PERIOPERATIVE MANAGEMENT OF THE PATIENT WITH RHEUMATOLOGIC DISEASE

Patients with rheumatologic disease (e.g. rheumatoid arthritis, systemic lupus erythematosus) should receive the same preoperative cardiovascular, pulmonary, and other risk assessment as other patients. 

Additional preoperative considerations:

• Preoperative assessment of the status of the patient’s rheumatologic disease.  In general, active flares of disease should be avoided.
• Recommend coordinated care with patient’s rheumatologist.
• Assessment of hypercoagulable states, especially in patients with SLE.
• Assessment of steroid use, including pulse of steroids within the last year, even if the patient is no longer taking steroids.  (see “Stress Dose Steroids”). 
• Assessment of level of immune suppression.

RHEUMATOID ARTHRITIS
Specific perioperative concerns include (Ref 1, 2, 11):

• Perioperative MI:  RA patients are at increased risk of cardiovascular disease, particularly those with poorly controlled or long-standing disease.  Risk is estimated to be similar to patients with diabetes.
• Pulmonary disease: Patients with RA can have a variety of different pulmonary complications of their disease including fibrosis, bronchiolitis, and pleuritis. Depending on their severity, these complications can impact patients’ perioperative course.
• Cricoarytenoid arthritis: Up to 75% of patients may be affected. Arthritis of these joints may lead to difficulties with intubation or postoperative airway obstruction (due to irritation from ET tube).  History of hoarseness, sore throat, and trouble with inspiration may be a clue to its presence although most patients are asymptomatic.  This entity should be considered in a postoperative patient who is having respiratory difficulty. (Ref 3)
• Cervical spine disease: C1-C2 subluxation, atlantoaxial impaction, subaxial disease.  Consider cervical spine films flexion/extension if: patient is undergoing orthopedic surgery for his/her disease (suggests more severe disease), has had disease for > 5 yrs , or has any neurologic abnormality.  Consider MRI if plain films abnormal and/or consider discussing with patients rheumatologist and anesthesia. (Ref 2)

History taking (Ref 11)

• Important preoperative historical features include length of disease (disease duration is associated with more joint damage, particularly neck involvement), current functional status, specific joints affected, current medications, previous use of steroids, extra-articular manifestations of disease, and previous complications associated with surgery

Studies to consider in preoperative evaluation (Ref 11)

• CBC to look for leukopenia related to drugs, anemia related to drug associated duodenal irritation and/or bone marrow suppression
• LFTs, renal function, given effects some RA drugs can have on these systems
• Walking O2 sat
• Consider cervical films as discussed above
• MRI of neck if any neurologic abnormalities on exam. 

Management of anti-rheumatic agents

Methotrexate	Usually given once weekly.  A prospective randomized trial of patients with RA undergoing elective orthopedic surgery showed fewer complications, infections, and flares in the group that continued methotrexate rather than discontinuing it.4 General consensus is to continue it.  Reasons to consider stopping medication include post op infection, rising infection, prolonged NPO state, patient over age 70.2 Recommend discussing with rheumatology if considering stopping.
Leflunomide	In general recommended to continue.  One trial showed no difference in wound healing in orthopedic surgery patients. 5 however a second trial showed that it did affect wound healing2.  Consider stopping in patients who you anticipate large wounds. Note long half-life (~ 2 wks) may make complete discontinuation problematic.
Sulfasalazine	Consider holding on day of surgery. 6
Azathioprine	Consider holding on day of surgery. 6
Hydroxychloroquine (Plaquenil)	Recommended to continue.  One retrospective study showed no difference in postoperative wound healing or infections.6
TNF-alpha inhibitors—infliximab (Remicade), adalimumab (Humira), etanercept (Enbrel)	Some small studies (n=31 or less) have not shown a difference in orthopedic surgery, but were likely underpowered.6,7,8  One group recommends for “sterile” site surgery to hold infliximab for 1 month, adalimumab for 3-4 wks, and etanercept for 1-2 wks, and for “septic” environment or risk surgery (abdominal surgery, joint replacement) to stop these agents for twice as long.  Postoperatively it is recommended restart these agents once wound healing is complete and there is no evidence of infection. 6 We recommend discussion with the patient’s rheumatologist and surgeon regarding use of these agents in the perioperative period.  If decision is to hold the drug (which is most likely the case for moderate to intense procedures), hold based on ½ life and hold at least 2 half lives. Half lives are listed below:2 -etanercept (Enbrel): 3.5-5.5 days -adalimumab (Humira): 10-20 days -infliximab (Remicade):  9.5 days -certolizumab (Cimzia): 14 days -golumimab (Simponi): 14 days Restart 10-14 days postop
Anakinra (Kineret), Rituximab, Abatacept (Orencia)	Recommend discussion with the patient’s rheumatologist.
NSAIDs	(see “PERIOPERATIVE MEDICATION MANAGEMENT”)

 Systemic Lupus Erythematosus

• Higher risk for CAD at a relatively younger age
• Patients with SLE and antiphospholipid antibodies are at higher risk for both heart valve disease as well as thrombosis
• 2-7 fold higher mortality rate for SLE patients undergoing both non-elective and elective hip and knee surgery compared to RA patients and controls independent of major medical co-morbidities (Ref 10)
• Important perioperative issues are medication management, hematologic abnormalities, renal disease, immune dysfunction, increased risk of CAD and thromboembolic disease (Ref 11)
• Reduce risk of perioperative MI and thrombosis by addressing preoperatively traditional risk factors such as smoking or use of OCP, having good BP and lipid control
• In patients with established thromboembolic disease and antiphospholipid antibody syndrome (APS), bridging therapy is recommended
• If patient has Raynaud’s phenomenon, cooling perioperatively should be limited to avoid digital ischemia

Other rheumatologic diseases:

• Consider involving the patients rheumatologist

References

1. Bandi V, Munnur U, Braman SS. Airway problems in patients with rheumatologic disorders. Crit Care Clin 2002;18:749-65
2. Gardner, G.  “Perioperative Issues in RA.”  Lecture November 2011, University of Washington. 
3. Bandi V, Munnur U, Braman SS. Airway problems in patients with rheumatologic disorders. Crit Care Clin. Oct 2002;18(4):749-765
4. Grennan DM, Gray J, Loudon J, et al.  Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery.  Ann Rheum Dis. 2001;60(3):214-217.
5. Tanaka N, Sakahashi H, Sato E, et al.  Examination of the risk of continuous leflunomide treatment on the incidence of infectious complications after joint arthroplasty in patients with rheumatoid arthritis.  J Clin Rheumatol.  2003;9:115–118. 
6. Pieringer H, Stuby U, Biesenbach G.  Patients with rheumatoid arthritis undergoing surgery: how should we deal with antirheumatic treatment?  Semin Arthritis Rheum.  2007;36(5):278-86. Epub 2007 Jan 3.
7. Bibbo C, Goldberg JW. Infectious and healing complications after elective orthopaedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy.  Foot Ankle Int.  2004;25:331-335.
8. Giles JT, Bartlett SJ, Gelber AC, et al. Tumor necrosis factor inhibitor therapy and risk of serious postoperative orthopedic infection in rheumatoid arthritis.  Arthritis Rheum.  2006;55:333–337.
9. Axford JS. Preoperative evaluation and perioperative management of patients with rheumatic diseases. UpToDate.  2006 Aug 28.
10. Domsic RT, Lingala B, Krishnan E. Systemic Lupus Erythematosus, Rheumatoid Arthritis, and Postarthroplasty Mortality: A Cross-sectional Analysis from the Nationwide Inpatient Sample. J Rheumatol. Jun 1 2010

 

 

Updated May 2011