Guidance on perioperative care of patients with autoimmune diseases requiring biologic therapy and temporizing strategies.
Perioperative management of autoimmune diseases on biologics demands careful planning, risk assessment, and tailored timing to optimize outcomes, reduce infections, and balance disease control with surgical healing.
Maintaining a patient-centered approach, perioperative planning begins with multidisciplinary collaboration among rheumatologists, surgeons, anesthesiologists, and specialists in infectious disease and pharmacy. Early communication clarifies which biologic agents are involved, their mechanisms, and potential implications for wound healing and infection risk. The team maps a timeline that accounts for the patient’s disease activity, prior responses to biologics, vaccination status, and comorbid conditions. Practical considerations include balancing the risk of disease flare against surgical infection risk, determining bridging strategies, and aligning perioperative plans with hospital protocols for biologic withholding, resuming, and monitoring laboratory parameters. Clear documentation aids shared decision-making and continuity of care.
A foundational step is assessing individual risk through structured preoperative evaluation. This assessment verifies current disease activity, prior infection histories, and concurrent medications such as corticosteroids or other immunosuppressants. The evaluation should include renal and liver function, complete blood counts, and inflammatory markers to establish a baseline. Vaccination status is reviewed, with attention to timing relative to surgery, especially for live vaccines where applicable. Shared decision-making should address whether to pause biologic therapy, use a shorter-acting agent as a bridge, or maintain some level of therapy when disease control is essential. The goal is a personalized plan that minimizes surgical risk while preserving autoimmune disease control.
Weighing biologic pause against infection risk and flare probability.
When considering biologic pauses, it is essential to understand the drug’s pharmacokinetics, including half-life and tissue persistence, as these factors influence when disease control may wane and when relapse risk rises. A common principle is to plan a biologic hold around the time of major procedures with substantial infection risk, allowing immune recovery to support healing. However, for some patients with aggressive disease, continuing low-dose or localized therapy may be preferable. Decisions hinge on the balance between surgical infection risk and the likelihood of a flare if the agent is stopped. Documentation should specify the exact timing, the rationale, and contingency steps if disease activity changes.
Temporizing strategies commonly employed include bridging with non-biologic immunomodulators or steroids, depending on the disease, prior response, and risk profile. The use of short courses of systemic steroids requires caution due to infection risk, hyperglycemia, and wound healing implications. Non-steroidal approaches such as calcineurin inhibitors or conventional disease-modifying antirheumatic drugs may be considered in certain contexts to maintain disease control while avoiding the heightened infection risk associated with some biologics. Each strategy should be individualized and revisited if surgical plans shift or postoperative healing is slower than anticipated.
Postoperative monitoring to balance healing with disease control needs.
In the postoperative period, vigilance for infection, wound dehiscence, and impaired healing is essential. Early signs of infection require prompt assessment and management without delaying necessary disease control. Patients should receive clear instructions on wound care, fever thresholds, and when to seek urgent care. The care team should monitor for adverse effects from bridging therapies and adjust regimens based on evolving clinical status. Coordination with pharmacy ensures appropriate resumption timing for biologics, minimizing gaps in treatment that could trigger flare while reducing perioperative infection risk. Patient education is a continuous component of safety.
Resuming biologic therapy after surgery must consider the risk of surgical site infection, tissue healing status, and the patient’s overall recovery. The timing of reinitiation often depends on wound healing progress, absence of signs of infection, and specific drug characteristics. For some agents with longer half-lives, delayed reintroduction may be prudent, whereas others with shorter half-lives permit earlier restart. The team documents the exact restart schedule, anticipated monitoring requirements, and contingency plans if postoperative complications arise. Shared decision-making remains central, aligning patient preferences with clinical realities.
Nutrition, physical health, and vaccination impact perioperative recovery.
The perioperative plan should include a risk stratification framework that guides intraoperative decisions such as tourniquet use, surgical duration, and prophylactic antibiotic choices. Patients with autoimmune diseases may benefit from tailored anesthesia plans aimed at minimizing immunosuppressive exposure and optimizing pain control. Multimodal analgesia can reduce opioid needs and support faster recovery, while regional anesthesia, when appropriate, can enhance comfort and reduce systemic immunosuppression. Each decision should be documented with rationale and linked to the patient’s therapeutic regimen to maintain clarity across care transitions.
Nutritional and physiologic optimization improves recovery for patients on biologics. Preoperative assessment should screen for malnutrition, anemia, and vitamin deficiencies, which can impair healing and infection resistance. Interventions may include targeted dietary optimization, iron supplementation if indicated, and metabolic optimization for patients with diabetes or cardiovascular risk factors. A proactive approach to physical conditioning, smoking cessation, and sleep hygiene further supports resilience. The care team should also review vaccination windows and ensure timely completion of non-live vaccines as appropriate, given surgical timing and immune status.
Individualized, evidence-based perioperative pathways matter most.
Communication with patients about expectations reduces uncertainty and improves adherence to the care plan. Shared decision-making should address the trade-offs between disease control and surgical risk, including the possibility of temporary disease activity fluctuations. Clear explanations of the rationale behind stopping or continuing therapy foster trust and empower patients to participate actively in their care. Written instructions, reminders about medication holds, and a private point of contact can streamline postoperative follow-up. The patient’s understanding of potential symptoms and when to seek help is as important as the clinical plan itself.
An evidence-informed framework supports consistency across clinicians and facilities. Guidelines emphasize individualized decisions rather than rigid rules, recognizing substantial heterogeneity in autoimmune diseases and biologics. The framework incorporates drug-specific data, timing relative to procedures, and institutional infection control practices. Continuous quality improvement, including audit and feedback on perioperative outcomes, helps refine protocols and identify opportunities to minimize risk without compromising disease management. Clinicians should stay updated with evolving research, expert consensus, and patient experiences to optimize care.
Ethical considerations underpin all decisions in perioperative care for patients on biologic therapy. Respect for patient autonomy entails thorough counseling about risks, benefits, and uncertainties associated with biologic holds or resumption. Equity requires that all patients receive consistent access to multidisciplinary teams, even in resource-constrained settings. Transparency about limitations of current knowledge encourages shared ownership of outcomes. Clinicians must balance patient preferences with clinical judgment, aiming to minimize harm while supporting disease control. Documentation should reflect the informed consent process and the collaborative nature of the plan.
Finally, the perioperative journey extends beyond the immediate surgical event. Post-discharge follow-up should monitor wound healing, infection signs, and autoimmune disease activity, adjusting therapy as needed. Regular check-ins enable early detection of problems and timely modifications to treatment. The integration of telemedicine options can enhance accessibility and adherence during recovery, especially for patients with mobility challenges or complex regimens. Empowered patients, supported by a cohesive care team, are better positioned to achieve favorable surgical outcomes while maintaining autoimmune disease control over the long term.
