202409172216
Status:
Tags: rheumatology
Anti-rheumatic drugs
Evidence on peri-op use is in general low
(level of evidence often low in guidelines)
SLE often considered separately from other rheumatological diseases
Severe SLE:
currently treated (induction or maintenance) for severe organ manifestations:
- lupus nephritis,
- CNS lupus,
- severe hemolytic anemia (hemoglobin <9.9 gm/dl),
- platelets <50,000,
- vasculitis (other than mild cutaneous vasculitis), including:
- pulmonary hemorrhage,
- myocarditis,
- lupus pneumonitis,
- severe myositis
- (with muscle weakness, not just high enzymes),
- lupus enteritis (vasculitis),
- lupus pancreatitis,
- cholecystitis,
- lupus hepatitis,
- protein-losing enteropathy,
- malabsorption,
- orbital inflammation/myositis,
- severe keratitis,
- posterior severe uveitis/retinal vasculitis,
- severe scleritis,
- optic neuritis,
- anterior ischemic optic neuropathy
- (derived from the SELENA–SLEDAI flare index and the BILAG 2004 index)
Summary of various guideline
| Drugs | Dosing interval | Recommended timing of surgery since last medication dose: ACR/AAHKS | Recommended timing of Surgery since last medication dose : BSR | When to restart post-operatively |
|---|---|---|---|---|
| 1. Glucocorticoids | Daily | Anytime | Anytime | |
| 2. Synthetic DMARDs | ||||
| (a) Methotrexate | Weekly | Anytime | Anytime | 3–5 days |
| (b) Sulfasalazine | Once or twice daily | Anytime | Anytime | 3–5 days |
| (c) Hydroxychloroquine | Once or twice daily | Anytime | Anytime | 3–5 days |
| (d) Leflunomide | Daily | Anytime | Anytime | 3–5 days |
| (e) Azathioprine | Daily | Anytime | Anytime | 3–5 days |
| (f) Mycophenolate Mofetil | Daily | Anytime | Anytime | 3–5 days |
| 3. Biologic DMARDs | ||||
| (a) Infliximab | Every 4, 6, or 8 weeks | Week 5, 7, or 9 | Week 5, 7, or 9 | 14 days |
| (b) Adalimumab | Every 2 weeks | Week 3 | Week 3 | 14 days |
| (c) Etanercept | Every week | Week 2 | Week 2 | 14 days |
| (d) Golimumab | Every 4 weeks (SC) | Week 5 | Week 5 | 14 days |
| Every 8 weeks (IV) | Week 9 | |||
| (e) Abatacept | Monthly (IV) | Week 5 | Week 5 | 14 days |
| Weekly (SC) | Week 2 | Week 3 | ||
| (f) Certolizumab | Every 2 weeks | Week 3 | Week 3 | 14 days |
| Every 4 weeks | Week 5 | |||
| (g) Rituximab | 2 doses 2 weeks apart every 4–6 months | Month 7 | Month 4–7 | 14 days |
| (h) Tocilizumab | Every week (SC) | Week 2 | Week 3 | 14 days |
| Every 4 weeks (IV) | Week 5 | Week 5 | ||
| (i) Anakinra | Daily | Day 2 | Day 2 | 14 days |
| (j) IL-17-Secukinumab | Every 4 weeks | Week 5 | Week 13 | 14 days |
| (k) Ustekinumab | Every 12 weeks | Week 13 | Week 13 | 14 days |
| 4. JAK inhibitors | ||||
| (a) Tofacitinib | Daily or twice daily | Day 4 | ||
| (b) Baricitinib | Daily | Day 4 | ||
| (c) Upadacitinib | Daily | Day 4 | ||
| (d) Filgotinib | Daily | Day 4 |
2022 ACR/AAHKS Guideline (elective THR/TKR)
| Dosing interval | Recommended timing of surgery since last medication dose | |
|---|---|---|
| Medications to continue through surgery | ||
| DMARDs: continue these medications through surgery (all patients) | ||
| Methotrexate | Weekly | Anytime |
| Sulfasalazine | Once or twice daily | Anytime |
| Hydroxychloroquine | Once or twice daily | Anytime |
| Leflunomide (Arava) | Daily | Anytime |
| Doxycycline | Daily | Anytime |
| Apremilast (Otezla) | Twice daily† | Anytime† |
| Severe SLE-specific medications: continue these medications in the perioperative period in consultation with the treating rheumatologist | ||
| Mycophenolate mofetil | Twice daily | Anytime |
| Azathioprine | Daily or twice daily | Anytime |
| Cyclosporine | Twice daily | Anytime |
| Tacrolimus | Twice daily (IV and PO) | Anytime |
| Rituximab (Rituxan) | IV every 4–6 months† | Month 4–6† |
| Belimumab SC (Benlysta) | Weekly† | Anytime† |
| Belimumab IV (Benlysta) | Monthly† | Week 4† |
| Anifrolumab (Saphnelo)§ | IV every 4 weeks† | Week 4† |
| Voclosporin (Lupkynis)§ | Twice daily† | Continue† |
| Medications to withhold prior to surgery | ||
| Biologics: withhold these medications through surgery | ||
| Infliximab (Remicade) | Every 4, 6, or 8 weeks | Week 5, 7, or 9 |
| Adalimumab (Humira) | Every 2 weeks | Week 3 |
| Etanercept (Enbrel) | Every week | Week 2 |
| Golimumab (Simponi)** | Every 4 weeks (SQ) or every 8 weeks (IV) | Week 5 Week 9 |
| Abatacept (Orencia) | Monthly (IV) or weekly (SC) | Week 5; week 2 |
| Certolizumab (Cimzia) | Every 2 or 4 weeks | Week 3 or 5 |
| Rituximab (Rituxan) | 2 doses 2 weeks apart every 4–6 months | Month 7 |
| Tocilizumab (Actemra) | Every week (SC) or every 4 weeks (IV) | Week 2; week 5 |
| Anakinra (Kineret) | Daily | Day 2 |
| IL-17 secukinumab (Cosentyx) | Every 4 weeks | Week 5 |
| Ustekinumab (Stelara) | Every 12 weeks | Week 13 |
| Ixekizumab (Taltz)§ | Every 4 weeks† | Week 5† |
| IL-23 guselkumab (Tremfya)§ | Every 8 weeks† | Week 9† |
| JAK inhibitors: withhold this medication 3 days prior to surgery# | ||
| Tofacitinib (Xeljanz) | Daily or twice daily† | Day 4† |
| Baricitinib (Olumiant)§ | Daily† | Day 4† |
| Upadacitinib (Rinvoq)§ | Daily† | Day 4† |
| Not severe SLE: withhold these medications 1 week prior to surgery | ||
| Mycophenolate mofetil | Twice daily | 1 week after last dose† |
| Azathioprine | Daily or twice daily | 1 week after last dose |
| Cyclosporine | Twice daily | 1 week after last dose† |
| Tacrolimus | Twice daily (IV and PO) | 1 week after last dose† |
| Rituximab (Rituxan) | Every 4–6 months | Month 7 |
| Belimumab IV (Benlysta) | Monthly† | Week 5† |
| Belimumab SC (Benlysta) | Weekly† | Week 2† |
| ¶ For patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, or all SLE for whom antirheumatic therapy was withheld prior to undergoing total joint arthroplasty, antirheumatic therapy should be restarted once the wound shows evidence of healing, any sutures/staples are out, there is no significant swelling, erythema, or drainage, and there is no ongoing nonsurgical site infection, which is typically ~14 days. |
Other sources
| Antirheumatic drug | Comments |
|---|---|
| Methotrexate (MTX) | • There is no increased risk of infection or other postoperative complications in patients with RA who continued MTX. • Continue the current dose of methotrexate for patients undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA). • Withheld the week before and the week after surgery if there are additional concerns regarding the perioperative safety of MTX such as renal insufficiency or if a more complex surgical intervention is required. • MTX should be reinstated as soon as the patient is stable postoperatively. • MTX treatment should be discontinued until full recovery if prolonged surgery or artificial respiration is anticipated or in case of pulmonary complications, to reduce the risk of pneumonia |
| TNF blockers | • It is recommend stopping TNF blockers use 1 to 4 weeks before surgery, proportional to the drugs half-lives. • Withhold TNF blockers and other biologic agents prior to surgery in patients undergoing elective THA or TKA, and schedule the surgery at the end of the dosing cycle. • Treatment may be restarted at minimum 14 days postoperatively if there is no evidence of infection and once wound healing is satisfactory |
| Tocilizumab | • Infection rates attributed to tocilizumab are comparable to those associated with other biologic DMARDs. • Discontinuing tocilizumab 11 to 13 days before surgery, based on the drug half-life, is a safe approach to perioperative therapy |
| SLE specific medications: Mycophenolate mofetil Azathioprine Cyclosporine Tacrolimus |
• Withhold their current doses 1 week prior to surgery in all patients with stable SLE undergoing THA or TKA. • Continue their current doses through the surgical period in all patients with severe SLE undergoing THA or TKA. |
| Rituximab | • Rituximab has been shown to be safe in patients with prior recurrent bacterial infections. • Compared with TNF blockers, rituximab is associated with a lower risk for bacterial infections, which are the primary concern in perioperative management, although the presence of low immunoglobulin levels in a small proportion of patients raises the infection risk. • Elective surgery can be arranged in the 7th month from the last given dose |
| Abatacept | • The risk of infection in patients treated with abatacept is not significantly increased over baseline non-biologic-treated RA patients. • Abatacept is administered either as a monthly infusion or a weekly subcutaneous injection, and conservative timing of surgery should be at the end of the dose cycle |
| Steroid | • In general, limiting minimal doses of steroids preoperatively should be considered to prevent impairment of wound healing and surgical site infections. • Chronic use of steroid also increases the potential risk of subversive consequences of an inadequate adrenal response |
Steroid
ACR suggests continuing the current daily dose of steroids in patients scheduled for surgery rather than administering glucocorticoids on the day of surgery. If patients require high doses of glucocorticoids, it implies indirectly that disease activity is not controlled, and for better outcomes, elective surgery needs to be postponed. Hydrocortisone can be considered in these patients if refractory hypotension occurs; however, the recommendations are irrelevant for patients with primary adrenal insufficiency
BSR reinstates that steroid exposure should be minimised prior to surgical procedures and that an increase in steroid dose to prevent adrenal insufficiency is not routinely required
References
Table 1 | Perioperative Management of Patients with Rheumatic Diseases | SpringerLink