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

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Semin Arthritis Rheum. 2007 Apr;36(5):278-86. Epub 2007 Jan 3.

Patients with rheumatoid arthritis undergoing surgery: how should we

deal with antirheumatic treatment?

Pieringer H, Stuby U, Biesenbach G.

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/pubmed/17204310

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