications, infection complications (including wound complications, sepsis, abscess, and anastomotic leakage), and noninfection complications (ileus, readmission, and return to operation), compared with no biological therapy and anti-TNF-α agents. At the same time, no significant evidence of difference was discovered in the comparison of preoperative UST and VDZ therapy in terms of overall complications, infectious complications (sepsis and abscess), and noninfectious complications (intestinal obstruction, readmission, and recovery surgery). CONCLUSION In general, compared with other biological agents, preoperative use of UST in the treatment of CD patients is usually safe and does not increase surgical complications.
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Affiliation(s)
- Lingna Li
- Pharmacy Department, The Affiliated Hospital of Ningbo University, LiHuiLi Hospital, Ningbo, China
| | - Ke Jiang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Dandi Lou
- The First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Mengting Zhang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yetan Shi
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jingyi Shen
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiaojun Fu
- Nursing Department, Ningbo No. 2 Hospital, Ningbo, China
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Perioperative Management of Pediatric Crohn's Disease. J Pediatr Gastroenterol Nutr 2023; 76:137-141. [PMID: 36302248 DOI: 10.1097/mpg.0000000000003648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Xia K, Gao RY, Wu XC, Yin L, Chen CQ. Timing of individualized surgical intervention in Crohn’s disease. World J Gastrointest Surg 2022; 14:1320-1328. [PMID: 36632120 PMCID: PMC9827570 DOI: 10.4240/wjgs.v14.i12.1320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/24/2022] [Accepted: 12/01/2022] [Indexed: 12/27/2022] Open
Abstract
Crohn’s disease (CD) is a chronic inflammatory disorder of the gastrointestinal tract with an increasing incidence worldwide. Comprehensive therapy for CD focuses on symptom control and healing the intestinal mucosa to improve the quality of life and prevent complications. Surgical intervention plays a vital role in comprehensive therapy. However, deciding the optimal timing for surgical intervention has long been a focus of controversy. This review provides insights into the timing of surgery for CD and guides clinicians in daily treatment.
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Affiliation(s)
- Kai Xia
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Ren-Yuan Gao
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Xiao-Cai Wu
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Lu Yin
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Chun-Qiu Chen
- Diagnostic and Treatment Center for Refractory Diseases of Abdomen Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai 200072, China
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