Perioperative management of tumor necrosis factor antagonists in patients with psoriasis and other inflammatory disorders

Abstract

Tumor necrosis factor alpha (TNF-α) plays an important role in host defense and possibly wound healing. It is also linked to the pathophysiology of many inflammatory diseases, including psoriasis. The TNF antagonists are a class of agents that have proven effective in treating psoriasis and psoriatic arthritis, yet the immunosuppressive effects of these agents raise concern over their use perioperatively. Currently, there is no consensus as to when TNF antagonists should be discontinued prior to surgery. Furthermore, data on the topic are limited to inflammatory bowel disease (IBD) and rheumatoid arthritis (RA). This paper reviews the literature on post-surgical outcomes in patients with RA and IBD receiving anti-TNF therapy. Although most studies reveal no statistically significant increased risk of post-surgical complications in these patients, the retrospective design and small sample size of these studies limits interpretation. Furthermore, when applying these data to psoriasis and psoriatic arthritis, physicians must also consider disease severity, individual comorbidities, and the pharmacokinetics of the different TNF antagonists. Additional studies are needed in psoriasis and psoriatic arthritis in order to develop truly evidence-based dermatologic guidelines for perioperative management of the TNF antagonists.

Key words::

• healing
• infection
• psoriasis
• psoriatic arthritis
• surgical complications
• tumor necrosis factor antagonists

Acknowledgements

The authors report that there are no funding sources. Meghan Hession has no conflicts of interest to declare. Nearly all of Dr Gottlieb's income is paid directly to her employer. Dr Gottlieb's current consulting/advisory board agreements include the following: Amgen, Inc., Centocor, Inc., Wyeth Pharmaceuticals, Celgene Corp., Bristol Myers Squibb Co., Beiersdorf, Inc., Abbott Labs, Roche, Sankyo, TEVA, Actelion, UCB, Novo Nordisk, Immune Control, DermiPsor, Incyte, Corgentech, PureTech, Magen Biosciences, Cytokine Pharmasciences, Inc., Ono, and Alnylam. Dr Gottlieb is the primary investigator on research/educational grants paid to Tufts Medical Center from Centocor, Amgen, Wyeth, Immune Control, Celgene, Incyte, Abbott, Pfizer, and Novo Nordisk.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.