[Perioperative management in the treatment of trauma for rheumatics under immunosuppression]

Perioperative management of patients with inflammatory rheumatic diseases : Updated recommendations of the German Society for Rheumatology

BACKGROUND

Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014.

METHODS

After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added.

RESULTS

The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing.

CONCLUSION

Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.

OSG-Prothesen am arthritischen und arthrotischen Fuß

Bei den endgradigen Zerstörungen am oberen Sprunggelenk kommt heute den operativen Verfahren der endoprothetischen Versorgung und der Versteifung die entscheidende Rolle zu. Die 3 am meisten betroffenen Patientengruppen sind die mit posttraumatischen, arthrotischen und rheumatischen Folgen. Es bestehen fulminante Unterschiede in den pathophysiologischen Abläufen der Gelenkaffektionen bei den primär degenerativen zu den chronisch-entzündlichen Erkrankungen. Letztere unterliegen besonderen lokalen, regionalen und systemischen Veränderungen, die in Bezug auf die Differentialindikation und das gesamte perioperative Management bekannt sein müssen, um Patienten optimal zu versorgen und Komplikationen zu vermeiden. Beim „Rheumatiker“ gesellt sich zu den immunologisch-induzierten Ko-Morbiditäten noch eine sehr gezielte Basismedikation dazu, die in ihren orthopädisch-unfallchirurgischen und den orthopädisch-rheumatologischen Auswirkungen zu bedenken ist. Initial stehen die gesamten Verfahren der konservativen Behandlung am Sprunggelenk und im Verlauf – vor allem bei entzündlich induzierten Synovialitiden – eine Spiegelung mit Schleimhautresektion und anschließender Radiosynoviorthese zur Verfügung. Zuletzt gewinnt die technisch anspruchsvolle endoprothetische Versorgung am oberen Sprunggelenk seit geraumer Zeit wieder mehr an Bedeutung, vielfach wird von fußchirurgischen Experten jedoch eine Fusion des tibio-talaren Gelenkes bei entsprechender Destruktion bevorzugt. In Deutschland werden rund 2000 OSG-TEP-Implantationen p.a. mit den heute üblichen zementfrei eingesetzten 3-Komponenten-Prothesen ausgeführt, die -besonders bei den rheumatischen Erkrankungen- mittelfristig recht gute Ergebnisse aufweisen. Sowohl die TEP-Versorgung als auch die Fusionseingriffe weisen spezifische Vor- und Nachteile sowie Komplikationsmuster auf. Die Indikation zu den Verfahren ist individuell zu stellen. Fußchirurgische und orthopädisch-rheumatologische Spezialisten für die jeweiligen Patientengruppen können den Fachgesellschaftsseiten entnommen werden.

[Perioperative management of treatment of patients with inflammatory rheumatic diseases : Updated recommendations of the German Society of Rheumatology]

BACKGROUND

Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014.

METHODS

After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added.

RESULTS

The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing.

CONCLUSION

Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.