Abstract
The perioperative care of patients with rheumatic diseases is hampered by a lack of evidence-based recommendations. Rheumatologists are called upon to 'clear' their patients for surgery, yet the evidence upon which to base decisions is fractionated and inconsistent. We have systematically reviewed the current literature and developed suggestions for three key areas that require particular deliberations in patients with rheumatic diseases scheduled for surgery: the management of cardiovascular risk, use of immunosuppressive drugs, and states of altered coagulation. For patients with rheumatic diseases associated with increased cardiovascular risk, such as rheumatoid arthritis and systemic lupus erythematosus, we suggest following the American College of Cardiology–American Heart Association guidelines using the underlying disease as a risk modifier. Most evidence suggests a neutral effect of conventional DMARDs in the perioperative period, with no need to discontinue them prior to surgery. Conversely, we suggest minimizing perioperative steroid use and unnecessary 'steroid preps'. The potential benefits of discontinuing biologic drugs in the perioperative setting needs to be carefully balanced with the risks associated with a disease flare. We discuss the American College of Chest Physicians guidelines, which classify individuals with antiphospholipid antibody syndrome as high-risk patients for perioperative thrombosis who are likely to require bridging therapy in most perioperative settings.
Key Points
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Patients with rheumatic diseases pose unique problems in the perioperative setting owing to their increased cardiovascular risk, use of immunosuppressive medications, and the possible need for anticoagulation in patients with antiphospholipid syndrome (APS)
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We suggest the inclusion of rheumatoid arthritis, systemic lupus erythematosus and psoriatic arthritis as additional cardiovascular risk factors in the current American College of Cardiology–American Heart Association (ACC/AHA) recommendations
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The lowest possible dose of steroids should be used in the perioperative setting in order to minimize unnecessary exposure and reduce the risk of surgical site infections and wound healing complications
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The majority of studies suggest that it is generally safe to continue conventional DMARDs, such as methotrexate, perioperatively
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Biologic agents are best withheld before surgery, owing to the current lack of data regarding their safety and evidence suggesting a general increase in infection risk associated with their use
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In patients with APS, a careful risk:benefit assessment, which balances the risk of a thromboembolic event with the risk of a major bleed, is required to determine whether perioperative bridging therapy is required
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References
Peters, M. J., van der Horst-Bruinsma, I. E., Dijkmans, B. A. & Nurmohamed, M. T. Cardiovascular risk profile of patients with spondylarthropathies, particularly ankylosing spondylitis and psoriatic arthritis. Semin. Arthritis Rheum. 34, 585–592 (2004).
Urowitz, M. B. et al. The bimodal mortality pattern of systemic lupus erythematosus. Am. J. Med. 60, 221–225 (1976).
Maradit-Kremers, H. et al. Increased unrecognized coronary heart disease and sudden deaths in rheumatoid arthritis: a population-based cohort study. Arthritis Rheum. 52, 402–411 (2005).
Meune, C., Touzé, E., Trinquart, L. & Allanore, Y. Trends in cardiovascular mortality in patients with rheumatoid arthritis over 50 years: a systematic review and meta-analysis of cohort studies. Rheumatology (Oxford) 48, 1309–1313 (2009).
Fleisher, L. A. et al. ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 2002 guidelines on perioperative cardiovascular evaluation for noncardiac surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J. Am. Coll. Cardiol. 50, 1707–1732 (2007).
Backer, C. L., Tinker, J. H., Robertson, D. M. & Vlietstra, R. E. Myocardial reinfarction following local anesthesia for ophthalmic surgery. Anesth. Analg. 59, 257–262 (1980).
Warner, M. A., Shields, S. E. & Chute, C. G. Major morbidity and mortality within 1 month of ambulatory surgery and anesthesia. JAMA 270, 1437–1441 (1993).
Nelson, C. L. et al. Relation of clinical and angiographic factors to functional capacity as measured by the Duke Activity Status Index. Am. J. Cardiol. 68, 973–975 (1991).
Gerson, M. C. et al. Cardiac prognosis in noncardiac geriatric surgery. Ann. Intern. Med. 103, 832–837 (1985).
Lindhardsen, J. et al. The risk of myocardial infarction in rheumatoid arthritis and diabetes mellitus: a Danish nationwide cohort study. Ann. Rheum. Dis. 70, 929–934 (2011).
Peters, M. J. et al. EULAR evidence-based recommendations for cardiovascular risk management in patients with rheumatoid arthritis and other forms of inflammatory arthritis. Ann. Rheum. Dis. 69, 325–331 (2010).
Yazdanyar, A. et al. Rheumatoid arthritis increases risk of perioperative cardiovascular events: an analysis using the national inpatient sample of the Healthcare Cost and Utilization Project [abstract 1035-189]. J. Am. Coll. Cardiol. 51, A361 (2008).
Yazdanyar, A., Wasco, M. C., Kraemer, K. L. & Ward, M. M. Hospital-based surgical procedures and the risk of perioperative cardiovascular events: a comparison study of rheumatoid arthritis and diabetes mellitus using the national inpatient sample of the Healthcare Cost and Utilization Project [abstract]. Arthritis Rheum. 62 (Suppl. 10), 1039 (2010).
Cinà, C. S. & Devereaux, P. J. Coronary-artery revascularization before elective major vascular surgery. Vasc. Med. 11, 61–63 (2006).
Mangano, D. T., Layug, E. L., Wallace, A. & Tateo, I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N. Engl. J. Med. 335, 1713–1720 (1996).
Smitten, A. L. et al. The risk of hospitalized infection in patients with rheumatoid arthritis. J. Rheumatol. 35, 387–393 (2008).
Kirwan, J. R. et al. The effect of therapeutic glucocorticoids on the adrenal response in a randomized controlled trial in patients with rheumatoid arthritis. Arthritis Rheum. 54, 1415–1421 (2006).
Kehlet, H. & Binder, C. Value of an ACTH test in assessing hypothalamic-pituitary-adrenocortical function in glucocorticoid-treated patients. Br. Med. J. 2, 147–149 (1973).
Coursin, D. B. & Wood, K. E. Corticosteroid supplementation for adrenal insufficiency. JAMA 287, 236–240 (2002).
Doran, M. F., Crowson, C. S., Pond, G. R., O'Fallon, W. M. & Gabriel, S. E. Predictors of infection in rheumatoid arthritis. Arthritis Rheum. 46, 2294–2300 (2002).
Smitten, A. L. et al. The risk of hospitalized infection in patients with rheumatoid arthritis. J. Rheumatol. 35, 387–393 (2008).
Stuck, A. E., Minder, C. E. & Frey, F. J. Risk of infectious complications in patients taking glucocorticosteroids. Rev. Infect. Dis. 11, 954–963 (1989).
Grennan, D. M. et al. Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery. Ann. Rheum. Dis. 60, 214–217 (2001).
Murata, K. et al. Lack of increase in postoperative complications with low-dose methotrexate therapy in patients with rheumatoid arthritis undergoing elective orthopedic surgery. Mod. Rheumatol. 16, 14–19 (2006).
den Broeder, A. A. et al. Risk factors for surgical site infections and other complications in elective surgery in patients with rheumatoid arthritis with special attention for anti-tumor necrosis factor: a large retrospective study. J. Rheumatol. 34, 689–695 (2007).
Kawakami, K. et al. Complications and features after joint surgery in rheumatoid arthritis patients treated with tumour necrosis factor-α blockers: perioperative interruption of tumour necrosis factor-α blockers decreases complications? Rheumatology (Oxford) 49, 341–347 (2010).
Giles, J. T. et al. Tumor necrosis factor inhibitor therapy and risk of serious postoperative orthopedic infection in rheumatoid arthritis. Arthritis Care Res. 55, 333–337 (2006).
Ruyssen-Witrand, A. et al. Complication rates of 127 surgical procedures performed in rheumatic patients receiving tumor necrosis factor alpha blockers. Clin. Exp. Rheumatol. 25, 430–436 (2007).
Dutch Society for Rheumatology. Medicines: the application of TNF blockade in the treatment of rheumatoid arthritis [online], (2003).
Ledingham, J. et al. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis (update of previous guidelines of April 2001). Rheumatology (Oxford) 44, 157–163 (2005).
Bongartz, T. et al. Anti-TNF antibody therapy in rheumatoid arthritis and the risk of serious infections and malignancies: systematic review and meta-analysis of rare harmful effects in randomized controlled trials. JAMA 295, 2275–2285 (2006).
Dixon, W. G. et al. Rates of serious infection, including site-specific and bacterial intracellular infection, in rheumatoid arthritis patients receiving anti-tumor necrosis factor therapy: results from the British Society for Rheumatology Biologics Register. Arthritis Rheum. 54, 2368–2376 (2006).
Keystone, E. C. Does anti-tumor necrosis factor-α therapy affect risk of serious infection and cancer in patients with rheumatoid arthritis?: a review of longterm data. J. Rheumatol. 38, 1552–1562 (2011).
Appau, K. A. et al. Use of infliximab within 3 months of ileocolonic resection is associated with adverse postoperative outcomes in Crohn's patients. J. Gastrointest. Surg. 12, 1738–1744 (2008).
Bongartz, T. Elective orthopedic surgery and perioperative DMARD management: many questions, fewer answers, and some opinions. J. Rheumatol. 34, 653–655 (2007).
Drenkard, C. et al. Influence of the antiphospholipid syndrome in the survival of patients with systemic lupus erythematosus. J. Rheumatol. 21, 1067–1072 (1994).
Asherson, R. A. et al. The “primary” antiphospholipid syndrome: major clinical and serological features. Medicine (Baltimore) 68, 366–374 (1989).
Sneddon, I. B. Cerebro-vascular lesions and lvedo reticularis. Br. J. Dermatol. 77, 180–185 (1965).
Wahl, D. G. et al. Meta-analysis of the risk of venous thrombosis in individuals with antiphospholipid antibodies without underlying autoimmune disease or previous thrombosis. Lupus 7, 15–22 (1998).
Emir, M. et al. Dural sinus thrombosis after cardiopulmonary bypass. Perfusion 19, 133–135 (2004).
Berkun, Y., Elami, A., Meir, K., Mevorach, D. & Naparstek, Y. Increased morbidity and mortality in patients with antiphospholipid syndrome undergoing valve replacement surgery. J. Thorac. Cardiovasc. Surg. 127, 414–420 (2004).
Erkan, D., Bateman, H. & Lockshin, M. D. Lupus anticoagulant-hypoprothrombinemia syndrome associated with systemic lupus erythematosus: report of 2 cases and review of literature. Lupus 8, 560–564 (1999).
Merrill, J. T. & Asherson, R. A. Catastrophic antiphospholipid syndrome. Nat. Clin. Pract. Rheumatol. 2, 81–89 (2006).
Douketis, J. D. et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133 (6 Suppl.), 299S–339S (2008).
National Institute for Health and Clinical Excellence (NICE). CG92: Venous thromboembolism—reducing the risk [online], (2011).
Crowther, M. A. et al. A comparison of two intensities of warfarin for the prevention of recurrent thrombosis in patients with the antiphospholipid antibody syndrome. N. Engl. J. Med. 349, 1133–1138 (2003).
Khamashta, M. A. et al. The management of thrombosis in the antiphospholipid-antibody syndrome. N. Engl. J. Med. 332, 993–997 (1995).
Hunt, B. J. The prevention of hospital-acquired venous thromboembolism in the United Kingdom. Br. J. Haematol. 144, 642–652 (2009).
Schulman, S. et al. Hemorrhagic complications of anticoagulant and thrombolytic treatment: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133 (6 Suppl.), 257S–298S (2008).
Erkan, D., Leibowitz, E., Berman, J. & Lockshin, M. D. Perioperative medical management of antiphospholipid syndrome: hospital for special surgery experience, review of literature, and recommendations. J. Rheumatol. 29, 843–849 (2002).
Spyropoulos, A. C. et al. Perioperative bridging therapy with unfractionated heparin or low-molecular-weight heparin in patients with mechanical prosthetic heart valves on long-term oral anticoagulants (from the REGIMEN Registry). Am. J. Cardiol. 102, 883–889 (2008).
Katholi, R. E., Nolan, S. P. & McGuire, L. B. The management of anticoagulation during noncardiac operations in patients with prosthetic heart valves. A prospective study. Am. Heart J. 96, 163–165 (1978).
Strebel, N., Prins, M., Agnelli, G. & Büller, H. R. Preoperative or postoperative start of prophylaxis for venous thromboembolism with low-molecular-weight heparin in elective hip surgery? Arch. Intern. Med. 162, 1451–1456 (2002).
Douketis, J. D., Johnson, J. A. & Turpie, A. G. Low-molecular-weight heparin as bridging anticoagulation during interruption of warfarin: assessment of a standardized periprocedural anticoagulation regimen. Arch. Intern. Med. 164, 1319–1326 (2004).
Kakkos, S. K. et al. Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD005258. doi:10.1002/14651858.CD005258.pub2 (2008).
Payne, D. A. et al. Combined therapy with clopidogrel and aspirin significantly increases the bleeding time through a synergistic antiplatelet action. J. Vasc. Surg. 35, 1204–1209 (2002).
Burger, W., Chemnitius, J. M., Kneissl, G. D. & Rücker, G. Low-dose aspirin for secondary cardiovascular prevention—cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation—review and meta-analysis. J. Intern. Med. 257, 399–414 (2005).
Iakovou, I. et al. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 293, 2126–2130 (2005).
Abualsaud, A. O. & Eisenberg, M. J. Perioperative management of patients with drug-eluting stents. JACC Cardiovasc. Interv. 3, 131–142 (2010).
Munster, T. & Furst, D. E. Pharmacotherapeutic strategies for disease-modifying antirheumatic drug (DMARD) combinations to treat rheumatoid arthritis (RA). Clin. Exp. Rheumatol. 17 (6 Suppl. 18), S29–S36 (1999).
Bibbo, C., Anderson, R. B., Davis, W. H. & Norton, J. Rheumatoid nodules and postoperative complications. Foot Ankle Int. 24, 40–44 (2003).
Jain, A., Witbreuk, M., Ball, C. & Nanchahal, J. Influence of steroids and methotrexate on wound complications after elective rheumatoid hand and wrist surgery. J. Hand Surg. Am. 27, 449–455 (2002).
Carpenter, M. T., West, S. G., Vogelgesang, S. A. & Casey Jones, D. E. Postoperative joint infections in rheumatoid arthritis patients on methotrexate therapy. Orthopedics 19, 207–210 (1996).
Escalante, A. & Beardmore, T. D. Risk factors for early wound complications after orthopedic surgery for rheumatoid arthritis. J. Rheumatol. 22, 1844–1851 (1995).
Kasdan, M. L. & June, L. Postoperative results of rheumatoid arthritis patients on methotrexate at the time of reconstructive surgery of the hand. Orthopedics 16, 1233–1235 (1993).
Sany, J. et al. Influence of methotrexate on the frequency of postoperative infectious complications in patients with rheumatoid arthritis. J. Rheumatol. 20, 1129–1132 (1993).
Perhala, R. S., Wilke, W. S., Clough, J. D. & Segal, A. M. Local infectious complications following large joint replacement in rheumatoid arthritis patients treated with methotrexate versus those not treated with methotrexate. Arthritis Rheum. 34, 146–152 (1991).
Bridges, S. L. Jr, López-Méndez, A., Han, K. H., Tracy, I. C. & Alarcón, G. S. Should methotrexate be discontinued before elective orthopedic surgery in patients with rheumatoid arthritis? J. Rheumatol. 18, 984–988 (1991).
Hirano, Y. et al. Influences of anti-tumour necrosis factor agents on postoperative recovery in patients with rheumatoid arthritis. Clin. Rheumatol. 29, 495–500 (2010).
Talwalkar, S. C., Grennan, D. M., Gray, J., Johnson, P. & Hayton, M. J. Tumour necrosis factor α antagonists and early postoperative complications in patients with inflammatory joint disease undergoing elective orthopaedic surgery. Ann Rheum. Dis. 64, 650–651 (2005).
Wendling, D. et al. Surgery in patients receiving anti-tumour necrosis factor α treatment in rheumatoid arthritis: an observational study on 50 surgical procedures. Ann. Rheum. Dis. 64, 1378–1379 (2005).
Bibbo, C. & Goldberg, J. W. Infectious and healing complications after elective orthopaedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy. Foot Ankle Int. 25, 331–335 (2004).
Acknowledgements
This article includes the schema presented by Dr Howard Weitz and Dr Mark Crowther at the 2010 ACR/ARHP Annual Scientific Meeting (https://acr.peachnewmedia.com/store/streaming/stream-details.php?mode=stream&id=244925#topic20653).
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T. Bongartz has received grant/research support from Wyeth. B. M. Akkara Veetil declares no competing interests.
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Akkara Veetil, B., Bongartz, T. Perioperative care for patients with rheumatic diseases. Nat Rev Rheumatol 8, 32–41 (2012). https://doi.org/10.1038/nrrheum.2011.171
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DOI: https://doi.org/10.1038/nrrheum.2011.171
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