Katinka Albrecht1, Denis Poddubnyy2, Jan Leipe3, Philipp Sewerin4, Christof Iking-Konert5, Roger Scholz6, Klaus Krüger7. 1. Deutsches Rheuma-Forschungszentrum Berlin, Berlin, Deutschland. 2. Rheumatologie am Campus Benjamin Franklin - Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité Universitätsmedizin Berlin, Berlin, Deutschland. 3. Sektion Rheumatologie, Medizinische Klinik V, Universitätsklinikum Mannheim, Mannheim, Deutschland. 4. Uniklinik Düsseldorf Poliklinik, Funktionsbereich & Hiller Forschungszentrum für Rheumatologie, UKD, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland. 5. Sektion Rheumatologie, Medizinische Klinik und Poliklinik III, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland. 6. Orthopädie und Unfallchirurgie, Collm Klinik Oschatz, Oschatz, Deutschland. 7. Rheumatologisches Praxiszentrum München, St.-Bonifatius-Str. 5, 81541, München, Deutschland. Klaus.Krueger@med.uni-muenchen.de.
Abstract
BACKGROUND: Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014. METHODS: After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added. RESULTS: The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing. CONCLUSION: Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.
BACKGROUND: Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014. METHODS: After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added. RESULTS: The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing. CONCLUSION: Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.
Authors: Susan M Goodman; Bryan Springer; Gordon Guyatt; Matthew P Abdel; Vinod Dasa; Michael George; Ora Gewurz-Singer; Jon T Giles; Beverly Johnson; Steve Lee; Lisa A Mandl; Michael A Mont; Peter Sculco; Scott Sporer; Louis Stryker; Marat Turgunbaev; Barry Brause; Antonia F Chen; Jeremy Gililland; Mark Goodman; Arlene Hurley-Rosenblatt; Kyriakos Kirou; Elena Losina; Ronald MacKenzie; Kaleb Michaud; Ted Mikuls; Linda Russell; Alexander Sah; Amy S Miller; Jasvinder A Singh; Adolph Yates Journal: Arthritis Rheumatol Date: 2017-06-16 Impact factor: 10.995
Authors: Michael D George; Joshua F Baker; Kevin L Winthrop; Seth D Goldstein; E Alemao; Lang Chen; Qufei Wu; Fenglong Xie; Jeffrey R Curtis Journal: Ann Rheum Dis Date: 2020-03-24 Impact factor: 19.103
Authors: Bella Mehta; Deanna Jannat-Khah; Mark Alan Fontana; Carine J Moezinia; Carol A Mancuso; Anne R Bass; Vinicius C Antao; Allan Gibofsky; Susan M Goodman; Said Ibrahim Journal: RMD Open Date: 2020-10