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Despite major advances in therapy, patients with chronic rheumatic diseases continue to require surgery to address pain and functional incapacity [1–3]. Most often of an orthopedic nature, particularly total joint arthroplasty, rheumatologists and increasingly specialists in hospital-based medicine are asked to evaluate and care for such patients in the perioperative setting. As modern day rheumatic disease therapy is a complex and rapidly evolving domain, perioperative management in this clinical context may seem challenging particularly to physicians less familiar with these therapies. This commentary presents a succinct summary of the relevant pharmacological considerations emphasizing the results of a recently published collaboration of American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) from which evidence-based guidelines for the perioperative management of anti-rheumatic drug therapy have been developed . Owing to their anti-inflammatory and immunosuppressive nature, concerns regarding the risk of postoperative infection as well as impaired wound healing have long encircled the use of these medications in the surgical setting. Given the high prevalence of their usage, decision-making is a frequently encountered conundrum and one that provides an opportunity for the mitigation of important postoperative risks.
By way of background, the anti-rheumatic disease medications are categorized as agents believed to modify disease activity (DMARDS) or as biologics, agents that target specific mediators (cytokines) of the inflammatory response. Corticosteroids as well as other agents of uncertain mechanism of action are also included in this review due to their long-standing usage and recognized efficacy in the therapy of rheumatic disease. On a practical level, the principle management questions are when a given medication should have been stopped preoperatively and in order to avoid postoperative disease flares, how soon can it be restarted afterward? In the case of the former, decisions are based on a medication’s half-life and with respect to the latter on the patient’s postoperative course. The literature upon which treatment considerations can be based is nonetheless sparse with no reported randomized controlled trials concerning this clinical problem. As such consensus-based approaches to guideline development are necessary.
As referenced above, the efforts of a panel of experts (rheumatologists, orthopedic surgeons, an infectious disease specialist and a methodologist) represents the most current and authoritative statement concerning this perioperative challenge. The methodology employed is summarized herein . After convening to construct the key clinical questions to be addressed in a relevant guideline, a systematic literature review pertaining to the continuing versus withholding of anti-rheumatic therapy was conducted. Patient values and preferences were then considered and the quality of evidence and strength of recommendations evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology [5, 6]. Group consensus was then reached by a voting panel of participating rheumatologists and orthopedic surgeons. Recommendation strength reflects the panel’s degree of certainty that the benefits of a given recommendation outweigh the potential harms vis-à-vis the quality of the supporting evidence and patient preferences.
Table Table11 presents the principles underlying the medication recommendations summarized in Table Table2.2. Further, but not included in the figure, glucocorticoid dosing in the perioperative setting was also addressed. Challenging the traditional, virtually rote application of a “stress-dose” paradigm, the continuance of the patient’s usual daily dose of glucocorticoid is thought to be, with few exceptions, sufficient .
These recommendations are intended to guide, not mandate, treatment, and it is recognized that not all perioperative scenarios are covered. While developed for total joint arthroplasty, these guidelines represent the best available evidence concerning the perioperative management of anti-rheumatic medication. As such, they can be extrapolated to other orthopedic settings including the spine, hand and foot, and to general surgical procedures.