RA biologics and elective surgery rules in the uk

[lindyloo2018]

Hello

has anyone on biologics had surgery ?

please could you tell me the rules are for stopping and restarting biologics and if any problems were encountered re healing and infections and how they were treated ?

many thanks

[Amnesiac3637]

Hi. Yes have had major surgeries whilst on biologics. Between them your rheumatologist and your surgeon will decide what stops when and for how long and your surgeon usually has the last word as they have responsibility for you whilst you are under their care. I was an orthopaedics sister and we do like people to ask questions!

When you go for your pre-op your medication should be discussed and you should be told then when/if it’s necessary to stop your drugs and for how long. If nobody mentions it then please do make sure you ask.

I had no problems with stopping my biologics when I was on them (and I healed well) and if you’re on steroids the anaesthetist will give you extra cover when you have the surgery. You haven’t said whether you’re having major or minor surgery which may make a difference to your drug regime but you will still need to discuss it. Best of luck and hope whatever op you’re having is a great success!

[lindyloo2018 in reply to Amnesiac3637]

thanks, I am having a wrist tendon op, 1.5 hours, guess that's minor surgery ? please could you tell me what drugs you take for RA? many thanks

[Amnesiac3637 in reply to lindyloo2018]

Yes it’s minor surgery though of course it may not feel like that to you!

Still take your doctors’ advice and make sure you’re clear about whether you should stop your drugs.

I’m on prednisolone 8mgs daily and Filgotinib (Jyseleca, a JAK inhibitor) for my RA. Best of luck with your surgery.

[lindyloo2018 in reply to Amnesiac3637]

many thanks, please could you tell me what biologic you were on and why you changed to JAK? I do not know how the RA team decide which biologic to start people on, it seems they always offer adalimumab first. is it trial and error? I don't know what choices of biologics I have inder the nhs ? many thanks

[Amnesiac3637 in reply to lindyloo2018]

I can’t better AgedCrone’s reply to you re what choice you have with regard to biologics as an NHS patient. So much does depend on your rheumatologist, the Integrated Care Board protocol and your own state of disrepair!

I am probably not the best one to ask about why I’m on a Jak but the reason is I am unable to tolerate all the biologics I’ve had (over the past 34 years I’ve had more or less everything) as they've either poisoned me or messed my bloods up. You can never compare with someone else’s regime as we’re all very different. My joints are irreversibly damaged but you may be much luckier and need a tweak of your medication once you’ve been put on one that suits you.

Long road, hard yards but you are unique so take what you’re offered and if it works, great and if it doesn’t talk to your doctors .

[Runrig01]

Hi I’ve just had foot surgery 3.5 weeks ago. I was asked to stop my biologic 2 weeks before, I also stopped my methotrexate then as well. The plan was to restart 2 weeks postop when wound had healed. Unfortunately a week after surgery I got an infection in the wound, and it has resulted in 2 sloughy areas which are slow to heal. I’ve been seeing my surgeon twice weekly since surgery, seen him today and to hold off meds for a further 2 weeks. I’ve also been restarted on another 2 week course of antibiotics.

Personally I wouldn’t wait till pre assessment, as mine was only 2 weeks prior to surgery. Some biologics you need to stop earlier, it depends on the half life of the biologic. I contacted my rheumatologist to get what they advised.

[Madmusiclover in reply to Runrig01]

I agree. I once had to postpone an op as pre assess too close to op for me to stop in time. Rheumy will advise. Don’t rely on pre assess. Their knowledge is limited.

[lindyloo2018 in reply to Runrig01]

sorry you had so much trouble, wish you well, did they give you post op antibiotics to take home ? missing your biologics for 4 weeks will result in a flare? then that may need steroids ?

[Runrig01 in reply to lindyloo2018]

I had an IV antibiotic on induction. However I didn’t get ABs till a week postop, when the gp at the utc wasn’t happy to just prescribe ABs and leave me for a week when I’d see the surgeon. He sent me to the hospital where an SHO was trying to argue it wasn’t infected. It was red, inflamed, oozing and I’d a temp of 38.3. He initially refused, till I said I assumed my FBC came back ok. He then had to admit my white cells were raised, so he prescribed. The surgeon said they were definitely needed.

I’m now 5.5 weeks off mine, and have gone into a flare, mainly nights I struggle as I can’t sleep due to the pains. I’m on lifelong steroids, and had to double whilst on ABs, but had to quickly taper back down. I’m only on 4.5mg which is a replacement dose, as I don’t produce cortisol, yet it’s still impacting healing. Increasing the dose isn’t an option. So I continue seeing him twice weekly, and today he said at least another two weeks off meds.

[lindyloo2018 in reply to Runrig01]

wow, I always ask for a course of AB to start the day after surgery, the risk of infection is too high for me. I have never had a surgeon refuse to give me AB post op. so the strategy has worked so far. now you are in a difficult phase. will salt water washes help the wound to heal ? that always seems to work with me also..all the best...

[Runrig01 in reply to lindyloo2018]

Most orthopaedic surgeons I worked with do not like to give prophylactic antibiotics, except for on induction, which I’m fine with, as you could end up with an infection resistant to antibiotics. I’ve been put back on 2 weeks of antibiotics by my respiratory specialist, which happens to be the same ones I had for the wound infection. So my surgeon is happy that it will deal with both. I’ve had previous injuries to the same leg, 2 which took 10 months to heal. Then last summer I gashed my leg in the shower and it took 10 weeks to heal, so I think reduced circulation is what causes some of the issues. I’m off my immunosuppressants for at least another 2 weeks. It’s definitely improving each time, so 🤞

[AgedCrone]

There seem to be no hard & fast rules to answer that question….So we really can’t t say ..I would imagine every patient would get individual advice.

I had surgery twice whilst on Rtx..but as it’s an infusion I didn’t have to do anything But for oral or injected Biologics you must just take your surgeon & rheumatologists advice.

Good Luck

[lindyloo2018 in reply to AgedCrone]

thanks you, what is Rtx ? are you still on it or changed to something else ? I do not know how the RA team decide which biologic to start people on, it seems they always offer adalimumab first. is it trial and error? I don't know what choices of biologics I have inder the nhs ? many thanks

[AgedCrone in reply to lindyloo2018]

I am on Rituximab infusions….since 2016.

In fact I had an infusion x one yesterday….I was in the hospital from 1030am until 5pm…then all over until the next time.Some people still remain on methotrexate with Rtx but I don’t. You are prescribed a biologic by your Rheumatologist offering what is thought most likely to be best for your condition. There is no first second and third choice, you are usually given a choice of maybe one,two or three different applications. Either tablets,injections or infusion …some people don’t like needles so they opt for tablets, others don’t mind . Ask you rheumy nurse’s opinion … you will probably be given some leaflets on your choice of bio.

On the NHS you actually take what your Rheumatologist advises you can’t just go in and ask what do you want. You will read on here, some people take very well to one drug, whereas others hate it - it really is just luck. It’s no reflection on your Rheumatologist if a drug doesn’t suit you….there are no 100% certainties with RA drugs.

[lindyloo2018 in reply to AgedCrone]

many thanks, I have asked the nurses they say they use criteria on nice for choosing which biologic, but I can't find it..

[AgedCrone in reply to lindyloo2018]

Just Google / Nice guidance rheumatoid arthritis Biologic drugs..but it probably won’t help you very much unless you know all your clinical details & even if you do….you won’t understand it ….your rheumy decides what you will be offered - guided by the years of experience gained rising to be a Consultant.We are all grateful we live in a country where if we qualify for these drugs we can have them without having to consider the cost. So take your rheumy team’s advice & get well.

[bpeal1]

There are no rules on this as there are so many varying factors which have to be weighed up including which biologic you are on, which other medications you take, the type of surgery, expected recovery time, infection risks (the infection risk from some surgeries is higher than others) and how well controlled your RA is (uncontrolled inflammation can put you at greater risk of infection than medication).

Ultimately it’s your surgeon’s decision as they are responsible for the surgery and its outcome however if they are not confident enough about making the decision they will take advice from your rheumatologist. When I had major surgery on my feet my surgeon (who knew my rheumatologist well) asked me to discuss it with rheumatologist and do whatever they said.

Make sure you highlight your medications to the surgeon when you next see them. You could also ask your rheumatologist for their opinion but at the end of the day you have to do what the surgeon says because they can refuse to do the surgery if you don’t.

[lindyloo2018 in reply to bpeal1]

ok thanks

[cathie]

I had two knee replacements while on rituximab. Obviously the medics timed the surgery so as not to overlap with the infusion, but they worked it out. I dont know if there's a protocol, but the surgeon and the rheumatologist know one another here and timed it well. It might be different if you inject the biologics weekly etc but they will be aware of that.

[lindyloo2018 in reply to cathie]

many thanks

[Jacey15]

My surgeon contacted rheumatology. I had to stop 2 weeks before and 2 weeks after but I imagine it will depend on what surgery you are having.

[lindyloo2018 in reply to Jacey15]

many thanks

[Tobymax35]

hi your R A nurse should have mentioned it to you about what to do if your having a op ,, if not I would contact them for advice , I’m on erelzi biological injection and I have to stop mine 2 week before the op and go back on it when all looks ok or healed I’ve had a couple of ops and waiting at present for a total shoulder replacement very soon so I will have to stop mine till everything is ok good luck with your op …

[Weemillie]

Hi there I have been on benipali for a number of years now . I went in for the 1st operation on my foot ,was told to Stop 2.weeks before and then I coudnt start it again until my foot had Healed completely.

And that was a long 10/12 weeks . I suppose it depends on which type of operation you are having as my foot was reconstructive surgery . Then 2 years later the rest of the foot was done including toes

So again 2 weeks before the operation then time it took to heal again it depends on the type of operation.

If they think there is any chance you can pick up any type of infection that's why your off it for so long .

Thats was my experience of it with the benipal hope it helps in some way . Take care . 👍

Foot after 2nd operation.

[lindyloo2018]

ok thanks, how did you control your RA whilst off biologics for a long time?