Rheumatoid arthritis

Research finds wide variation in approach to peri-operative bDMARDs

New research has uncovered “considerable variation” in how rheumatologists and orthopaedic surgeons approach the management of biological disease modifying anti-rheumatic drugs (bDMARDs) in patients due to undergo orthopaedic surgery.

In a paper published in Rheumatology Advances in Practice, UK researchers led by Dr Bernard van Duren, from the Leeds Institute of Rheumatic and Musculoskeletal Medicine, noted that up to 44% of patients with rheumatoid arthritis undergoing a joint replacement are taking bDMARDs and are therefore at higher risk of infection.

As the consequences of infected metalwork are potentially serious, clinicians can “err on the side of caution, often withholding bDMARDs peri-operatively as a blanket rule for all patients,” but this “often precipitates disease flares, which can significantly hinder post-operative recovery,” they said.

According to guidelines from the British Society of Rheumatology, surgery in RA patients should be undertaken in the week after a scheduled bDMARD dose, though there is an absence of definite evidence to support this. The authors also highlighted that “no randomised control trials have addressed whether bDMARDs should be stopped or continued peri-operatively.”

A national survey of consultant rheumatologists and orthopaedic surgeons was undertaken to assess how patients on bDMARDS are currently managed during the perioperative period. Completed questionnaires were received from 68 rheumatologists and 106 surgeons.

The results showed that up to a third of respondents continued bDMARDs at the time of operations involving metalwork insertion, such as joint replacements.

Rheumatologists more frequently recommended continuing bDMARDs for soft tissue procedures than surgeons (73% versus 45%, respectively), but the proportions were more similar when considering procedures involving metalwork (33% versus 31%) or joint replacement (27% versus 30%).

Interestingly, while the majority of rheumatologists (59%) claimed responsibility for deciding whether or not to stop treatment with bDMARDs peri-operatively, just 21% of surgeons concurred. In the same vein, 24% of surgeons said this decision was made by a surgeon as opposed to 1% of the rheumatologists, while 35% and 58%, respectively, said it was a joint decision.

There was also a difference between the two groups in the guidelines being followed; 79% of rheumatologists said they follow current BSR guidelines compared to 39% of the orthopaedic surgeons.

The authors also noted that when patients were informed that the risk of infection was thought to be around 3%-7% in people taking a bDMARD, they would accept this risk “to prioritise the prevention of flares”. They were also willing to take part in clinical trials to better determine the right path with regards to bDMARDs in the peri-operative setting.

“Current guidelines are not based on trial evidence; our survey data suggests a strong appetite for multi-centre RCTs in this area from patients, rheumatologists and orthopaedic surgeons alike,” the authors concluded.

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