Perioperative management of patients with rheumatoid arthritis
Keywords:perioperative management, rheumatoid arthritis, joint replacement, infection, risk, disease modifying antirheumatic drugs, glucocorticoids, biological therapy, tumor necrosis factor inhibitors
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.
Cordtz RL, Hawley S, Prieto-Alhambra D, et al. Incidence of hip and knee replacement in patients with rheumatoid ar-thritis following the introduction of biological DMARDs: an interrupted time-series analysis using nationwide Danish healthcare registers. Ann Rheum Dis. 2018;77(5):684-689. https://doi.org/10.1136/annrheumdis-2017-212424.
Gualtierotti R. Parisi M, Ingegnoli F. Perioperative Management of Patients with Inflammatory Rheumatic Diseases Un-dergoing Major Orthopaedic Surgery: A Practical Overview. Adv Ther. 2018;35:439–456 https://doi.org/10.1007/s12325-018-0686-0.
Bissar L, Almoallim H, Albazli K, Alotaibi M, Alwafi S. Perioperative management of patients with rheumatic diseases. Open Rheumatol J. 2013 Aug 19;7:42-50. https://doi.org/10.2174/1874312901307010042.
Bushnell BD, Horton KJ, McDonald MF, Robertson PG. Perioperative medical comorbidities in the orthopaedic patient. J Am Acad Orthop Surg. 2008;16(4):216-27.
Nguyen HV, Ludwig SC, Silber J, et al. Rheumatoid arthritis of the cervical spine. Spine J. 2004;4(3):329-34. https://doi.org/10.1016/j.spinee.2003.10.006.
Gillick JL, Wainwright J, Das K. Rheumatoid Arthritis and the Cervical Spine: A Review on the Role of Surgery. Int J Rheumatol. 2015;2015:252456. https://doi.org/10.1155/2015/252456.
Kolman J, Morris I. Cricoarytenoid arthritis: a cause of acute upper airway obstruction in rheumatoid arthritis. Can J Anaesth. 2002 Aug-Sep;49(7):729-32. https://doi.org/10.1007/BF03017454.
Avin˜a-Zubieta JA, Choi HK, Sadatsafavi M, Etminan M, Esdaile JM, Lacaille D. Risk of cardiovascular mortality in pa-tients with rheumatoid arthritis: a meta-analysis of observational studies. Arthritis Rheum. 2008 Dec 15;59(12):1690-7. https://doi.org/10.1002/art.24092.
Roubille C, Richer V, Starnino T, et al. The effects of tumour necrosis factor inhibitors, methotrexate, non-steroidal anti-inflammatory drugs and corticosteroids on cardiovascular events in rheumatoid arthritis, psoriasis and psoriatic arthritis: a systematic review and meta-analysis. Ann Rheum Dis. 2015 Mar;74(3):480-9. https://doi.org/10.1136/annrheumdis-2014-206624.
Maradit-Kremers H, Nicola PJ, Crowson CS, Ballman KV, Gabriel SE. Cardiovascular death in rheumatoid arthritis: a population-based study. Arthritis Rheum. 2005 Mar;52(3):722-32. https://doi.org/10.1002/art.20878.
Biskup M, Biskup W, Majdan M, Targońska-Stępniak B. Cardiovascular system changes in rheumatoid arthritis pa-tients with continued low disease activity. Rheumatol Int. 2018 Jul;38(7):1207-1215. https://doi.org/10.1007/s00296-018-4053-x.
Agca R, Heslinga SC, Rollefstad S, et al. EULAR recommendations for cardiovascular disease risk management in pa-tients with rheumatoid arthritis and other forms of inflammatory joint disorders: 2015/2016 update. Ann Rheum Dis. 2017 Jan;76(1):17-28. https://doi.org/10.1136/annrheumdis-2016-209775.
Jacobs AM. Perioperative management of the patient with rheumatoid arthritis. Clin Podiatr Med Surg. 2010 Apr;27(2):235-42. https://doi.org/10.1016/j.cpm.2010.02.001.
Lake F, Proudman S. Rheumatoid arthritis and lung disease: from mechanisms to a practical approach. Semin Respir Crit Care Med. 2014 Apr;35(2):222-38. https://doi.org/10.1055/s-0034-1371542.
Mori S, Koga Y, Sugimoto M. Different risk factors between interstitial lung disease and airway disease in rheumatoid ar-thritis. Respir Med. 2012 Nov;106(11):1591-9. https://doi.org/10.1016/j.rmed.2012.07.006.
Roubille C, Haraoui B. Interstitial lung diseases induced or exacerbated by DMARDS and biologic agents in rheumatoid arthritis: a systematic literature review. Semin Arthritis Rheum. 2014 Apr;43(5):613-26. https://doi.org/10.1016/j.semarthrit.2013.09.005.
Goodman SM, Figgie MA. Arthroplasty in patients with established rheumatoid arthritis (RA): mitigating risks and opti-mizing outcomes. Best Pract Res Clin Rheumatol. 2015 Aug-Dec;29(4-5):628-42. https://doi.org/10.1016/j.berh.2015.09.004.
Chung WS, Peng CL, Lin CL, et al. Rheumatoid arthritis increases the risk of deep vein thrombosis and pulmonary thromboembolism: a nationwide cohort study. Ann Rheum Dis. 2014 Oct;73(10):1774-80. https://doi.org/10.1136/annrheumdis-2013-203380.
Stundner O, Chiu YL, Sun X, et al. Perioperative outcomes in patients with rheumatoid versus osteoarthritis for total hip arthroplasty: a population-based study. Clin Exp Rheumatol. 2013 Nov-Dec;31(6):889-95.
Cordtz RL, Zobbe K, Højgaard P, et al. Predictors of revision, prosthetic joint infection and mortality following total hip or total knee arthroplasty in patients with rheumatoid arthritis: a nationwide cohort study using Danish healthcare regis-ters. Ann Rheum Dis. 2018 Feb;77(2):281-288. https://doi.org/10.1136/annrheumdis-2017-212339.
Kurdi AJ, Voss BA, Tzeng TH, Scaife SL, El-Othmani MM, Saleh KJ. Rheumatoid Arthritis vs Osteoarthritis: Compari-son of Demographics and Trends of Joint Replacement Data from the Nationwide Inpatient Sample. Am J Orthop (Belle Mead NJ). 2018 Jul;47(7). https://doi.org/10.12788/ajo.2018.0050.
Horowitz JA, Puvanesarajah V, Jain A, et al. Rheumatoid Arthritis Is Associated With an Increased Risk of Postopera-tive Infection and Revision Surgery in Elderly Patients Undergoing Anterior Cervical Fusion. Spine (Phila Pa 1976). 2018 Sep 1;43(17):E1040-E1044. https://doi.org/10.1097/BRS.0000000000002614.
Diaper R, Wong E, Metcalfe SA. The implications of biologic therapy for elective foot and ankle surgery in patients with rheumatoid arthritis. Foot (Edinb). 2017 Mar;30:53-58. https://doi.org/10.1016/j.foot.2017.01.009.
Smolen JS, Landewe´ R, Bijlsma J, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2016 update. Ann Rheum Dis. 2017 Jun;76(6):960-977. https://doi.org/10.1136/annrheumdis-2016-210715.
Goodman SM. Rheumatoid arthritis: perioperative management of biologics and DMARDs. Semin Arthritis Rheum. 2015 Jun;44(6):627-32. https://doi.org/10.1016/j.semarthrit.2015.01.008.
Uehara R, Suzuki Y, Ichikawa Y. Methotrexate (MTX) inhibits osteoblastic differentiation in vitro: possible mechanism of MTX osteopathy. J Rheumatol. 2001 Feb;28(2):251-6.
Annussek T, Kleinheinz J, Thomas S, Joos U, Wermker K. Short time administration of antirheumatic drugs—methotrexate as a strong inhibitor of osteoblast’s proliferation in vitro. Head Face Med. 2012 Sep 29;8:26. https://doi.org/10.1186/1746-160X-8-26.
Sindhu K, Cohen B, Gil JA. Perioperative management of rheumatoid medications in orthopedic surgery. Orthopedics. 2017 Sep 1;40(5):282-286. https://doi.org/10.3928/01477447-20170518-04.
Goodman SM, Springer B, Guyatt G, et al. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic dis-eases undergoing elective total hip or total knee arthroplasty. Arthritis Rheumatol. 2017 Aug;69(8):1538-1551. https://doi.org/10.1002/art.40149.
Holroyd CR, Seth R, Bukhari M. The British Society for Rheumatology biologic DMARD safety guidelines in inflamma-tory arthritis-Executive summary. Rheumatology (Oxford). 2019 Feb 1;58(2):220-226. https://doi.org/10.1093/rheumatology/key207.
Lee JK, Choi CH. Total knee arthroplasty in rheumatoid arthritis. Knee Surg Relat Res. 2012 Mar;24(1):1-6. https://doi.org/10.5792/ksrr.2012.24.1.1.
Mak A. Orthopedic surgery and its complication in systemic lupus erythematosus. World J Orthop. 2014 Jan 18;5(1):38-44. https://doi.org/10.5312/wjo.v5.i1.38.
Teerawattananon C, Tantayakom P, Suwanawiboon B, Katchamart W. Risk of perioperative bleeding related to highly selective cyclooxygenase-2 inhibitors: A systematic review and meta-analysis. Semin Arthritis Rheum. 2017 Feb;46(4):520-528. https://doi.org/10.1016/j.semarthrit.2016.07.008.
Nissen SE, Yeomans ND, Solomon DH, et al. Cardiovascular Safety of Celecoxib, Naproxen, or Ibuprofen for Arthritis. N Engl J Med. 2016 Dec 29;375(26):2519-29. https://doi.org/10.1056/NEJMoa1611593.
Randelli P, Randelli F, Cabitza P, Vaienti L. The effects of COX-2 anti-inflammatory drugs on soft tissue healing: a re-view of the literature. J Biol Regul Homeost Agents. 2010 Apr-Jun;24(2):107-14.
Chikazu D, Tomizuka K, Ogasawara T, et al. Cyclooxygenase-2 activity is essential for the osseointegration of dental implants. Int J Oral Maxillofac Surg. 2007 May;36(5):441-6. https://doi.org/10.1016/j.ijom.2006.11.011.
Mochizuki T, Yano K, Ikari K, et al. Tramadol hydrochloride/acetaminophen combination versus non-steroidal anti-inflammatory drug for the treatment of perioperative pain after total knee arthroplasty: A prospective, randomized, open-label clinical trial. J Orthop Sci. 2016 Sep;21(5):625-9. https://doi.org/10.1016/j.jos.2016.07.011.
Smilowitz NR, Oberweis BS, Nukala S, et al. Perioperative antiplatelet therapy and cardiovascular outcomes in patients undergoing joint and spine surgery. J Clin Anesth. 2016 Dec;35:163-169. https://doi.org/10.1016/j.jclinane.2016.07.028.
Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012 Feb;141(2 Suppl):e326S-e350S. https://doi.org/10.1378/chest.11-2298.
Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Dec 9;130(24):2215-45. https://doi.org/10.1161/CIR.0000000000000105.
Fleury G, Mania S, Hannouche D, Gabay C. The perioperative use of synthetic and biological disease-modifying an-tirheumatic drugs in patients with rheumatoid arthritis. Swiss Med Wkly. 2017 Dec 11;147:w14563. https://doi.org/10.4414/smw.2017.14563.
Wiese MD, Alotaibi N, O’doherty C, et al. Pharmacogenomics of NAT2 and ABCG2 influence the toxicity and efficacy of sulphasalazine containing DMARD regimens in early rheumatoid arthritis. Pharmacogenomics J. 2014 Aug;14(4):350-5. https://doi.org/10.1038/tpj.2013.45.
Rempenault C, Combe B, Barnetche T, et al. Metabolic and cardiovascular benefits of hydroxychloroquine in patients with rheumatoid arthritis: a systematic review and meta-analysis. Ann Rheum Dis. 2018 Jan;77(1):98-103. https://doi.org/10.1136/annrheumdis-2017-211836.
Jenks KA, Stamp LK, O’Donnell JL, Savage RL, Chapman PT. Leflunomide-associated infections in rheumatoid arthri-tis. J Rheumatol. 2007 Nov;34(11):2201-2203.
Strand V, Cohen S, Schiff M, et al. Treatment of active rheumatoid arthritis with leflunomide compared with placebo and methotrexate. Leflunomide Rheumatoid Arthritis Investigators Group. Arch Intern Med. 1999 Nov 22;159(21):2542-50. https://doi.org/10.1001/archinte.159.21.2542.
Smolen JS, Kalden JR, Scott DL, et al. Efficacy and safety of leflunomide compared with placebo and sulphasalazine in active rheumatoid arthritis: a double-blind, randomised, multicentre trial. European Leflunomide Study Group. Lancet. 1999 Jan 23;353(9149):259-66. https://doi.org/10.1016/s0140-6736(98)09403-3.
Fuerst M, Mohl H, Baumgartel K, Ruther W. Leflunomide increases the risk of early healing complications in patients with rheumatoid arthritis undergoing elective orthopedic surgery. Rheumatol Int. 2006 Oct;26(12):1138-42. https://doi.org/10.1007/s00296-006-0138-z.
Tanaka N, Sakahashi H, Sato E, Hirose K, Ishima T, Ishii S. Examination of the risk of continuous leflunomide treat-ment on the incidence of infectious complications after joint arthroplasty in patients with rheumatoid arthritis. J Clin Rheumatol. 2003 Apr;9(2):115-8. https://doi.org/10.1097/01.RHU.0000062514.54375.bd.
Muller M, Pippi-Ludwig W. Perioperative management of patients with rheumatoid arthritis. Anaesthesist. 2014 Nov;63(11):883-94; quiz 895-6. https://doi.org/10.1007/s00101-014-2333-8.
Lin JA, Liao CC, Lee YJ, Wu CH, Huang WQ, Chen TL. Adverse outcomes after major surgery in patients with systemic lupus erythematosus: a nationwide population-based study. Ann Rheum Dis. 2014 Sep;73(9):1646-51. https://doi.org/10.1136/annrheumdis-2012-202758.
Lenguerrand E, Whitehouse M R, Beswick A D, et al. Risk factors associated with revision for prosthetic joint infection after hip replacement: a prospective observational cohort study. Lancet Infect Dis. 2018 Sep;18(9):1004-1014. https://doi.org/10.1016/S1473-3099(18)30345-1.
Somayaji R, Barnabe C, Martin L. Risk factors for infection following total joint arthroplasty in rheumatoid arthritis. Open Rheumatol J. 2013 Nov 29;7:119-24. https://doi.org/10.2174/1874312920131210005.
George MD, Baker JF, Winthrop K, et al. Risk of Biologics and Glucocorticoids in Patients With Rheumatoid Arthritis Undergoing Arthroplasty: A Cohort Study. Ann Intern Med. 2019 May 21;170(12):825-836. https://doi.org/10.7326/M18-2217.
Kirwan JR, Hickey SH, Hällgren R, et al. The effect of therapeutic glucocorticoids on the adrenal response in a random-ized controlled trial in patients with rheumatoid arthritis. Arthritis Rheum. 2006 May;54(5):1415-21. https://doi.org/10.1002/art.21747.
Fein AW, Figgie CA, Dodds TR, et al. Systemic Lupus Erythematosus Does Not Increase Risk of Adverse Events in the First 6 Months After Total Knee Arthroplasty. J Clin Rheumatol. 2016 Oct;22(7):355-9. https://doi.org/10.1097/RHU.0000000000000435.
Marik PE, Varon J. Requirement of perioperative stress doses of corticosteroids: a systematic review of the literature. Arch Surg. 2008 Dec;143(12):1222-6. https://doi.org/10.1001/archsurg.143.12.1222.
Danoff JR, Moss G, Liabaud B, Geller JA. Тotal knee arthroplasty considerations in rheumatoid arthritis. Autoimmune Dis. 2013;2013:185340. https://doi.org/10.1155/2013/185340.
Randelli P, Evola FR, Cabitza P, Polli L, Denti M, Vaienti L. Prophylactic use of antibiotic-loaded bone cement in prima-ry total knee replacement. Knee Surg Sports Traumatol Arthrosc. 2010 Feb;18(2):181-6. https://doi.org/10.1007/s00167-009-0921-y.
Singh JA, Cameron C, Noorbaloochi S, et al. Risk of serious infection in biological treatment of patients with rheumatoid arthritis: a systematic review and meta-analysis. Lancet. 2015 Jul 18;386(9990):258-65. https://doi.org/10.1016/S0140-6736(14)61704-9.
Galloway JB, Mercer LK, Moseley A, et al. Risk of skin and soft tissue infections (including shingles) in patients exposed to anti-tumour necrosis factor therapy: results from the British Society for Rheumatology Biologics Register. Ann Rheum Dis. 2013 Feb;72(2):229-34. https://doi.org/10.1136/annrheumdis-2011-201108.
Strangfeld A, Eveslage M, Schneider M, et al. Treatment benefit or survival of the fittest: what drives the time-dependent decrease in serious infection rates under TNF inhibition and what does this imply for the individual patient? Ann Rheum Dis. 2011 Nov;70(11):1914-20. https://doi.org/10.1136/ard.2011.151043.
Yun H, Xie F, Delzell E, et al. Comparative Risk of Hospitalized Infection Associated With Biologic Agents in Rheuma-toid Arthritis Patients Enrolled in Medicare. Arthritis Rheumatol. 2016 Jan;68(1):56-66. https://doi.org/10.1002/art.39399.
George MD, Baker JF, Hsu JY, et al. Perioperative Timing of Infliximab and the Risk of Serious Infection After Elective Hip and Knee Arthroplasty. Arthritis Care Res (Hoboken). 2017 Dec;69(12):1845-1854. https://doi.org/10.1002/acr.23209.
Goodman SM, Menon I, Christos PJ, Smethurst R, Bykerk VP. Management of perioperative tumour necrosis factor α inhibitors in rheumatoid arthritis patients undergoing arthroplasty: a systematic review and meta-analysis. Rheumatolo-gy (Oxford). 2016 Mar;55(3):573-82. https://doi.org/10.1093/rheumatology/kev364.
Mabille C, Degboe Y, Constantin A, Barnetche T, Cantagrel A, Ruyssen-Witrand A. Infectious risk associated to ortho-paedic surgery for rheumatoid arthritis patients treated by anti-TNFalpha. Joint Bone Spine. 2017 Jul;84(4):441-445. https://doi.org/10.1016/j.jbspin.2016.06.011.
Abou Zahr Z, Spiegelman A, Cantu M, Ng B. Perioperative use of anti-rheumatic agents does not increase early postop-erative infection risks: a Veteran Affairs' administrative database study. Rheumatol Int. 2015 Feb;35(2):265-72. https://doi.org/10.1007/s00296-014-3121-0.
Lau C, Dubinsky M, Melmed G, et al. The impact of preoperative serum anti-TNFα therapy levels on early postoperative outcomes in inflammatory bowel disease surgery. Ann Surg. 2015 Mar;261(3):487-96. https://doi.org/10.1097/SLA.0000000000000757.
Momohara S, Hashimoto J, Tsuboi H, et al. Analysis of perioperative clinical features and complications after ortho-paedic surgery in rheumatoid arthritis patients treated with tocilizumab in a real-world setting: results from the multicen-tre TOcilizumab in Perioperative Period (TOPP) study. Mod Rheumatol. 2013 May;23(3):440-9. https://doi.org/10.1007/s10165-012-0683-0.
Godot S, Gottenberg JE, Paternotte S, et al. Safety of surgery after rituximab therapy in 133 patients with rheumatoid ar-thritis: data from the autoimmunity and rituximab registry. Arthritis Care Res (Hoboken). 2013 Nov;65(11):1874-9. https://doi.org/10.1002/acr.22056.
Latourte A, Gottenberg JE, Luxembourger C, et al. Safety of surgery in patients with rheumatoid arthritis treated by abatacept: data from the French Orencia in Rheumatoid Arthritis Registry. Rheumatology (Oxford). 2017 Apr 1;56(4):629-637. https://doi.org/10.1093/rheumatology/kew476.
George MD, Baker JF, Winthrop K, et al. Timing of Abatacept Before Elective Arthroplasty and Risk of Post-operative Outcomes. Arthritis Care Res (Hoboken). 2019 Sep;71(9):1224-1233. https://doi.org/10.1002/acr.23843.
George MD, Baker JF. Perioperative management of immunosuppression in patients with rheumatoid arthritis. Curr Opin Rheumatol. 2019 May;31(3):300-306. https://doi.org/10.1097/BOR.0000000000000589.
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