New advice on withdrawal of DMARDs before surgery

Rheumatology patients and clinicians should welcome American College of Rheumatology (ACR) guidelines on the perioperative management of anti-rheumatic drugs around major joint replacements.

The guidelines, coauthored by the American Association of Hip and Knee Surgeons, provide some certainty where there has been none – in part due to the paucity of good quality evidence.

The initiative included a systematic review and feedback from both patient and expert panels.

Professor Ric Day, rheumatologist and clinical pharmacologist from the University of NSW and St Vincent’s Hospital, told the limbic the guidelines were a ‘good practical contribution’ to the problem.

The recommendations include continuing conventional DMARDs in adult patients undergoing elective total hip and total knee arthroplasties.

However biologic therapy should be stopped prior to surgery and re-started 14 days postoperatively, after evidence of wound healing. Surgery should be scheduled at the end of the last treatment cycle.

SLE-specific medications such as mycophenolate mofetil, azathioprine and cyclosporine should be continued in patients with severe disease to avoid the risk of organ damage.

However the medications should be discontinued one week ahead of surgery in patients with less severe disease.

“We’ve probably been more conservative and commonly fall on the side of worrying about immunosuppression and the risk of infection. While an infection in the joints is pretty rare, it is a catastrophe when it happens,” Professor Day said.

“The consequence of a big flare in lupus or rheumatoid arthritis can also be terrible and it can be hard to regain control. We certainly don’t want to overdo the withholding period.”

He said the contribution of the patient panel was important as the discussions often started with them.  The patient panel reported they were more concerned about the risk of infection during surgery than the risk of a flare by interrupting their regular medications.

Rheumatologists could help patients by raising the discussions early and allowing sufficient time to plan the surgery in line with the recommendations.

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