NPF Releases Perioperative DMARD Guidelines in PsA

Based on level III evidence, infliximab, adalimumab, etanercept, methotrexate, and cyclosporine can be continued throughout perioperative period for low-risk operations in patients with psoriasis and psoriatic arthritis

Certain systemic immunomodulatory agents commonly used to treat moderate-to-severe plaque psoriasis and psoriatic arthritis (PsA) are safe to continue in the perioperative period  in patients undergoing certain low-risk surgeries, concluded the authors of a literature review published in the October issue of The Journal of the American Academy of Dermatology.1

Written under the auspices of the Medical Board of the National Psoriasis Foundation, the paper’s recommendations should be considered as an official guideline from that organization, said co-author Jashin J. Wu, MD,  in an email interview with Rheumatology Advisor. Dr Wu is director of dermatology research at Kaiser Permanente Medical Center, Los Angeles, California.

Surgical interventions are known to induce widespread immune suppression and interfere with cell-mediated immunity, leading to concerns that the use of systemic immunomodulators could compound the risk of infection and impede postoperative wound healing. Conflicting data have left the effect of immunomodulatory therapy on the risk of post-operative infection unclear.

Using the Medline PubMed database, the investigators identified studies published from January 1, 1970, to November 27, 2015 on the topic of perioperative complications associated with the use of immunomodulatory drugs in patients with psoriasis, PsA, rheumatoid arthritis (RA), or inflammatory bowel disease (IBD).

High Yield Data Summary

  • Infliximab, adalimumab, etanercept, methotrexate, and cyclosporine can be safely continued throughout the perioperative period in certain “low-risk” surgeries

The investigators included relevant studies on RA and IBD because of a scarcity of studies specific to psoriasis or PsA. 

The drugs included in the literature search were oral methotrexate (MTX), cyclosporine, and the 8 current FDA-approved biologic therapies for psoriasis, PsA, or both. These include etanercept, adalimumab, infliximab (IFX), golimumab, secukinumab, ustekinumab, and certolizumab.

A total of 46 studies were included in the final analysis. Following the categorization and grading of evidence, the investigators concluded that IFX, adalimumab, etanercept, MTX, and cyclosporine are safe to continue in patients undergoing low-risk surgeries.  For the purposes of this study, low-risk procedures were defined as: endoscopy, bronchoscopy, hysteroscopy, cystoscopy, dermatologic procedures, breast biopsy/excision, ophthalmologic procedures, and any ambulatory procedures.

Dr Wu noted that the data on the perioperative use of golimumab, certolizumab pegol, ustekinumab, apremilast, secukinumab, and ixekizumab was insufficient to make firm recommendations.  “It would be helpful if future studies examined these agents,” he stated.

Prior recommendations from the Medical Board of the National Psoriasis Foundation asserted that tumor necrosis factor (TNF)-alpha inhibitors should be discontinued for a period of 4 half-lives before surgery. Current clinical practice guidelines from various rheumatology and dermatology associations are similarly conservative. Although they stipulate varying time periods during which biologic agents should be withheld before surgery, none allow for their perioperative use.

More guidance is forthcoming about the use of immunomodulatory agents in surgical patients, according to Jon T Giles, MD, MPH, assistant professor of medicine, from the Division of Rheumatology at Columbia University, New York.The [American College of Rheumatology] is publishing a higher profile guideline on this topic from a task force of rheumatologists and orthopedists.  It will cover inflammatory arthritis and lupus and is more thorough on evidence evaluation,” he told Rheumatology Advisor.

Summary and Clinical Applicability

“Based on the evidence, we believe that IFX, adalimumab, etanercept, MTX, and cyclosporine should be safely continued through low-risk surgery,” concluded the research team. “For intermediate- and high-risk operations, a more conservative case-by-case approach should be taken based on the patient’s individual risk factors and comorbidities.”

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Limitations and Disclosures

Dr. Weinberg is a consultant for AbbVie, Celgene Corporation, Pfizer, and Eli Lilly; is on the speaker’s bureau for AbbVie; and received research funding from Celgene Corporation, LEO Pharma, Amgen, and Novartis. 

Dr Yamauchiis a consultant for AbbVie, Amgen, Janssen, Eli Lilly, Pfizer, Celgene Corporation, and Novartis, and on the speaker’s bureau for AbbVie, Amgen, Janssen, Celgene Corporation, and Novartis. 

Dr Wu is a consultant for AbbVie, Amgen, Celgene Corporation, Dermira, Eli Lilly, Pfizer, Regeneron, and Sun Pharmaceutical Industries, and received research funding from AbbVie, Amgen, AstraZeneca, Boehringer Ingelheim, Coherus Biosciences, Dermira, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Regeneron, Sandoz, and Sun Pharmaceutical Industries. 

Dr Armstrong is an investigator for and/or consultant to AbbVie, Amgen, Celgene Corporation, Janssen, Merck, Eli Lilly, Novartis, and Pfizer. 

Dr Van Voorhees is an investigator for and/or consultant to Amgen, AbbVie, Novartis, Pfizer, Janssen,
Leo, Celgene Corporation, Aqua, Dermira and Astra Zeneca, and receives a portion of her ex-spouse’s pension from Merck.

Dr Siegel is employed by the National Psoriasis Foundation, which receives unrestricted financial support from companies that make products used to treat psoriasis and psoriatic arthritis, including Abbvie, Amgen Inc, Celgene Corporation, Eli Lilly and Co, Galderma Laboratories LP, Janssen Biotech Inc, LEO Pharma Inc, Novartis, Pfizer Inc, and Stiefel, a GSK

Drs Choi and Debbaneh declared no potential conflicts of interest.


  1. Choi YM, Debbaneh M, Weinberg JM, et al. 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. 2016;75(4):798-805.e7. doi:10.1016/j.jaad.2016.06.014.

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