Q: Dr. Eppley, I am interested in having a tummy tuck but do have a bit of a twist with my medical history. I have rheumatoid arthritis and have been on Xeljanz 10mg twice a day to control my symptoms. It has controlled them fairly well and I am not keen on potentially going off of it to have surgery. Can I have a tummy tuck while on this medication?
A: Xeljanz, known generically as Tofacitinib, is a recently approved drug (2012) for the treatment of rheumatoid arthritis. It works as an inhibitor of the enzyme janus kinase 3 (JAK3) which interferes ultimately with DNA transcription in the cell nucleus. It helps in arthritis because it inhibits production of inflammatory mediators in joint tissue. As an inhibitor of the inflammatory process, the drug is known to increase the risk of opportunistic infections such as tuberculosis, cancers and lymphomas.
But as it relates to surgery, the key questions are does it present an increased risk of infection or in any way impede wound healing?This would be particularly relevant in a large healing wound like that of a tummy tuck. There is no specific information in the medical literature that addresses the specific effect on wound healing of the Xeljanz medication. This is likely because it is relatively new although almost all anti-rheumatoid drugs, with the exception of corticosteroids, have a similar void of specific information on their effects on postoperative wound healing.
What I can find is from the newsletter Drug Safety Quarterly Fall 2013 issue which has an article entitled ‘Wound Healing and Anti-Rheumatic Drugs’ authored by Drs. Goodman et al from NYU. From it I quote…
‘Healthy wound healing proceeds through an inflammatory phase, followed by wound remodeling and finally re-epithelialization of the skin edges. These are the normal sequential stages of wound healing. Patients with rheumatoid arthritis (RA) are often on multiple medications to control their symptoms. These medications may include analgesic, anti-inflammatory, biologic or synthetic disease-modifying antirheumatic drugs. (DMARDs) With the exception of methotrexate, there are very few controlled studies that have evaluated the effects of these medications on wound healing and infection risk after surgery.’
‘…with the exception of methotrexate, there is a lack of data regarding optimal practice for perioperative management of antirheumatic treatment in RA patients undergoing surgery. Existing data, however, indicates that methotrexate may be continued throughout the perioperative period for otherwise healthy individuals. For the other anti-rheumatic drugs, while continuing medication may hamper wound healing and predispose to infections, discontinuation may lead to disease flare, which increases the need for corticosteroids or other medications that may also increase the risk for inadequate wound healing and infection to regain disease control. Moreover, there is no consensus among the various rheumatic disease societies regarding optimal practice. Although there are clear effects of anti-rheumatic therapy on wound healing and clear infection risk, the role of RA inflammatory activity on wound healing, infection, and rehabilitation should also be considered. For surgeries such as the implantation of a prosthetic joint, where surgical site infection carries significant morbidity, current practice favors a conservative approach.’
This summary comes from an institution that is performing joint replacements in orthopedic surgery. So these types of patients have significant functional and pain issues related to joint dysfunction. So accepting whatever increased wound healing or infection risk may be worth the trade-off for the benefits. Tummy tuck surgery is much more elective and those unquantified risks must be considered even more carefully.
This is a good discussion you should have with your rheumatologist. He/she probably will not be as understanding about tummy tuck surgery as the need for a joint replacement. But in the end you should follow their advice. The only thing we know for sure is that you are at some increased risk of potential wound healing problems or infection if choosing tummy tuck surgery while on Xeljanz but the magnitude of that risk is unknown.
Dr. Barry Eppley