Hepatitis Ahas made little appearance in the literature in relation to biologic use.Hepatitis B
in patients being treated with anti-TNF or rituximab therapy is quite clearly associated with
potentially devastating disease. Ascertainment ofHepatitis Bstatus is now standard of care prior
to biologic treatment with positivity warranting co-administration of a nucleoside analogue like
lamivudine with subsequent evaluation of aminotransferases.
In Consideration of Surgery
Glucocorticoids
There are three important considerations with regard to surgical intervention in a patient
taking exogenous glucocorticoids:
- Integrity of the hypothalamic axis
- Risk of infection
- Effects on wound healing and bleeding
For this reason, careful attention to development of infection, hematoma, dehiscence, and
hemodynamic decompensation are important constellations in postsurgical care. Again, the
decision for supplemental steroid use to compensate for the stress of surgery is based on
individual cases with consideration of degree of hypothalamic suppression and the intensity of
the surgery.
Biologic Agents
Uncertainty surrounds the perioperative use of anti-TNF agents. Limited information culled
from bowel surgeries for Crohn’s disease and rheumatoid foot surgeries initially suggested
perioperative use of biologics had little adverse effect on healing with small studies (51–53).
Larger patient samples suggested that continuation of anti-TNF therapy increased risk of
postoperative infection (54,55), the most important risk factor for infection being previous
history of surgical site infection (56). All published studies on this topic contain major
limitations making a clear conclusion elusive.
The controversy of continuation of biologic agents in the setting of surgical intervention
lies within the benefits on wound healing, vascular integrity, and general wellness associated
with control of underlying inflammatory disease versus the potential increased risk of
infection. The British registry that tries to maintain information on all patients receiving anti-
TNF agents found a significantly increased risk of skin and soft tissue infections—this however
was not defined within the context of surgery (57). Interestingly, a large retrospective study
identified previous history of joint surgery as the single risk factor for serious infection in
patients receiving anti-TNF therapy (56). Studies defined within the surgical setting identified
the most important risk factor being that of prior history of either surgical site or skin infection
(54).
The general consensus for when to discontinue agents in the perioperative period is quite
varied and somewhat arbitrary. The British Society of Rheumatology supports discontinuation
two to four weeks prior to surgery (58) while both the Dutch and French Societies of
Rheumatology both support discontinuation for the quadrupled half-life of the agent before
surgery. Most common practice in the States is to withhold anti-TNF therapy by at least one
dosing interval. For example, a patient would be scheduled for surgery at least one week after
discontinuing an anti-TNF agent that is given weekly.
Currently, studies regarding perioperative infection and abatacept (interruption of T-cell
co-stimulation with APC) are not available. Caution would suggest withholding infusion for
one dosing interval in nonemergent surgical procedures. Regarding, B-cell-depleting therapy
such as rituximab, it may take up to one year for repletion of circulating B cells. Measurement
of peripheral CD19þpositive B cells are thought to be a good estimation of returned humoral
immunity. Though it is important to bear in mind that B-cell depletion potentially incites other
B-cell-related mechanisms of immune suppression other than pure B-cell lysis, which is not
quantifiable at this time. Close observation for the development of infection is warranted in
these patients.
Infections Related to Steroids and Biologics in Critical Care 383