Most patients with rheumatoid arthritis (RA) will undergo orthopaedic surgery during the course of their disease, and more than 80% of that cohort will be taking traditional or biologic disease-modifying antirheumatic drugs (DMARDs) at the time of their operations. That presents a dilemma, because stopping DMARDs can raise the risk of a rehab-hampering postoperative RA flare, while continuing the drugs is thought to increase the risk of postoperative infection.
A recent literature review in Seminars in Arthritis & Rheumatism suggests that surgeons should feel comfortable allowing patients to continue taking traditional DMARDs, such as sulfasalazine, as long as renal function is monitored. Emphasizing that more research is needed to pinpoint optimal start and stop dates for other DMARDs, review author Susan Goodman, MD, makes the following suggestions:
–Methotrexate: Continuing is recommended.
–Leflunomide: Discontinue for 1 week prior to surgery.
–Anti-TNF Alpha Drugs: Withhold therapy for 1.5 times the dosing interval.
–Tocilizumab: Exercise increased vigilance due to possible masking of signs of infection.
–Abatacept: Withhold for 2 to 3 weeks prior to surgery.
–Tofacitinib: Withhold for 2 days prior to surgery.
Dr. Goodman also observes that preoperative doses of corticosteroids, often used to cover RA flares in patients who’ve discontinued DMARDS, are often far higher than necessary, which could also increase infection risk.