Stopping DMARDs before orthopaedic surgery may raise flare risk without reducing postoperative infections, according to an Australian‑led Cochrane review.

The review set out to find out the benefits and risks of stopping treatment around the time of surgical procedures for patients with inflammatory arthritis, looking for studies referencing flares, infections after surgery and unwarranted adverse events after surgery [link here].

Monash University’s Professor Rachelle Buchbinder and colleagues found three studies including 306 participants, all of whom had rheumatoid arthritis. Their review found:

• Discontinuing DMARD treatment before a planned orthopaedic surgery may increase risk of flare: 37% more patients who stopped treatment had a flare or worsening disease activity compared to those who continued on DMARDs,
• Stopping therapy may have little effect on postoperative infections, with both groups of patients having 3 instances of post-op infection,
• Only one study reported post-op joint infections, with none among patients who had ceased their DMARD treatment,
• Discontinuation may have little effect on unwanted events after surgery, according to the three studies.

The authors pointed to little confidence in the evidence available, however, given the few studies which referenced disease activity after a change in medications for this patient group. Patients in the studies that did exist were aware of which treatment they were getting.

Professor Rachelle Buchbinder.

This could “affect their reporting of disease flare, unwanted events and serious unwanted events, but it probably does not affect how they reported postoperative infections”, the authors said.

Meanwhile, there was limited evidence on the risk of prosthetic joint infections, though observational data suggested there could be little to no reduction in risk when discontinuing DMARDs perioperatively.

“People with rheumatoid arthritis undergoing elective orthopaedic surgery could be informed that temporary worsening of the underlying disease may occur if the csDMARD therapy is discontinued,” the Cochrane authors found.

“However, it is unclear if continuing the medication could increase immediate postoperative complications or adverse events.”

Either way, the data suggested the overall absolute risk of postoperative complications was low, at between 3 and 4 per cent.

“For types of surgery other than total joint replacement, the effects of perioperative DMARD discontinuation on flare, postoperative infections or adverse events are unknown,” the authors said.