Perioperative Management of Antirheumatic Medications in Patients with RA and SLE Undergoing Elective Foot and Ankle Surgery

Historically, patients have been advised to withhold their Disease-modifying antirheumatic drugs (DMARDs) preoperatively, but the other joints suffer, and the patients struggle.  Updates both in arthroplasty and foot and ankle surgery recommend continuing methotrexate.

DMARDs have made a massive improvement to medical management of rheumatoid arthritis, and other inflammatory joint disorders, reducing the previous reliance on steroids.  The first generation of these are the “non-biologicals”.   A number of RCT’s have been published, and the risk of infection was DECREASED with continuing non-biological DMARDs, with a relative risk of 0.39 (CI 0.17-0.91). Biological drugs act like proteins targeting specific areas of the immune system, examples include TNF inhibitors, Rituximab, and Belimumab.  Currently most the data on the biologicals is not regarding perioperative periods.  Although the infection rates may be lower, the scientific proof is not there yet. Generally, then, it is advised to do surgery in the week after missing a dose and recommencing once wound healing progressed.

For patients with severe SLE, it has been recommended to continue Mycophenolate mofetil, azathioprine, cyclosporine, and tacrolimus, but to withhold them for non-severe SLE.  A discussion with the patient’s rheumatologist is clearly needed in SLE.

 

SUMMARY

DMARDs – continue

methotrexate
leflunomide
hydroxychloroquine
sulfasalazine

Biologics – do surgery in the week after a missed dose, recommence once wound healing is progressing well.

Patients with severe SLE – don’t withhold medication, get rheumatologist advice

Mild SLE – withhold:

Mycophenolate mofetil

azathioprine
cyclosporine
tacrolimus

Prednisolone
preferably operate with daily dose 20mg or less