Inflammatory Bowel Disease


Drug

Recommendation for practice

Evidence levelb

Glucocorticoids

Continue; administer stress dose
 
5-ASA

Discontinue on day of surgery and resume 3 days after surgery if normal renal function

C

Azathioprine, 6-MP

Discontinue on day of surgery and resume 3 days after surgery if normal renal function

B, C

Methotrexate

Continue, unless previous poor wound healing or postoperative infections

B, C

Cyclosporine

Continue but carefully monitor for opportunistic infectious complications

B, C

Infliximab

Continue without interruption

B


Adapted with permission from [8]

a5-ASA = 5-aminosalicylic acid; 6-MP = 6-mercaptopurine

bEvidence level A = multiple populations evaluated (trials and clinical registries), multiple randomized clinical trials, or meta-analysis; evidence level B = limited populations evaluated, data derived from a single randomized trial or nonrandomized studies; evidence level C = very limited populations evaluated or consensus opinion of experts, case studies, or standards of care





Monitoring/Prevention of Complications


Patients undergoing surgery for IBD present clinicians with unique postoperative challenges that can delay recovery including limited options for pain management, hyperglycemia in patients on glucocorticoids, and poor nutritional status. The following measures may help guide clinicians in the appropriate postoperative management of these patients.



  • Close attention to perioperative glycemic control for patients on glucocorticoids given that persistent hyperglycemia can delay wound healing and lead to surgical site complications.


  • Attempt to minimize the use of narcotic analgesia, though it is important to note that narcotic agents are preferred over other pain medications, as studies have shown a possible association between NSAID use and IBD flares [13].


  • Transfuse to maintain hemoglobin >7 g/dL.


  • Close collaboration with nutrition colleagues to maintain adequate supplementation and aid postoperative healing—patients may need TPN depending on underlying malnutrition and disease severity particularly if patient is undergoing a two- or three-stage procedure.


  • Early antibiotic therapy and surgical exploration if concerned for intra-abdominal source of sepsis.



References



1.

Narula N, Charleton D, Marshall JK. Meta-analysis: peri-operative anti-TNFα treatment and post-operative complications in patients with inflammatory bowel disease. Aliment Pharmacol Ther. 2013;37(11):1057–64. doi:10.​1111/​apt.​12313.PubMedCrossRef


2.

Nasir BS, Dozois EJ, Cima RR, et al. Perioperative anti-tumor necrosis factor therapy does not increase the rate of early postoperative complications in Crohn’s disease. J Gastrointest Surg. 2010;14(12):1859–66. doi:10.​1007/​s11605-010-1341-5.PubMedCrossRef

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Oct 6, 2016 | Posted by in RESPIRATORY | Comments Off on Inflammatory Bowel Disease

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