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Perioperative care for patients with rheumatic diseases

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

  • 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)

  • 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

  • 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

  • The majority of studies suggest that it is generally safe to continue conventional DMARDs, such as methotrexate, perioperatively

  • 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

  • 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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Figure 1: Algorithm for cardiac risk assessment before surgery.5
Figure 2: A practical approach to risk stratification in patients requiring anticoagulation in the perioperative period.44

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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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Both authors contributed equally to researching data for the article, discussing the content, writing and review/editing of the manuscript before submission.

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Correspondence to Tim Bongartz.

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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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