Patients with Rheumatoid Arthritis Undergoing Surgery: How Should We Deal with Antirheumatic Treatment?
Section snippets
Methods
The review is based on a MEDLINE (PubMed) search of the English-language literature from 1965 to 2005, using the index keywords “RA” and “surgery”. As co-indexing terms the different DMARDs as well as “NSAIDs” and “glucocorticoids” were used. In addition, citations from retrieved articles were scanned for additional references. Furthermore, because the number of published articles is so limited, relevant abstracts presented at congresses were included in the analysis.
Mtx
The first studies on MTX and perioperative complications were published in the 1990s. The number of patients per trial was usually small and the results were controversial. Bridges and coworkers (2) performed a retrospective analysis of 38 RA patients undergoing elective orthopedic surgery. Those who continued MTX had local infections more often than those who stopped the DMARD (4 of 19 procedures versus 0 of 34). Perhala and coworkers retrospectively analyzed 60 patients with and 61 without
Discussion
A limited number of authors have addressed the question of how to best handle antirheumatic treatment in RA patients undergoing surgery (93, 95, 96). The main results of this review are summarized in Table 2. Continuing medication may hamper wound healing and predispose to infections. Discontinuation may lead to disease flare, which may increase the need for corticosteroids for disease control and, furthermore, limit mobilization and effective rehabilitation after surgery.
How long a DMARD can
Acknowledgment
We thank Ms. Jane Neuda for editorial assistance.
References (99)
- et al.
Influence of steroids and methotrexate on wound complications after elective rheumatoid hand and wrist surgery
J Hand Surg [Am]
(2002) Hydroxychloroquine and postoperative thromboembolism after total hip replacement
Am J Med
(1988)- et al.
Infliximab (chimeric anti-tumour necrosis factor alpha monoclonal antibody) versus placebo in rheumatoid arthritis patients receiving concomitant methotrexate: a randomised phase III trial
Lancet
(1999) - et al.
TEMPO (Trial of Etanercept and Methotrexate with Radiographic Patient Outcomes) study investigatorsTherapeutic effect of the combination of etanercept and methotrexate compared with each treatment alone in patients with rheumatoid arthritis: double-blind randomised controlled trial
Lancet
(2004) - et al.
Nonsteroidal antiinflammatory drugs, perioperative blood loss, and transfusion requirements in elective hip arthroplasty
J Arthroplasty
(1993) - et al.
High-dose diclofenac for postoperative analgesia after elective caesarean section in regional anaesthesia
Int J Obstet Anesth
(2002) - et al.
Effect of rofecoxib on platelet aggregation and blood loss in gynaecological and breast surgery compared with diclofenac
Br J Anaesth
(2004) - et al.
Opioid-sparing effects of diclofenac and paracetamol lead to improved outcomes after cardiac surgery
J Cardiothorac Vasc Anesth
(2004) - et al.
Implications of preoperative administration of aspirin in patients undergoing coronary artery bypass grafting
J Am Coll Cardiol
(1990) - et al.
Antithrombotic therapy for coronary artery disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy
Chest
(2004)
Coronary syndromes following aspirin withdrawal: a special risk for late stent thrombosis
J Am Coll Cardiol
Recovery of the hypothalamic-pituitary-adrenal (HPA) axis in patients with rheumatic diseases receiving low-dose prednisone
Am J Med
Alternate-day corticosteroid therapy
Am J Med
A double-blind study of perioperative steroid requirements in secondary adrenal insufficiency
Surgery
Severe flare of rheumatoid arthritis after discontinuation of long-term methotrexate therapyDouble-blind study
Am J Med
Disease modifying treatment and elective surgery in rheumatoid arthritis: the need for more data
Ann Rheum Dis
Should methotrexate be discontinued before elective orthopedic surgery in patients with rheumatoid arthritis?
J Rheumatol
Local infectious complications following large joint replacement in rheumatoid arthritis patients treated with methotrexate versus those not treated with methotrexate
Arthritis Rheum
Postoperative results of rheumatoid arthritis patients on methotrexate at the time of reconstructive surgery of the hand
Orthopedics
Influence of methotrexate on the frequency of postoperative infectious complications in patients with rheumatoid arthritis
J Rheumatol
Postoperative joint infections in rheumatoid arthritis patients on methotrexate therapy
Orthopedics
Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery
Ann Rheum Dis
Infektionen des Bewegungsapparates bei der chronischen Polyarthritis ẅhrend einer Kombinationstherapie mit Methotrexat und Leflunomid
Z Orthop Ihre Grenzgeb
Leflunomid increases the risk of early healing complications in patients with rheumatoid arthritis undergoing elective orthopaedic
Rheumatol Int
Examination of the risk of continuous leflunomide treatment on the incidence of infectious complications after joint arthroplasty in patients with rheumatoid arthritis
J Clin Rheumatol
Clinical pharmacokinetics of leflunomide
Clin Pharmacokinet
Risk factors for early wound complications after orthopedic surgery for rheumatoid arthritis
J Rheumatol
The effect of immunosuppression on wound healing
Surg Gynecol Obstet
Early post-operative complications are not increased in patients with Crohn’s disease treated perioperatively with infliximab or immunosuppressive therapy
Am J Gastroenterol
A randomized trial comparing double-drug and triple-drug therapy in primary cadaveric renal transplants
Transplantation
The influence of rheumatoid chemotherapy, age, and presence of rheumatoid nodules on postoperative complications in rheumatoid foot and ankle surgery: analysis of 725 procedures in 104 patients
Foot Ankle Int
Prevention of venous thromboembolism by administration of hydroxychloroquineA preliminary report
J Bone Joint Surg Am
Hydroxychloroquine sulfate prophylaxis for pulmonary embolism for patients with low-friction arthroplasty
Clin Orthop Relat Res
Failure of orally administered hydroxychloroquine sulphate to prevent venous thromboembolism following elective hip operations
J Bone Joint Surg Am
Hydroxychloroquine in prophylaxis of pulmonary embolism following hip arthroplasty
Clin Orthop Relat Res
Pharmacokinetics of hydroxychloroquine and chloroquine during treatment of rheumatic diseases
Lupus
Adalimumab, a fully human anti-tumor necrosis factor alpha monoclonal antibody, for the treatment of rheumatoid arthritis in patients taking concomitant methotrexate: the ARMADA trial
Arthritis Rheum
Clinical and radiological effects of anakinra in patients with rheumatoid arthritis
Rheumatology (Oxford)
Efficacy of B-cell-targeted therapy with rituximab in patients with rheumatoid arthritis
N Engl J Med
Treatment of rheumatoid arthritis by selective inhibition of T-cell activation with fusion protein CTLA4Ig
N Engl J Med
Tumor necrosis factor and wound healing
Ann Surg
In vivo effects of tumor necrosis factor-alpha on incised wound and gunshot wound healing
J Trauma
Tumor necrosis factor-alpha inhibits collagen synthesis in human and rat granulation tissue fibroblasts
Experientia
The local effects of cachectin/tumor necrosis factor on wound healing
Ann Surg
Infectious and healing complications after elective orthopaedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy
Foot Ankle Int
Infectious complications in elective surgery in RA patients in the anti-TNF era: a retrospective study
Ann Rheum Dis
Tumor necrosis factor inhibitor therapy and risk of serious postoperative orthopedic infection in rheumatoid arthritis
Arthritis Rheum
Infliximab and its impact on surgical outcomes in patients with rheumatoid arthritis
Ann Rheum Dis
Tumour necrosis factor antagonists and early postoperative complications in patients with inflammatory joint disease undergoing elective orthopaedic surgery
Ann Rheum Dis
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2019, Clinics in Podiatric Medicine and SurgeryCitation Excerpt :Due to decreasing bone quality with prolonged steroid therapy, some literature recommends adjunctive therapy using Teriparatide to improve bone mineral density as well as decrease fracture risk.40,59,60 The literature recommends that individuals undergoing glucocorticoid therapy for RA should be tapered to an appropriate preoperative dose, while also preventing the risk of Addisonian crisis via adrenal insufficiency and also preventing postoperative infection from diminished wound healing.40,61,62 Although the literature suggests that doses be less than 15 mg per day of steroid, specifically prednisolone in this instance, the literature does have controversy and lacks concrete evidence to support recommendations for particular dosing strategies.57,58
The authors have no conflicts of interest to disclose.