Patients with Rheumatoid Arthritis Undergoing Surgery: How Should We Deal with Antirheumatic Treatment?

https://doi.org/10.1016/j.semarthrit.2006.10.003Get rights and content

Objectives

To review published data on the perioperative management of antirheumatic treatment and perioperative outcome in patients with rheumatoid arthritis (RA).

Methods

The review is based on a MEDLINE (PubMed) search of the English-language literature from 1965 to 2005, using the index keywords “rheumatoid arthritis” and “surgery”. As co-indexing terms the different disease-modifying antirheumatic drugs (DMARDs) as well as nonsteroidal anti-inflammatory drugs (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.

Results

Continuation of methotrexate (MTX) appears to be safe in the perioperative period. Only a limited number of studies address the use of leflunomide and the results are conflicting. Because of the very long drug half-life, its discontinuation would need to be of long duration and is probably not necessary. Data on hydroxychloroquine do not show increased risks of infection. Regarding sulfasalazine, there are no studies from which definite answers could be drawn on whether it should be withheld perioperatively. Preliminary data show that the risk of infections during treatment with TNF-blocking agents may be lower than initially expected. The only available recommendation (Club Rhumatismes et Inflammation, CRI) suggests discontinuing the drugs before surgery for several weeks, depending on the risk of infection and the drug used. They should not be restarted until wound healing is complete. To avoid the antiplatelet effect during surgery, NSAIDs other than aspirin should be withheld for a duration of 4 to 5 times the drug half-life. Patients with chronic glucocorticoid therapy and suppressed hypothalamic-pituitary-adrenal (HPA) axis need perioperative supplementation.

Conclusions

While continuation of MTX likely is safe, data on other DMARDs are sparse. In particular, more data on the perioperative use of the biologic agents are needed.

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.

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      Citation 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

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    The authors have no conflicts of interest to disclose.

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