Perioperative management of patients with rheumatoid arthritis
Patients with rheumatoid arthritis (RA), despite the success of conservative therapy, have an urgent need for the orthopedic surgical interventions, as well as operations for somatic indications. These patients need a careful perioperative assessment and instruction for the favorable results of surgical treatment and management to be achieved in the postoperative period. A detailed history should be compiled, a thorough physical examination with appropriate laboratory evaluation of the organic and systemic functions, differentiation of the organic damage secondary to the RA or associated with comorbidity, should be carried out. Patients should be informed about the potential risks of surgery, including an increased risk of infection, delayed wound healing and development of venous thromboembolism events, as well as the key possibilities in terms of cardiovascular, pulmonary and neurological disorders that may be caused by surgery. Clinical studies over the past few years have improved our understanding of the proper perioperative management of patients with the RA. This article summarizes the latest advances in this field and considers the latest recommendations proposed by the American College of Rheumatology and the American Association of Hip and Knee Surgeons guidelines (2017) for the perioperative management of antirheumatic therapy in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty, and The British Society for Rheumatology guidelines on the disease-modifying antirheumatic drugs (DMARD) safety in inflammatory arthritis. The management of DMARDs in the preoperative period should be carried out under the recommendations of the leading rheumatological societies, but the approach should be individualized with the involvement of a multidisciplinary team. Today, the recommendations support the continuation of synthetic DMARDs throughout the entire perioperative period and recommend a short-term interruption of biological therapy at one dosing interval before surgery with a continuation of administration within 14 days after surgery. The higher doses of glucocorticoids contribute to the risk of postoperative infection more significantly than the biological therapy. It is recommended to avoid the planned surgery if the patients are receiving prednisone at a dose of more than 20 mg per day. Before surgery, it is recommended to reduce the dose of glucocorticoids to the lowest possible level. Even though uncertainty remains, these recent studies and recommendations allow a more rational and scientifically sound approach to the management of RA patients who are scheduled for surgery or who need to get operated urgently.
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