RESEARCH - Patients with RA undergoing surgery: how should we deal with antirheumatic treatment?

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Semin Arthritis Rheum. 2007 Jan 2

Patients with Rheumatoid Arthritis Undergoing Surgery: How Should We Deal

with Antirheumatic Treatment?

Section of Rheumatology, 2nd Department of Medicine, General Hospital Linz,

Linz, Austria.

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.

PMID: 17204310

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed & cmd=Retrieve & dopt=Abstra\

ctPlus & list_uids=17204310

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