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Increased Risk of Infections with Anti-TNF Agents in Patients with Crohn’s Disease After Elective Surgery: Meta-Analysis

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Abstract

Background

Postoperative complication rates in patients with inflammatory bowel disease (IBD) receiving preoperative biologics have been analyzed without considering the surgical context. Emergency surgery may be associated with an increased risk of infectious complications, compared to elective operations.

Aims

To conduct a systematic review and meta-analysis investigating the relationship between preoperative biologic therapy and postoperative outcomes in Crohn’s disease (CD) and ulcerative colitis (UC), focusing on elective surgery.

Methods

Electronic databases were searched up to February 12, 2020, for studies of patients with IBD undergoing elective abdominal surgery receiving biologic therapy within 3 months before surgery compared to no therapy, or another biologic therapy. Certainty of evidence was evaluated using GRADE. The primary outcomes were the rate of infections and total complications within 30 days. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

Results

Thirty-three studies were included. Preoperative treatment with anti-tumor necrosis factor (TNF) therapy in patients with CD undergoing elective surgery was associated with increased odds of infection (OR 2.05; 95% CI 1.40–3.01), but not total complications (OR 1.03; 95% CI 0.71–1.51). In elective surgery for UC, preoperative anti-TNF therapy was not associated with infectious (OR 1.03; 95% CI 0.34–3.07) or total complications (OR 0.67; 95% CI 0.29–1.58). Limited data indicate that emergency surgery did not significantly affect the rate of complications.

Conclusions

Anti-TNF therapy prior to elective surgery may increase the odds of postoperative infection in CD, although the certainty of evidence is very low. More evidence is needed, particularly for newer biologics.

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Abbreviations

CD:

Crohn’s disease

CI:

Confidence interval

GRADE:

Grading of Recommendations, Assessment, Development and Evaluation

IBD:

Inflammatory bowel disease

NOS:

Newcastle–Ottawa Scale

OR:

Odds ratio

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-analyses

TNF:

Tumor necrosis factor

UC:

Ulcerative colitis

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Authors and Affiliations

  1. Department of Gastroenterology, UMC Ljubljana, University of Ljubljana, Japljeva ulica 2, 1000, Ljubljana, Slovenia

    Jurij Hanzel

  2. Alimentiv Inc. (Formerly Robarts Clinical Trials Inc.), 100 Dundas Street, Suite 200, London, ON, 27N6A 5B6, Canada

    Jurij Hanzel, Ahmed Almradi, Claire E. Parker, Leonardo Guizzetti, Christopher Ma & Vipul Jairath

  3. Department of Medicine, Division of Gastroenterology, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada

    Ahmed Almradi & Vipul Jairath

  4. Division of General Surgery, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada

    Alexandra C. Istl & Mei Lucy Yang

  5. Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St, London, ON, N6A 3K7, Canada

    Katherine A. Fleshner

  6. Division of Gastroenterology and Hepatology, Departments of Medicine and Community Health Sciences, University of Calgary, 2500 University Dr NW, Calgary, AB, T2N 1N4, Canada

    Christopher Ma

  7. Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, USA

    Siddharth Singh

  8. Department of Epidemiology and Biostatistics, Western University, London, ON, Canada

    Vipul Jairath

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Contributions

JH, CM, SS, and VJ contributed to conception and design of the study. JH, AA, ACI, MLY, KAF, and LG were involved in data acquisition and analysis. JH, LG, CM, SS, and VJ contributed to interpretation of data. JH, AA, ACI, MLY, KAF, CEP, LG, CM, SS, and VJ were involved in drafting the work or revising it critically for important intellectual content. VJ and CM contributed to study supervision. All authors approved the final version of the manuscript.

Corresponding author

Correspondence to Vipul Jairath.

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Conflicts of interests

JH has received speaker’s fees from Biogen, Janssen, and Takeda. AA has no conflict of interest. ACI has no conflict of interest. MLY has no conflict of interest. KAF has no conflict of interest. CEP is an employee of Alimentiv Inc. (formerly Robarts Clinical Trials). LG is an employee of Alimentiv Inc. (formerly Robarts Clinical Trials). CM has received consulting fees from AbbVie, AVIR Pharma Inc., Mylan, Janssen, Pfizer, Alimentiv (formerly Robarts Clinical Trials), and Takeda; speaker’s fees from AbbVie, Janssen, Pfizer, and Takeda; and research support from Pfizer. VJ has received consulting fees from AbbVie, Eli Lilly, GlaxoSmithKline, Arena pharmaceuticals, Genentech, Pendopharm, Sandoz, Merck, Takeda, Janssen, Robarts Clinical Trials, Topivert, Celltrion; and speaker’s fees from Takeda, Janssen, Shire, Ferring, AbbVie, and Pfizer.

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Hanzel, J., Almradi, A., Istl, A.C. et al. Increased Risk of Infections with Anti-TNF Agents in Patients with Crohn’s Disease After Elective Surgery: Meta-Analysis. Dig Dis Sci 67, 646–660 (2022). https://doi.org/10.1007/s10620-021-06895-6

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