Perioperative management of patients with rheumatoid arthritis in the era of biologic response modifiers

Abstract

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.

Do patients with RA receiving anti-TNF agents have an increased risk of surgical site infections?

“…1 Anti-TNF therapy can be resumed 2 weeks after surgery, or after complete wound healing in the absence of infection. 4,5 …”

The serum concentration of infliximab in cases of autologous blood donation for patients with rheumatoid arthritis

“…Infl iximab is administered as the TNF-α inhibitor, and it improves patients' symptoms and function. 5 However, this agent has been reported to be associated with risks in healing properly and infectious complications due to the systemic blockade of TNF-α, a ubiquitous mediator required in the normal infl ammatory response in tissue healing and infection surveillance. 6 Currently, little information is available regarding the relationship between infliximab treatment and surgery outcomes.…”

Perioperative management of tumor necrosis factor antagonists in patients with psoriasis and other inflammatory disorders

“…However, the slight trend towards increased frequency of infections and delayed wound healing in the setting of insufficiently powered studies has led most authors to advocate a more cautious approach. Most reviews of the rheumatologic literature recommend discontinuing any TNF antagonist for a week prior to surgery, with resumption of treatment 2-4 weeks after surgery (4,54,70). Until further studies are conducted in psoriasis and psoriatic arthritis, a reasonable approach would be to follow these rheumatologic recommendations.…”