Executive Summary: From the Medical Board of the National Psoriasis Foundation: Perioperative management of immunomodulatory agents in patients with psoriasis and psoriatic arthritis

Abstract

BackgroundSystemic 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 and complication. ObjectiveTo evaluate the risk of surgical site infection and complication in patients with chronic autoimmune inflammatory disease receiving immunomodulatory agents (tumor necrosis factor-alpha inhibitors, interleukin [IL]-12/23 inhibitor, IL-17 inhibitors, IL-23 inhibitors, cytotoxic T-lymphocyte–associated antigen-4 co-stimulator, phosphodiesterase-4 inhibitor, Janus kinase inhibitors, tyrosine kinase 2 inhibitor, cyclosporine, and methotrexate) undergoing surgery. MethodsWe performed a search of the MEDLINE PubMed database of patients with chronic autoimmune inflammatory disease on immune therapy undergoing surgery. ResultsWe examined 48 new or previously unreviewed studies; the majority were retrospective studies in patients with rheumatoid arthritis and inflammatory bowel disease. ConclusionFor low-risk procedures, TNF-alpha inhibitors, IL-17 inhibitors, IL-23 inhibitors, ustekinumab, abatacept, methotrexate, cyclosporine, and apremilast can safely be continued. For intermediate- and high-risk surgery, methotrexate, cyclosporine, 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.