Not Necessary to Discontinue Preop DMARDS?

In the quest for an infection-free surgical environment, we now have a bit more helpful information. According to new work from the University of Washington, rheumatoid arthritis (RA) patients who stay on their disease-modifying antirheumatic drugs (DMARDs) prior to surgery do not have an increased risk of infection after their procedures. For this work, researchers examined data from 9, 362 surgeries performed on 5, 544 RA patients to assess the risk of infection.

“Patients have higher chances of flare-ups if they discontinue their RA medication for a period of time prior to surgery, ” said Hsin-Husan Juo, M.D., a rheumatology fellow the University of Washington School of Medicine and the lead author of the study in the November 12, 2016 news release. “Prednisone is well known for delaying wound healing and increasing the rate of infection, which would increase post-surgical complications. Therefore, whether discontinuing DMARDs or TNF-inhibitors [tumor necrosis factor] prior to elective surgeries is necessary or not is an important issue.”

According to the news release, the researchers identified surgical procedures performed on RA patients between 1999 and 2009 by using the United States Department of Veterans Affairs (VA) databases and surgical quality registry. The patients selected were on at least one DMARD or biologic drug, such as TNFi drugs, prior to surgery.

“…Out of 2, 600 surgeries on patients taking methotrexate alone, therapy was continued in 1, 961 procedures. Out of 2, 012 surgeries on patients taking hydroxychloroquine alone, therapy was continued in 1, 496 procedures. Out of 652 surgeries on patients taking leflunomide alone, therapy was continued in 508. Out of 386 surgeries on patients taking a combination of methotrexate and TNFi, both drugs were continued in 196 surgeries, while methotrexate was stopped and TNFi continued in 59 surgeries. In 72 surgeries, TNFi was stopped but methotrexate was continued. Both drugs were stopped in 59 surgeries. Continuation of therapy prior to surgery was not associated with increased rates of overall post-operative infections or wound infections in any of these treatment groups.”

“Our findings show that discontinuing methotrexate, hydroxychloroquine, leflunomide monotherapy and TNFi plus methotrexate therapy is not associated with increased risk of post-operative infectious complications, ” said Dr. Juo. “Therefore, surgeons and rheumatologists should consider continuing medication during the perioperative period to have better control over RA. This will decrease the possibility of requiring steroid therapy and maintain better post- operative functional status.”

Dr. Juo told OTW, “I’d like to let orthopedic surgeons know that it might not always be necessary to discontinue DMARDs (limited to the ones in the study) prior to surgery or postpone urgent surgeries due to those medications simply because of concerns for post operative infectious complications. It is always appreciated if they could discuss with the patient’s rheumatologist and come up with the best plan for the patient.”

“I am planning to obtain more data, increase the time frame to 2015, look at new biologic agent, do subgroup analysis on various surgeries, emergent versus elective, and add more data to reflect disease activity in the analysis in the future.”