Perioperative management of patients with RA in the era of biologic response modifiers

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Curr Opin Rheumatol. 2004 May;16(3):192-198.

Perioperative management of patients with rheumatoid arthritis in the

era of biologic response modifiers.

ndich PA, Kelley JT 3rd, Conn DL.

Division of Rheumatology, Emory University School of Medicine Atlanta,

Georgia; and the private practice of Dr. Kelley, Sarasota, Florida, USA.

PURPOSE OF REVIEW: This article provides guidelines for the

perioperative management of the most commonly used antirheumatic drugs

being used to treat patients with rheumatoid arthritis, with an emphasis

on the relatively new addition of biologic response modifiers. RECENT

FINDINGS: Few clinical data exist examining the perioperative management

of the biologic drugs, which include the inhibitors of tumor necrosis

factor-alpha (etanercept, infliximab, and adalimumab), the interleukin-1

receptor antagonist anakinra, and to a much lesser extent the CD20

inhibitor rituximab. The only human data available in that regard is

based on the use of the tumor necrosis factor-alpha inhibitor infliximab

in surgical patients with Crohn disease. Although quite limited, that

data appeared favorable in finding that infliximab did not result in an

increased risk of postoperative complications in that setting.

SUMMARY: Perioperative guidelines have never been well established for a

majority of the traditional antirheumatic drugs in use today.

Recommendations for the perioperative use of nonsteroidal

antiinflammatory drugs and glucocorticoids have the most evidence-based

support. Data for the use of methotrexate are also available from which

to generate reasonable guidelines; however, for the remaining

antirheumatic drugs in current use, the available data cannot support

any clear evidence-based recommendations. To provide reasonable

guidelines for the use of the biologics, perhaps the best we can do is

to extrapolate from the very limited data coming from the concurrent use

of infliximab in patients with Crohn disease who have undergone surgery.

Beyond that, we are left with animal and tissue culture data from which

any recommendations would be rather tenuous.

PMID: 15103244

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