1 / 43

Miguel Regueiro, M.D. Professor of Medicine Associate Chief for Education

Pro: Perioperative anti-TNF Biologics are safe and do not increase complications associated with surgery. . Miguel Regueiro, M.D. Professor of Medicine Associate Chief for Education Clinical Head and Co-Director, IBD Center University of Pittsburgh School of Medicine.

manny
Download Presentation

Miguel Regueiro, M.D. Professor of Medicine Associate Chief for Education

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Pro: Perioperative anti-TNF Biologics are safe and do not increase complications associated with surgery. Miguel Regueiro, M.D. Professor of Medicine Associate Chief for Education Clinical Head and Co-Director, IBD Center University of Pittsburgh School of Medicine

  2. Probability of using IMM before 1stabd surgery (n=296) Peyrin-Biroulet L et al. Gut 2011

  3. Probability of receiving at least 1 antiTNF before 1st surgery (296) Peyrin-Biroulet L et al. Gut 2011

  4. This means that most IBD patients undergoing surgery are taking an IMM and/or antiTNF If it’s an emergent surgery, we don’t have much choice on altering pre-op meds. Should the type of operation be altered? If the surgery is elective: Should we alter pre-op meds? Is starting an antiTNF in the postop setting safe?

  5. Dr Remzi will argue that peri-operative antiTNF is unsafe As you may know, there’s a bit of a rivalry between Pittsburgh and Cleveland

  6. Pittsburgh vs Cleveland

  7. Despite the intercity rivalry, I have the utmost respect for Dr Remzi and the Cleveland Clinic In reality, our hospitals and cities are quite similar

  8. UPMC and Pittsburgh on a typical summer morning

  9. Cleveland Clinic on that same, bright summer morning

  10. A Tale of Two Cities – a surgeon’s perspective on postop outcome • 27 yo CD from Youngstown OH sees Dr Regueiro in Pittsburgh on AZA/ADA • Develops SBO while in Cleveland and requires emergent surgery w Dr Remzi • Scenario 1: dc’d 4 days later, “great!” – Dr Remzi – “I am a brilliant surgeon!!” • Scenario 2: POD 2 develops an anast leak – Dr Remzi – “it’s all because of those poisons Dr Regueiro was giving you!”

  11. Three Scenarios to Consider • PRE-operative antiTNF for CROHN’S disease and POST-op complications • PRE-operative antiTNF for ULCERATIVE COLITIS disease and POST-op complications • POST-operative antiTNF for CROHN’S disease and POST-op complications

  12. PRE-operative antiTNF for CROHN’S disease and POST-op complications What are the data?

  13. 9 Crohn’s ds Postop References • Tay et al. Surgery 2003 • Marchal et al. Aliment Pharmacol Ther 2004 • Colombel et al. Am J Gastroenterol 2004 • Appau et al. J Gastrointest Surg 2008 • Indar et al. World J Surg 2009 • Canedo et al. Colorectal Dis 2011 • Nasir et al. J Gastrointest Surg 2012 • Kasparek et al. Inflamm Bowel Dis 2012 • Kopylov et al. Inflamm Bowel Dis 2012

  14. Tay – Multivariate analysis suggests improved perioperative outcome in CD pts receiving IMMs before resection • Overall, 11% Postop complications (5.6% on IMM, 25% not on IMM)

  15. Marchal – The risk of postop complications associated with IFX for CD: a controlled cohort study • 12.5% IFX vs 7.7% control: Early complication

  16. Colombel – Early postop complications are not increased in CD treated preop with IFX or IMM • Overall, 23 % postoperative complications

  17. Indar – Effect of periop IMM/TNF on early outcome in CD pts • Overall, 33% postoperative complications

  18. Canedo – Surgical resection in CD: is IMM associated with higher postop infxn rates?

  19. Nasir – Periop antiTNF does not increase the early postop complications in CD • Overall, 29% postoperative complications

  20. Kasparek – IFX does not affect postop complication rates in CD • Overall, 59% postoperative complications

  21. Appau – Use of IFX within 3 mos of IC resection IS associated with postop AEs..Dr Remzi is co-author...hmmmm…… • Overall, 72% postop complications

  22. Kopylov – AntiTNF and Postop complications in CD: Systematic Review and Meta-analysis - OR 1.7 (CI, .93-3.19) postop complications - Number Needed to Harm = 20

  23. ORs Overall Complications

  24. Risk of postop complications in CD – only one “Yes” Kopylov et al. IBD 2012

  25. PRE-operative antiTNF for ULCERATIVE COLITIS disease and POST-op complications What’s the data?

  26. UC Postop References • Selvasekar et al J Am Coll Surg 2007 • Schluender et al Dis Colon Rectum 2007 • Mor et al Dis Colon Rectum 2008 • Ferrante et al Inflamm Bowel Dis 2009 • Norgard et Aliment Pharmacol Ther 2012 • Yang et al Aliment Pharmacol Ther 2010 UC and CD Studies combined: • Kunitake et al J Gastrointest Surg 2008 • Waterman et al Gut 2012

  27. Selvasekar – Effect of IFX on short-term complications in pts undergoins operation for chronic UC – 62% complicaiton with IFX

  28. Mor – IFX in UC is associated with an increased risk of postop complications after restorative proctocolectomy • OR early complication IFX 3.54 (P = 0.004; 95% CI1.51-8.31). • OR sepsis IFX 13.8 (P = 0.011; 95% CI, 1.82-105) • OR late complication IFX 2.19 times (P = 0.08; 95% CI, 0.91-5.28)

  29. Norgard – Pre-op use of antiTNF and the risk of postop complications in pts with UC – a nationwide cohort study • 1226 UC pts – 199 IFX • Most underwent ileostomy (not IPAA) • OR reoperation 1.07 (95% CI: 0.71-1.59) • OR anastomosis leakage 0.52 (95% CI: 0.06-4.11) respectively

  30. Ferrante – Corticosteroids but not IFX increase short-term postop infectious complications in pts with UC

  31. Yang – Meta-analysis: pre-op IFX + short-term postop complications UC pts • short term infxn (NO) • 2. short term non infxn (NO) • 3. short term overall (YES)

  32. Periop antiTNF UC studies

  33. Is starting POST-op antiTNF within 1 mos of CD surgery safe? Postoperative infliximab is not associated with an increase in adverse events in Crohn's disease. Regueiro M, El-Hachem S, Kip K, et al. Dig Dis Sci. 2011 Dec;56(12):3610-5.

  34. No Difference in Adverse Events between Placebo and Infliximab (started within 4 wks of surgery)

  35. Is peri-op antiTNF Safe? Scorecard of Study Results

  36. What I do in practice?

  37. My Practice – periop management

  38. My Practice – periop management

  39. My Practice – periop management

  40. My Practice – periop management

  41. My Practice – periop management

  42. Summary Periop antiTNF • CD: antiTNF is not associated with increased risk when used in the perioperative period • UC: severity of ds is most associated with complications rather than antiTNF • 3 step IPAA being done anyway • Practically speaking: surgery should NOT be delayed because a patient is on antiTNF

  43. With that, I give you Dr Remzi

More Related