pre op' tx.pptx
- 1. FATHY abo mokh haj perioperative management of disease modifying medications for adults with rheumatic diseases
- 2. Stages of wound healing (A) Hemostasis (B) Inflammation (C) Proliferation (D) remodeling. Wound healing is classically divided into 4 stages:
- 4. AVASTIN INDICATIONS AND USAGE- • Metastatic colorectal cancer, in combination with intravenous fluorouracil-based chemotherapy for first- or second-line treatment. • Metastatic colorectal cancer, in combination with fluoropyrimidine- irinotecan- or fluoropyrimidine-oxaliplatin-based chemotherapy for second-line treatment in patients who have progressed on a first- line bevacizumab product-containing regimen • Unresectable, locally advanced, recurrent or metastatic non- squamous non-small cell lung cancer, in combination with carboplatin and paclitaxel for first-line treatment. • Recurrent glioblastoma in adults. • Metastatic renal cell carcinoma in combination with interferon-alfa. • Persistent, recurrent, or metastatic cervical cancer, in combination with paclitaxel and cisplatin, or paclitaxel and topotecan. • Epithelial ovarian, fallopian tube, or primary peritoneal cancer:
- 6. ROLE OF VEGF IN HEALING PROCESS • Vascular endothelial growth factor (VEGF) is functions as an endothelial cell mitogen , chemotactic agent , and inducer of vascular permeability Other angiogenic growth factors such as basic fibroblast growth factor (bFGF) and transforming growth factor β (TGF-β) have been described, but VEGF is unique for its effects on multiple components of the wound healing cascade, including angiogenesis and recently shown epithelization and collagen deposition.
- 7. Side effects fistula hypertension proteinuria epistaxis Bleeding Back pain Headache Taste change Dry skin
- 8. Side effects
- 9. precution • Gastrointestinal Perforations and Fistula: Discontinue for gastrointestinal perforations, tracheoesophageal fistula, or fistula formation involving any organ. • Surgery and Wound Healing Complications: In patients who experience wound healing complications during MVASI treatment, withhold MVASI until adequate wound healing. Withhold for at least 28 days prior to elective surgery. Do not administer MVASI for at least 28 days following a major surgery, and until adequate wound healing. The safety of resumption of bevacizumab products after resolution of wound healing complication has not been established. Discontinue for wound healing complication of necrotizing fasciitis. • Hemorrhage: Severe or fatal hemorrhages have occurred. Do not administer for recent hemoptysis. Discontinue for Grade 3-4 hemorrhage. • Arterial Thromboembolic Events (ATE): Discontinue for severe ATE. • Venous Thromboembolic Events (VTE): Discontinue for Grade 4 VTE. • Hypertension: Monitor blood pressure and treat hypertension. Withhold if not medically controlled; resume once controlled. Discontinue for hypertensive crisis or hypertensive encephalopathy.
- 10. Tumor Necrosis Factor Inhibitors Tumor necrosis factor (TNF)-alpha inhibitors, including Etanercept, infliximab, adalimumab, certolizumab pegol, golimumab. are biologic agents which are FDA-approved to treat ankylosing spondylitis Crohn disease hidradenitis suppurativa juvenile idiopathic arthritis plaque psoriasis polyarticular juvenile idiopathic arthritis psoriatic arthritis rheumatoid arthritis ulcerative colitis uveitis
- 11. mechanism • TNF is made intracellularly, mainly by activated macrophages. The precursor TNF is converted to soluble TNF after proteolysis by the TNF-converting enzyme. This soluble TNF then oligomerizes and forms the biologically active homotrimer TNF. There are two types of TNF, which are very closely related, TNF-alpha and TNF-beta. The activities of both TNFs are mediated through binding to the TNF receptors I and II (TNFRI and TNFRII), which are present on almost all cell types (except erythrocytes). • The binding of TNF to TNFRI and TNFRII activates several signaling pathways, including transcription factor activation (nuclear factor-κB), proteases (caspases), and protein kinases (c-Jun N-terminal kinase, MAP kinase). This signaling leads to activation of the target cell leading to the inflammatory and immune response by releasing several cytokines and apoptotic pathway initiation. Thus, the biological effects of TNF include activation of other cells (macrophages, T- cells, B-cells), proinflammatory cytokine production (IL-1, IL-6), chemokine production (IL-8, RANTES), expression of adhesion molecule (ICAM-1, E-selectin), inhibition of regulatory T-cells, RANK-ligand expression upregulation, matrix metalloproteinase production and induction of apoptosis.
- 14. Infections • Serious infections are a significant and concerning adverse effect of anti-TNF agents and may include bacterial, fungal, viral, or atypical infections. These infections may be fatal. Infections are more common in patients receiving multiple immunosuppressive agents such as methotrexate or corticosteroids combined with anti-TNF agents. Reports exist of the reactivation of tuberculosis and viral hepatitis B and C, and it is a recommendation to screen individuals for these before initiating an anti-TNF agent. In cases of reactivated latent tuberculosis, the reactivation occurs within the first few months of treatment with TNF-alpha inhibitors. Patients with latent tuberculosis should receive treatment with isoniazid or combination anti-tuberculosis agents before initiating anti-TNF agents. Patients living in areas with a higher incidence of certain fungal infections such as blastomycosis, coccidioidomycosis, or histoplasmosis should have screening for these conditions before initiating anti-TNF agents. Lastly, clinicians should hold anti-TNF therapy in patients who develop a serious infection, and they can consider resuming treatment after complete recovery from the infection, provided the benefits of restarting the anti-TNF therapy outweighs the risk of recurrent infections in the particular patient.
- 15. Cont… • Anti-TNF agents may be associated with a higher risk in patients undergoing major surgeries such as hip or knee replacement. The recommendation is to hold these medications one week and one dosing cycle before the surgery. They can be resumed two weeks after the surgery, provided there is no infection and incisions are healing well.
- 18. REFERENCES • MVASI® (bevacizumab-awwb) injection, for intravenous use Initial U.S. Approval: 2017 MVASI (bevacizumab-awwb) is biosimilar* to AVASTIN® (bevacizumab) • Sun BK, Siprashvili Z, Khavari PA. Advances in skin grafting and treatment of cutaneous wounds. Science 2014; 346:941.
Editor's Notes
- #4: PDGF: platelet-derived growth factor; TGF: transforming growth factor; FGFs: fibroblast growth factors; IL-1: interleukin-1; TNF: tumor necrosis factor; KGF: keratinocyte growth factor; IGF: insulin-like growth factor; IFN: interferon; VEGF: vascular endothelial growth factor; HGF: hepatocyte growth factor; MMP: matrix metalloproteinase; TIMP: tissue inhibitor of metalloproteinase
- #18: Dosing intervals obtained from prescribing information provided online by pharmaceutical companies. DMARDs = disease-modifying antirheumatic drugs; SQ = subcutaneous; IV = intravenous; SLE = systemic lupus erythematosus; PO = oral. *2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Anti-rheumatic Medication in Patients with Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty Shading with Bold italics indicates recommendation that has changed since 2017. † Drug added for 2022 update. †† Severe SLE indicates organ threatening disease. ** Recommendation pertains to infection risk and does not account for risk of cardiac events or venous thromboembolism. ***For patients with RA, AS, PsA, or all SLE for whom anti-rheumatic therapy was held prior to undergoing TJA, restarting the anti-rheumatic therapy once the wound shows evidence of healing, any sutures/staples are out, there is no significant swelling, erythema or drainage, and there is no ongoing non-surgical site infection, which is typically about 14 days.