The perioperative use of synthetic and biological disease-modifying antirheumatic drugs in patients with rheumatoid arthritis.

Disease-modifying antirheumatic drugs (DMARDs) have become essential treatments in the management of patients with inflammatory rheumatic diseases. Their use has resulted in a marked improvement of disease control and a limitation of joint damage, although some patients still require subsequent corrective or joint replacement surgery. Due to their immunosuppressive effects, some DMARDs are associated with an increased risk of infection. The aim of this review is to discuss the available literature on the management of DMARDs during the perioperative period, particularly in the case of orthopaedic surgery. Conventional synthetic DMARDs such as methotrexate, sulfasalazine, leflunomide, hydroxychloroquine appear to be safe during the perioperative period. Conflicting results on biological DMARDs, mainly tumour necrosis factor antagonists, are reported in the literature, including both increased and unchanged risk of superimposed infections after surgery. Taking into account the available literature, we included some propositions for the management of patients who will undergo surgical interventions.