We are treating a patient who is currently on infliximab (Remicade) and methotrexate for severe Crohn’s disease and rheumatoid arthritis. Because of severe joint pain, she would like to have her knee replaced. Her gastroenterologist is concerned about a possible flare of her Crohn’s and does not want to stop the Remicade or methotrexate prior to surgery. What do you suggest for optimum results in this patient?
—ANNELIESE JACOBSON, PA-C, Pinehurst, N.C.

This question will come up more frequently as an increasing number of people are placed on biologics (e.g., infliximab, adalimumab) and other anti-tumor necrosis factor-a agents. Unfortunately, the scientific data available are insufficient to give a definitive answer. Infliximab and methotrexate are excellent agents for the management of  autoimmune diseases, such as rheumatoid arthritis and Crohn’s disease, because they prevent the action of the immune system. The downside of this action is an increase in the risk of infection, whether or not the patient is undergoing surgery.

While I was unable to locate any data specific to orthopedic surgery, there are data on Crohn’s disease patients on a regimen of inflixmab who underwent intestinal resection (Aliment Pharmacol Ther. 2004;19:749-754). Researchers observed a non-statistically significant increase in postoperative infection rate in the group taking infliximab. This study relates well to the case in question because the infliximab group was also more likely to be utilizing other immunosuppressants, such as methotrexate. If surgery is unavoidable, consideration should be given to stopping the methotrexate, perhaps two to three weeks prior to the procedure. The infliximab is easier to manage: Since this agent is generally infused every eight weeks, the optimal time to do the surgery is a week or two prior to the next infusion. The patient will definitely be at a higher risk for infection and flare of Crohn’s disease in the perioperative period, and she should be made aware of this.
—Bruce D. Askey, MSN, CRNP (119-17)