When Sarah scheduled her long-overdue knee replacement surgery, she thought the hardest part would be the recovery. Instead, she found herself caught in a medical maze of conflicting advice about her adalimumab injections. Her orthopedic surgeon wanted her to stop the biologic four weeks before surgery. Her gastroenterologist recommended two weeks. Her primary care physician wasn’t sure. Meanwhile, Sarah’s Crohn’s disease began flaring from the stress and uncertainty, threatening to derail her surgery altogether.

Sarah’s experience isn’t unique—it’s the norm. The lack of standardized protocols for managing IBD medications during elective surgery is creating unnecessary risks, delays, and anxiety for millions of patients. We need a comprehensive, evidence-based timeline that every healthcare provider can follow, ensuring consistent care that balances surgical safety with IBD management.

This isn’t just about convenience—it’s about patient safety and optimal outcomes. When medication management varies wildly between providers, patients suffer the consequences of poorly coordinated care.

The Current Chaos: A System Without Standards

Today’s landscape for IBD medication management during elective surgery resembles a patchwork quilt sewn by different hands using different patterns. Some surgeons demand that all immunosuppressive medications be stopped weeks before any procedure, regardless of the drug’s half-life or the surgery’s complexity. Others take a more nuanced approach but lack specific guidelines for timing.

The problem stems from several sources. First, most surgeons receive limited training in IBD medication management during their residency. They understand the general principle that immunosuppression increases infection risk, but they may not grasp the significant differences between a TNF-alpha inhibitor like infliximab and a traditional immunosuppressant like azathioprine.

Second, gastroenterologists often focus primarily on maintaining IBD remission, sometimes underestimating surgical infection risks or unfamiliar with the specific requirements of different procedures. A dental extraction requires vastly different medication timing than a major orthopedic surgery, yet these distinctions are often overlooked.

The result? Patients like Sarah find themselves navigating contradictory advice, often leading to suboptimal outcomes. Some stop medications too early, triggering disease flares that delay surgery. Others continue medications too long, increasing infection risks. Many fall into communication gaps between their various specialists, leaving them to make complex medical decisions without adequate guidance.

Recent surveys suggest that up to 40% of people with IBD have experienced conflicting advice about medication management for elective procedures. This isn’t acceptable for a condition affecting over 3 million Americans.

A Protocol-Driven Solution: The Path Forward

The solution lies in developing and implementing standardized, evidence-based protocols that account for the specific characteristics of each IBD medication class and surgical procedure type. We need clear timelines that remove guesswork and ensure consistent, safe care across all healthcare settings.

For biologic medications, the protocol should be based on drug half-lives and mechanism of action. TNF-alpha inhibitors like adalimumab and infliximab require different hold periods—adalimumab with its 14-day half-life needs a longer pre-operative window than infliximab’s 8-10 day half-life. Newer biologics like vedolizumab, with gut-selective action, may require shorter holds for many procedures.

The protocol must also differentiate between procedure types. A routine dental cleaning might not require any medication holds, while a joint replacement demands careful timing. The infection risk profile of each surgery should drive medication decisions, not blanket policies that treat all procedures identically.

Post-operative restart timing is equally critical. The protocol should establish clear criteria for resuming medications based on wound healing progress, absence of infection signs, and procedure-specific recovery milestones. For most biologics, this typically means waiting 10-14 days post-surgery, but high-risk procedures or complicated recoveries may require longer delays.

Communication templates are essential components of this protocol. Standardized forms should facilitate information exchange between IBD specialists and surgical teams, ensuring critical details about medication timing, disease activity, and patient-specific risk factors are clearly communicated. These templates should include emergency contact information and clear instructions for managing IBD flares during the perioperative period.

The protocol must also address combination therapy scenarios. Many IBD patients take multiple medications—a biologic plus an immunomodulator, or combination therapy with different mechanisms of action. The timing for each medication class should be clearly specified, preventing confusion about which drugs to hold and when.

Addressing the Skeptics: Why Standardization Won’t Limit Clinical Judgment

Critics of standardized protocols often argue that medicine is too complex for cookbook approaches, that each patient requires individualized assessment that protocols might constrain. This perspective, while well-intentioned, misses the mark when applied to IBD medication management during elective surgery.

Standardized protocols don’t eliminate clinical judgment—they enhance it by providing evidence-based starting points that clinicians can modify based on patient-specific factors. A protocol that recommends holding adalimumab two weeks before major surgery doesn’t prevent a physician from extending that timeline for a patient with diabetes or other infection risk factors. Instead, it ensures that the baseline recommendation is consistent and appropriate.

Some gastroenterologists worry that surgical teams will use protocols as justification for unnecessarily long medication holds, potentially triggering IBD flares. This concern is valid but addresses a problem that protocols actually solve. Clear, evidence-based guidelines make it harder for surgeons to demand arbitrary medication holds that aren’t supported by data.

Surgeons sometimes express concern that protocols might pressure them to accept higher infection risks. However, well-designed protocols based on current evidence actually help surgeons make more informed decisions about acceptable risk levels. When a protocol specifies that vedolizumab can be continued closer to surgery due to its gut-selective mechanism, it provides surgeons with the scientific rationale they need to feel confident in that approach.

The reality is that the current system’s lack of standardization creates more clinical uncertainty, not less. Protocols provide a foundation of evidence-based practice that supports better clinical decision-making for all involved providers.

What Must Change: A Roadmap for Implementation

Creating effective protocols requires collaboration between gastroenterology and surgical societies to develop evidence-based guidelines that both specialties can endorse. These protocols should be living documents, updated regularly as new research emerges and new medications enter the market.

Medical education must be reformed to include specific training on IBD medication management for surgical residents and continuing education for practicing surgeons. Similarly, gastroenterology training should include more emphasis on perioperative care and surgical risk assessment.

Healthcare systems should implement these protocols at the institutional level, creating standardized order sets and decision support tools that guide providers through appropriate medication timing. Electronic health records should include alerts and reminders that help coordinate care between specialties.

Professional societies must take the lead in developing and disseminating these protocols. The American Gastroenterological Association, American College of Surgeons, and relevant specialty surgical societies should collaborate to create unified guidelines that carry the weight of professional endorsement.

Patient education materials should accompany these protocols, empowering people with IBD to advocate for appropriate care and recognize when they’re receiving conflicting or potentially inappropriate advice about medication management.

Insurance companies and healthcare quality organizations should recognize adherence to evidence-based protocols as quality metrics, creating financial incentives for providers to follow standardized approaches to IBD medication management during elective surgery.

The Time for Action Is Now

Every day that passes without standardized protocols for IBD medication management during elective surgery, patients like Sarah face unnecessary risks and anxiety. The medical knowledge exists to create these protocols—what’s missing is the collective will to implement them systematically.

The IBD community has made tremendous strides in developing personalized treatment approaches and achieving better disease outcomes. Now we must apply that same innovation and dedication to ensuring that elective surgery doesn’t become a minefield of conflicting advice and suboptimal care.

Standardized protocols for IBD medication management during elective surgery aren’t just a nice-to-have improvement—they’re a patient safety imperative. When we have the knowledge and tools to provide consistent, evidence-based care, anything less is a disservice to the millions of people living with IBD who deserve better coordination between their healthcare providers.

The question isn’t whether we can develop these protocols—it’s whether we have the commitment to implement them. Our patients are waiting, and they deserve an answer.