Minor surgical stress (hernia repair)
Moderate surgical stress (cholecystectomy, colectomy)
Major surgical stress (cardiac surgery, hepatobiliary surgery)
No HPA axis suppression:
Continue usual daily glucocorticoid dose
Continue usual daily glucocorticoid dose
Continue usual daily glucocorticoid dose
• <5 mg prednisone or equivalent/day, any duration
• <3 weeks of glucocorticoid use, any dose
HPA axis suppression
Continue usual daily glucocorticoid dose
Hydrocortisone 50 mg IV (induction),then 25 mg IV every 8 h for 24–48 h, then resume normal dose
Hydrocortisone 100 mg
IV (induction), then 50 mg IV every 8 h for 48–72 h, then resume normal dose
• >20 mg prednisone or equivalent for ≥3 weeks
• Cushingoid
• Positive ACTH stimulation test
Uncertain HPA axis suppression
Continue usual daily glucocorticoid dose
Perform ACTH stimulation test
Perform ACTH stimulation test
• 5–20 mg prednisone or equipvalent for ≥3 weeks
• If suppressed, give hydrocortisone 100 mg IV (induction), then 50 mg IV every 8 h for 48–72 h, then resume normal dose
• If suppressed, give hydrocortisone 50 mg IV (induction), then 25 mg IV every 8 h for 24–48 h, then resume normal dose
• ≥5 mg of prednisone or equivalent for ≥3 weeks in the last year
• Otherwise continue usual daily glucocorticoid dose
• Otherwise continue usual daily glucocorticoid dose
Table 29.2
Perioperative medication management in ulcerative colitis
Drug | Colectomy/IPAA (level of evidence) | Other surgery (level of evidence) |
|---|---|---|
5-Aminosalicylates | Discontinue 2 days before surgery; do not resume postoperatively (C) | Hold 2 days before surgery; resume 3 days postoperatively or when creatinine is stable (C) |
Glucocorticoids | Minimize dose preoperatively; administer stress-dose steroids if indicated (see Table 29.2); taper postoperatively (B) | Minimize dose preoperatively; administer stress-dose steroids if indicated (B) |
Azathioprine or 6-MP | No need to postpone surgery; hold 2 days prior to elective surgery if possible; do not resume postoperatively (unless indicated for a non-IBD diagnosis) (B,C) | No need to postpone surgery; hold 2 days prior to elective surgery if possible; resume 3 days after surgery when eating and when creatinine is stable (B,C) |
Biologics | No need to postpone surgery; continue prior to colectomy if needed; do not resume postoperatively (unless indicated for a non-IBD diagnosis) (B) | Discuss with surgeon; if high risk for disease flare with discontinuation of biologic, continue biologic and monitor closely postoperatively (B) |
Cyclosporine | No need to postpone surgery; do not resume postoperatively; watch for opportunistic infections (B,C) | Delay elective surgery until cyclosporine therapy completed if possible; if surgery is urgent, continue cyclosporine, watch for opportunistic infections and consider trimethoprim-sulfamethoxazole prophylaxis (B,C) |
Conclusion
This chapter provides suggestions about management of medical therapy in the preoperative and postoperative patient with ulcerative colitis. However, there is limited published literature available regarding the perioperative use of these medications. As a result, no formal guidelines have been published by the major gastroenterological or rheumatologic societies. Prospective data from high-quality studies are needed in order to inform the decision regarding the perioperative use of immunosuppressant medications. In the meantime, the decision regarding the use of 5-ASA and immunosuppressant therapy in the perioperative setting must be individualized for each patient and should involve a discussion between the gastroenterologist and the surgeon.
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Wicke C, Halliday B, Allen D, et al. Effects of steroids and retinoids on wound healing. Arch Surg. 2000;135:1265–70.PubMedCrossRef
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