Perioperative utilization of JAK inhibitors in Perianal Fistulizing Crohn's disease

With the recent approval of small molecule drugs such as upadacitinib in adult inflammatory bowel disease (IBD), their utilization is becoming more common; however, there is limited data on perioperative risks or optimal timing of cessation and resumption to mitigate flares. Current recommendations suggest holding these medications for 14 days postoperatively for IBD-related surgeries. We present a 17-year-old female with severe fistulizing perianal and rectosigmoid Crohn's disease who required diverting sigmoidostomy for her perianal disease. Her disease was controlled on upadacitinib for 1 year; however, she had reoccurrence of fistulizing disease with perianal abscess after stopping upadacitinib for 14 days following sigmoidostomy takedown. This 14-day timeline puts patients at risk of resumption of active disease, with fistula recurrence being a disease subset that may not be able to be salvaged with medication resumption alone. Shared decision-making is crucial before deciding how long to withhold these medications, but more research is needed to provide concrete guidelines.