Stopping biologics before surgery

In patients with ulcerative colitis there is likely no need for stopping biologic agents before surgery as there is poor systemic bioavailability of the drug in a majority of patients. Keywords: Crohn's disease; anti-TNF; biologic; complication; drug level; surgery; ulcerative colitis The best option, at least for patients who use the biologic abatacept (Orencia), seems to be to skip just one dose prior to surgery. That's the conclusion of a new analysis, published in the journal Arthritis Research & Therapy Stop biologics prior to dental extractions Stop biologics prior to biopsies resulting in open granulation tissue Do not stop biologics prior to endoscopy, cystoscopy, liver/kidney biopsy, lymph node biopsy or punch biopsy For bloodless procedures (such as cataract surgery) we would not advise routinely stopping biologics Given these potential risks and benefits, the question of how best to manage biologic therapy before planned surgery is an important consideration for practitioners. In an attempt to answer this question, we performed a review of the literature on this topic. Keywords psoriasis, rheumatoid arthritis, surgery, complications, biological therapy

Various guidelines suggest that such patients stop taking biologics before undergoing elective surgery, but withholding these drugs for too long might allow underlying diseases (e.g., rheumatoid arthritis) to flare, resulting in poorer surgical outcomes While observational studies have not shown clear differences in the rate of postoperative infection in patients who stop biologics before surgery, concerns remain given known risks associated with these therapies; performing surgery at the end of the biologic dosing cycle and restarting at approximately 2 weeks after the wound has closed achieved consensus support from the guideline development panel of the ACR/AAHKS the biologic 4 weeks before surgery and resume 4 weeks after surgery, keeping the patient on the same dosing in-terval; b) in a patient with stricturing CD who has been on biologic therapy without improvement, discontinue the biologic when surgery is decided upon, and ideally wait 4 weeks before operating; c) in urgent or emergent situa

There are a number of situations when your biologic treatment should be temporarily stopped such as: Before surgery or major dental procedures When trying to become pregnant or father a child. Please remember that other drugs such as methotrexate need to be considered too The following table gives the washout period for each biologic dru The American College of Rheumatology and British Society of Rheumatology recommend holding TNF-alpha antagonists for one dosing cycle before major surgery. For etanercept (Enbrel), that translates to a 1-week before surgery hold, for infliximab (Remicade) 6-8 weeks, and for adalimumab (Humira) 2 weeks For most biologics (exceptions: RTX and TCZ), consideration should be given to planning surgery when at least one dosing interval has elapsed for that specific drug; for higher risk procedures consider stopping 3-5 half-lives before surgery (if this is longer than one dosing interval) (grade 2B, SOA 97%) Current guidelines from the American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) recommend holding tofacitinib starting 7 days before total knee or total hip surgery due to increased risk of infectious complications. It can be resumed as early as 14 days after surgery. 1

Biologic agents should be held with surgery scheduled at the end of dosing cycle and restarted when the wound is healed, sutures/staples are removed, and there are no signs of infection (~14 days). Tofacitinib should be held for all conditions except SLE for 1 week Nevertheless, due to the enduring effects of infliximab, there is an increased risk of 13% and 43%, respectively, in temporarily stopping therapy 2-5 half-lives before orthopaedic and abdominal surgery. Thus if cessation of therapy is to be recommended, typical guidelines now advise stopping it 4-5 weeks before elective surgery as shorter temporary stoppage of infliximab increases the likelihood of psoriatic flare-up (P=0.003) Whether and when you stop biologic therapy before elective surgery will depend on the specific drug that you're on. It's recommended that your biologic be stopped more than four half-lives before your surgery. A drug's half-life is the time it takes for half the drug dose to be broken down into other substances in the body Most patients with rheumatoid arthritis (RA) will undergo orthopaedic surgery during the course of their disease, and more than 80% of that cohort will be taking traditional or biologic disease-modifying antirheumatic drugs (DMARDs) at the time of their operations. That presents a dilemma, because stopping DMARDs can raise the risk of a rehab-hampering postoperative R Patients were grouped by infliximab stop timing: <4 weeks, 4 to 8 weeks, and 8 to 12 weeks before surgery. Infliximab stop timing <4 weeks and 4 to 8 weeks prior to surgery were associated with similar rates of serious infection at 30 days and prosthetic joint infection at 1 year compared with infliximab stop timing 8 to 12 weeks

stopped before surgery for IBD, one must ask whether the patient has UC or CD, evaluate the urgency of the need for surgery and evaluate preoperative anti-TNF levels if available. In patients with UC, there is likely no role in stopping biologic agents before surgery as there is poor systemic bioavailability of the drug in the majority of patients One biologic may work very well for some people, but not for others. And a biologic may work for you at first, but then stop working after a while. If the first one you try doesn't work or stops working for you, your doctor will suggest other biologics or options The document suggests discontinuing biologic therapy prior to surgery in patients with inflammatory arthritis, as well as withholding tofacitinib for at least 7 days prior to surgery in rheumatoid arthritis, spondyloarthritis, and juvenile idiopathic arthritis patients The guidelines for periopetrative cessation periods of biologic DMARDs differ among countries but generally a stop of the biotherapy 2 to 6 weeks before programmed surgery is recommended. Anti-TNF can be resumed after wound healing. The purpose of this current study was to ask

Should biologic agents be stopped before surgery for

tamoxifen, anastrozole, exemestane Continue BUT increased DVT risk If stopping do so 4 to 6 weeks before surgery. Biologic response modifiers etanercept, infliximab, rituximab, adalimumab Rheumatology - stop 14 days before surgery (risk of sepsis) Gastroenterology - continue Rheumatology - restart 14 days post op if tolerating oral intak Discontinuing biologic therapy before surgery in patients with inflammatory arthritis and planning the surgery at the end of the dosing cycle. Withholding tofacitinib for at least 7 days before surgery in patients with RA, SpA, and JIA. Withholding rituximab and belimumab before surgery in all patients with SLE undergoing arthroplasty I have been on a couple of biologics when facing surgery. I had both hips replaced, followed by both knees replaced and for both operations, I had to stop my biologic a week before surgery? Restarting 10-14 days after surgery In the past and currently, surgeons stopped biologics before surgery and one of her potential surgeons wants her to stop the Stelara 8 weeks before surgery and start again 4 weeks after

Withholding intravenous abatacept (Orencia) for longer than a month before hip or knee arthroplasty among patients with rheumatoid arthritis (RA) did not lower the risk for postoperative infection, a retrospective claims-based analysis found. Compared with stopping the biologic less than 4 weeks prior to surgery, stopping 4 to 8 weeks before the procedure was not associated with a greater risk. As a result, there is no theoretical basis for stopping biologic therapy. Safety considerations Causality is difficult to establish when evaluating the incidence of serious infection in patients with IBD receiving multidrug therapy.(6) A Mayo Clinic case-control study of 100 consecutive patients with opportunistic infections and 200 matched. Biologic agents can safely be continued before low-risk surgery (i.e. surgery without a break in sterile technique during which the respiratory, gastrointestinal, and genitourinary tracts are not entered) e.g. endoscopy, bronchoscopy, hysteroscopy, cystoscopy, breast biopsy, dermatologic or ophthalmological procedures 4, 5 The authors found that those on leflunomide at time of surgery had a statistically significant increased risk of infection during wound healing (P=0.01) [26]. With the conflicting numbers regarding wound healing complications, their recommendation was to wash out leflunomide using cholestyramine in adults with RA 1 week before surgery [17,20] Patients who take biologic therapies for autoimmune diseases are at heightened risk for infections. Various guidelines suggest that such patients stop taking biologics before undergoing elective surgery, but withholding these drugs for too long might allow underlying diseases (e.g., rheumatoid arthritis) to flare, resulting in poorer surgical outcomes

Have a Hip or Knee Surgery for RA? Skipping One Dose of

before surgery in patients with those patients stopping TNFi prior to orthopaedic surgery.32 Less data exist for other surgery types, many of which may be associated with higher risks of complications. cations and that the timing of biologics before surgery wa Biologic therapies should be withheld for surgery and prior to surgery, biologics should be held for one-dosing cycle or surgery should be planned for the end of the dosing cycle. of that medication. Tofacitinib be withheld 7 days before surgery in patients with RA, SpA and JIA o For most procedures stop two weeks before surgery o In high risk procedure you should have a full wash out (ie 3-5 half-lives), see table 1 Rituximab it is ideal to delay surgery until 3-6 months after treatment Tocilizumab stop 4 weeks before surgery If you or your partner are considering pregnanc Hold biologics for one dosing cycle before surgery Hold tofacitinib (Xeljanz) for 7 days prior to surgery Plan surgery for end of dosing cycle for rituximab and belimumab (Benlysta

Medications to Avoid Before Surgery. Share this. The medications listed below (and potentially many others) may have an effect on your blood's ability to coagulate. Please review all your medications-both over the counter and prescription drugs-with your surgeon. In many cases, your medication will have no effect on your surgery, and you be. surgery (can be between 3 to 6 weeks before surgery) (4) Short interval biologics (Humira, Cimzia, Simponi) - last dose should be given 2-3 weeks before surgery (5) If interval between pre-op dose and post-op dose is longer than previous dosing interval, should schedule re-load of the Biologic at the first GI postoperative visit Lightner et al. conducted a retrospective single-center review of 94 IBD patients who had received vedolizumab within 12 weeks before major abdominal surgery, compared to contemporary controls treated with TNF-α inhibitors and non-biologic therapy. They found a significant increase in overall complications—53% for vedolizumab vs. 33% for TNF.

A European Perspective. Alessandro Armuzzi, MD PhD. Treat-to-target approach. The treat-to-target approach to managing patients with inflammatory bowel disease (IBD) involves risk-stratifying patients, treating high-risk patients with combined immunosuppression that incorporates biologic therapy, selecting a treatment target, implementing regular objective monitoring, and adjusting therapy to. Abstract: The emergence of biologic response modifiers and earlier use of immunomodulators for inflammatory bowel disease (IBD) patients have improved outcomes. Durable remissions have been achieved in many IBD patients on these treatments, but the duration of treatment and identifying which patients may stop therapy is yet unresolved

Joint Guidelines for the Management of Interruption of

Download Citation | Do We Have to Stop Biologics before Surgery? | The recent development of biological therapy has revolutionized care for patients with psoriasis, psoriatic arthritis, rheumatoid. Your doctor will tell you to stop your biologic before surgery. You can start again when your wounds have healed and your chance of getting an infection has passed. WebMD Medical Reference

Do We Have to Stop Biologics before Surgery? - Faten

Her decline on Humira was so rapid, she had to stop the biologic and undergo J-pouch surgery. She wasn't sure she wanted to try another biologic, and didn't for the last five years because after. It depends on the surgeon. Some want you to stop prednisone or biologics, others do not. I was on Remicade and a bunch of other crap before my colectomy and my surgeon didn't feel there was any additional risk of infection to continue meds, so I continued. My last Remicade infusion was 1 week before surgery. Surgeon preference It may be advisable to consider stopping TNF inhibitors 1 administration interval before surgery, since the risk of postoperative infection appears to be higher if the operation occurs within this. Flares are frequent in patients with RA undergoing arthroplasty. Higher baseline disease activity significantly increases the risk. Although more patients stopping biologics flared, this did not independently predict flaring. The effect of early postsurgery flares requires further study

When Should Biologics Be Stopped Prior to Joint

  1. Biologics are increasingly used in the treatment of a variety of inflammatory immune-mediated conditions. Generated by recombinant biotechnology, biologics comprise a number of humanised or chimaeric (mouse-human) monoclonal antibodies or variant fusion proteins that target specific steps in proinflammatory pathways (Chong and Wong, 2007; Shirota et al, 2008)
  2. With elective surgery, there are no recommendations from the companies as to whether to temporarily stop treatment. There is limited and conflicting data on the effect of TNF blockers on surgical outcomes. In most cases, I recommend stopping Enbrel 1-2 weeks before surgery, and resume 1 week later, if there are no signs or symptoms of infection
  3. g of surgery based on drug dosing intervals and pharmacokinetic half-lives of various biologic therapies. 1
  4. It is generally recommended that these agents be discontinued in patients with a recent diagnosis of cancer, so most patients will have stopped biologics before surgery. Case 2 A 44-year-old woman with seropositive rheumatoid arthritis, on triple-DMARD therapy (methotrexate, sulfasalazine, and hydroxychloroquine), presents with a 1.5-cm nodule.
  5. I stopped Humira for 4 weeks for lower back surgery. (2 before and 2 after). I have a very high pain tolerance. I have PsA and the pain was so bad (not the surgical pain, the arthritis pain!) I was on max opioids until I resumed Humira. Talk to your rheumy and surgeon if you can stay on biologics. I haven't had any outbreaks of Psoriasis.
  6. Stopping biologic disease-modifying antirheumatic drugs (bDMARDs) for patients with rheumatoid arthritis (RA) before they undergo hip or knee replacement might increase postoperative infection risk if it leads to increased use of glucocorticoids (GCs) to control disease flares, a study suggests

This is because when you stop taking a biologic, your body can grow antibodies against the drug, which makes it less effective in the future. It could even lead to adverse reactions Stopping biologics months before elective surgery may not be necessary to reduce infection risk as was once believed. In a study of 4,288 patients who underwent elective hip or knee surgery, stopping infliximab just 4 weeks before surgery presented no more infection risk than stopping the drug 8 to 12 weeks before surgery

'Should we stop or continue conventional synthetic

  1. Scher advocated stopping aspirin therapy before any elective surgery if it is not an emergency procedure. Continuous diffuse bleeding was present after surgery in patients taking aspirin therapy . Similarly, a case was reported by Foulke in which bleeding episode occurred after oral prophylaxis with ultrasonic scaler
  2. Many surgeons allow continuation of biologic therapy before, during and after the procedure. Some insist that patients be off treatment for several weeks. There is no evidence that any of the biologic drugs interfere with wound healing after surgery. Good luck and HTH
  3. Best of luck with the surgery. Lovie. Sara, from what I can get from all of the info I've found you do have to notify the dentist if you have a prosthetic joint, ie: hip,knee,shoulder,elbow,etc, before undergoing any type of work even a cleaning. Then you'll probably be prescribed an anitbiotic as a preventive measure before the appt
  4. Answers. I am currently on Entyvio, and I'm pretty certain you can just stop. I was supposed to have an infusion on the 19th of September, but it has been put on hold for no one is sure how long due to a surgery I had to have a couple weeks ago. My GI and the colon/rectal surgeon have both said that I can continue the Entyvio once I have healed.
  5. Cannot advise on biologic's but I have had double hip replacement, stayed on MTX for the first one, taken 6 days before surgery, one day post surgery when MTX offered to me also decided to forego medication that particular week.. 2nd time around, my surgery was on the Monday morning, and my MTX over the weekend, I decided not to take my MTX that week, a big sigh of relief from the surgical.
  6. G&H What are the most common reasons that patients with inflammatory bowel disease have a drug holiday from biologic therapy?. DR The most common reasons are delays related to insurance re-authorizations and elective discontinuations due to infections or surgeries. One of the other reasons that patients stop biologic therapy is that they are doing well, and they (and/or their physician) think.

  1. The findings contradict those from a larger retrospective study (Arthritis Care Res. 2006;55:333-7) that linked biologic therapy before orthopedic surgery to a fourfold rise in the odds of postoperative infections, the investigators noted. Whilst the current evidence, not surprisingly, suggests a link between stopping treatment and disease.
  2. surgery. For patients receiving tocilizumab IV stop at least 4 weeks before surgery; for SC tocilizumab stop at least 2 weeks before surgery. Table One: Time to stop biologic prior to surgery Biologic agent Dosing frequency Half-life (days) Time to stop prior to surgery Abatacept Weekly 14 2 weeks Adalimumab Every 2 weeks 14 2 week
  3. An increased infection risk may mean more frequent mild infections such as the common cold. But inflammatory arthritis is also associated with the risk of more serious infections. A serious infection is one that requires intravenous antibiotics or hospitalization. Pneumonia, staph infections and sepsis are a few examples of serious infections
  4. Avoid in sufferers fasting previous to surgery. Consider starting off PPI or H2-. DMARD plus biologic agent or steroid) was being taken. A hundred and twenty. Doctors in the emergency room gave her steroids and an inhaler. Principal clinic at Beaumont they have been going to do emergency surgery, Tamica stated
  5. Otezla is a pill you take once in the morning and once at night, every day. On your first day, you only take one pill. People with severe kidney disease will take Otezla once a day and will follow a different schedule for their titration period. This gradual increase over the first 5 days is meant to help reduce the gastrointestinal symptoms.
  6. or surgeries it is generally considered safe to continue use). Biologics have been.

Day of surgery: If blood glucose >150 mg/dL, give 50% of usual AM dose as NPH. Insulin pump Continue basal rate the morning of surgery. Immunosuppressants and Rheumatologic Medications*/** Corticosteroids Continue up to and including day of surgery. Biologic Response Modifiers (e.g. etanercept, infliximba, anakinra, rituximab, adalimumab Panel 1: Medicines that may need to be stopped Cytokine modulators Cytokine modulators could increase risk of infection and delay wound healing. 1,4,5 Consider stopping two to four weeks before surgery depending on risk (higher risk includes grade 3+ surgery and patients with diabetes). Consult a rheumatologist if necessary. Lithium Electrolyte disturbances and reduced renal function can.

The evidence for the relationship between biologic drugs and surgery that we present herein is based on a total of 11 clinical studies , , , , , , , , , , .All of them had a retrospective design, except for Bibbo and Goldberg's prospective study .The majority of the patient populations consisted of RA patients, with a minority of patients with ankylosing spondylitis and psoriatic arthritis We strongly recommend stopping these drugs five to seven days before surgery to reduce your risk of bleeding, but discussion with your cardiologist and surgeon is advised. We also recommend avoiding herbal medications such as gingko biloba and ginseng, for five to seven days prior to surgery, as they increase your risk of bleeding G&H Has the rate of inflammatory bowel disease surgery changed since biologic agents were introduced?. EL The surgical rate has decreased with the advent of biologic agents. According to the results of Olmsted County studies, the cumulative risks for surgery (defined as bowel resection, and not perianal surgery, for Crohn's disease, and as colectomy for ulcerative colitis) 30 years from. Jaime Weinstein: I wish I'd known that there are more co-therapy meds available to stop antibody building than just methotrexate, imuran, and 6MP. I think my existence on anti-TNFs may have had a. In general, we ask patients to hold their ibrutinib for 3 days before and after minor procedures (tooth extractions, bunion surgery, etc.) and 7 days before and after for major surgeries (gall bladder removal, knee surgery). Also, we do not start ibrutinib until all bleeding complications have resolved post-surgery

Biologics reduce the risks of premature death, increased heart disease and the need for joint surgery. Patients with uncontrolled RA are also at higher risk of infection, so controlling the arthritis can also reduce overall infection risk. On balance, you are much better off with treated disease than untreated. Author: Jennifer Davis Yes you can. I have been off and on Cimzia at least 4 different times and Humira twice. I had multiple bone surgeries and stayed off the biologics awhile after each surgery to heal. I was told by two different GI's that there is a chance you may have a reaction to the drug but it is only a small chance, unlike restarting Remi. There is also a. Stop sulfonylureas the night before surgery. Stop OCPs and HRT four weeks before surgery, if possible. Stop nonselective NSAIDs two to three days before surgery, but continue COX-2 inhibitors. Continue outpatient dosing of corticosteroids and add a stress dose. Stop DMARDs and biologics one week before surgery

Hold the immunomodulators for surgery? Maybe yes, maybe no

British Society for Rheumatology biologic DMARD safety

1. Don't stop Remicade because your condition is in remission. Some conditions, like Crohn's disease, will have periods during which symptoms seem disappear or go into remission, but the condition is still present. Stopping your medication during these periods may cause your condition to flare up again. Talk to your doctor before stopping. Stopping treatment with biologics may cause a relapse, during which symptoms return. More research is necessary to confirm if and when people can stop using biologics without experiencing a relapse I've been on seven - count them - seven different biologic medicines since being diagnosed with rheumatoid arthritis. I started with several anti-TNF biologics and then moved to several others even bouncing back to try another anti-TNF before eventually trying Rituxan. I've self-injected with auto-inject pens, self-injected with needles, and seems like I've had every type of infusion. In my practice, I stop methotrexate 1 week prior to surgery and restart 2 weeks after surgery. Remicade is trickier. Since most patients are receiving Remicade every 8 weeks, I tell patients to try to plan the surgery about 6 weeks after the last Remicade infusion and then if the surgery goes well without post-op infections, then restart the.

Erelzi. Erelzi (etanercept) is a biologic medicine that helps the pain and swelling of arthritis. It is used in the treatment of Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis, and other types of arthritis.. Erelzi works by blocking Tumor Necrosis Factor (TNF), a type of signalling protein (called a cytokine), that is involved in systemic inflammation Biologics. Biologic drugs for the treatment of rheumatoid arthritis (RA) are made from proteins. They work by blocking the activity of a key chemical or cell or protein involved in inflammation that gives rise to joint swelling and other symptoms. They are powerful and specific therapies that target very particular parts of the immune system THURSDAY, March 16, 2017 (HealthDay News) -- Quitting smoking before knee or hip replacement surgery may cut the risk of complications after surgery, a new study suggests The primary outcome used to assess failure of stopping was an increase of 50% or more in the asthma exacerbation rate in the six months after discontinuing the biologic compared to the six -month period before biologic initiation. Among a cohort of 4,960 asthma biologic users, 1,249 were observed to stop use after 6-12 months of use Biologic treatment may need to be stopped for one to two weeks before surgery, and can usually restart one to two weeks after surgery, once the wound is healed and you are free of infections. Do I need to stop any of my medications for dental treatment? No, we recommend that you continue on your medication

Is it safe to continue biologic agents during surgery in

Disease modifying antirheumatic drugs (DMARDs) have become the cornerstone of treatment for patients with rheumatoid arthritis. The use of these drugs during the perioperative period has caused debate amongst rheumatologists and surgeons. Concerns focus on their potential to increase the risk of infection by affecting the immune response. Rheumatoid patients are at increased risk of infection. You may have to stop Golimumab while being treated for an infection. You may also have to stop if you are planning a surgery. You will need to have a negative tuberculosis (TB) skin test before beginning Golimumab therapy. Your doctor may also want to check your blood to be sure you do not have Hepatitis B or C Orencia before surgery Download Here Free HealthCareMagic App to Ask a Doctor All the information, content and live chat provided on the site is intended to be for informational purposes only, and not a substitute for professional or medical advice

Summary of guidelines for DMARDs for elective surgery

Baseline health care utilization was assessed as a measure of CD severity before biologic therapy and included prior corticosteroid use (remote was defined as 365 to 90 days before anti-TNF therapy and recent was defined as within 90 days before anti-TNF therapy), number of hospitalizations in the year before starting anti-TNF (categorized as 0. Stop taking Aspirin, Anti-inflammatory medicines (e.g., Ibuprofen, Aleve, Advil), Fish Oil, or Vitamin E supplements 1 week before surgery. If you are on a blood thinner (e.g., Aspirin, Coumadin, Lovenox), please check with your primary care physician when to stop these medications

Stopping and Restarting Biologic Medications for Psoriasi

The biologics we use for allergy and asthma work on the allergic arm of the immune system, said Jeffrey Factor, MD, from the Connecticut Asthma & Allergy Center in West Hartford The current types of biologics available for treating psoriatic disease include those that inhibit cytokine and tumor necrosis factor (TNF) proteins, as well as interleukin-17 (IL-17) inhibition, IL-12/23, and T cell co-stimulation and Janus-kinase (JAK) inhibition. The most commonly prescribed biologics for psoriatic disease include: 5  The study included more than 6,200 rheumatoid arthritis patients who started treatment by taking either tumor necrosis factor inhibitors (TNFi) or non-TNFi biologics. In the TNFi group, the percentages of patients who continued taking their medications were about 82 percent at six months, 68 percent at 12 months and 52 percent at 24 months Multimodality Therapy before and after Surgery in Patients with Squamous Cell Carcinoma of the Head and Neck such as carboplatin, nab-paclitaxel, and cisplatin, work in different ways to stop the growth of tumor cells, either by killing the cells, by stopping them from dividing, or by stopping them from spreading. (IP), biologic or. Second, in order to look at the effect of stopping the drug a set period of time prior to surgery, a risk window of 28 days was chosen. Patients who stopped their anti-TNF drug before the 28-day window were classified as the off-28 group, and those who stopped sometime closer to the surgery were defined as the on-28 group, he said

Stopping DMARDs Often Unnecessary for RA Patients Prior to

Co-author Serena Hu, M.D. explained to OTW why she and her colleagues tackled this well-known and still very challenging issue, As the senior spine surgeon involved in this paper, I have long required patients to quit smoking before elective spine surgery because of the well-known compromise of fusion rates and increased complication rates. Questions To Ask Before Elbow Surgery Here's a list of questions that may be helpful to ask your doctor before your elbow surgery. We suggest you print this list and take it with you on your appointment duration of disease, prior surgery, and disease location). Medication use. Information was collected on medica-tion use before conception, during pregnancy, and for 1 year postpartum. Exposure was defined as use of thiopurines or biologic in the 3 months before last menstrual period or any time during pregnancy. Women were assigned to 1 of 4.