REVIEW - Perioperative management of the rheumatic disease patient

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Bulletin on the Rheumatic Disease

Volume 51, Number 6

Perioperative Management of the Rheumatic Disease Patient

Excerpt:

Methotrexate. Weekly methotrexate therapy became popular among

rheumatologists in the 1980s and continues to be one of the most commonly

used disease-modifying antirheumatic drugs (DMARDs). The relationship

between methotrexate and postoperative complications, such as local

infections and poor wound healing, has been a controversial topic over the

past decade due to the lack of definitive studies (10). Most of the studies

have involved rheumatoid arthritis patients undergoing elective orthopedic

surgery.

A small retrospective study published in 1991 suggested that methotrexate

increases the risk of postoperative complications (11). The authors were

unable to draw any definite conclusions, however, due to the small number of

patients and the nonrandomized selection of therapy. Other small studies

around the same time failed to show a significant increase in complications

in patients taking methotrexate perioperatively (12-14).

In 2001, a prospective randomized study of postoperative infection or

surgical complications in patients with rheumatoid arthritis who underwent

elective orthopedic surgery was published (15). Three hundred eighty-eight

patients with rheumatoid arthritis who were to undergo elective orthopedic

surgery were divided into two groups. One group continued methotrexate and

the other group discontinued methotrexate from 2 weeks before surgery until

2 weeks after surgery. Their complication rates were compared with

complications occurring in 228 rheumatoid arthritis patients not receiving

methotrexate who also underwent elective orthopedic surgery. Methotrexate

use was not associated with an increased incidence of complications and, in

fact, those patients that continued methotrexate had significantly less

complications or infections than either of the other two groups (p < 0.003).

Additionally, discontinuation of methotrexate led more commonly to disease

flares within 6 weeks following surgery (15).

With the information available, it would be reasonable to continue the

methotrexate weekly administration schedule pre- and postoperatively in most

situations. Situations in which methotrexate could be withheld the week

before and after surgery might be in the elderly, frail patient on many

other drugs and with some renal insufficiency. If methotrexate therapy is

interrupted, it is imperative to reinitiate therapy as soon as possible

given the risk of having a disease flare (15).

http://www.arthritis.org/research/Bulletin/vol51no6/51_6_Printable.htm

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