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Koh YR, Cummings KC. Newer Immunosuppressants for Rheumatologic Disease: Preoperative Considerations. Rheum Dis Clin North Am 2024; 50:545-557. [PMID: 38942584 DOI: 10.1016/j.rdc.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
With the advent of small-molecule immune modulators, recombinant fusion proteins, and monoclonal antibodies, treatment options for patients with rheumatic diseases are now broad. These agents carry significant risks and an individualized approach to each patient, balancing known risks and benefits, remains the most prudent course. This review summarizes the available immunosuppressant treatments, discusses their perioperative implications, and provides recommendations for their perioperative management.
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Affiliation(s)
- Ye Rin Koh
- Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA
| | - Kenneth C Cummings
- Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA.
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2
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Koh YR, Cummings KC. Newer Immunosuppressants for Rheumatologic Disease: Preoperative Considerations. Anesthesiol Clin 2024; 42:131-143. [PMID: 38278585 DOI: 10.1016/j.anclin.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
With the advent of small-molecule immune modulators, recombinant fusion proteins, and monoclonal antibodies, treatment options for patients with rheumatic diseases are now broad. These agents carry significant risks and an individualized approach to each patient, balancing known risks and benefits, remains the most prudent course. This review summarizes the available immunosuppressant treatments, discusses their perioperative implications, and provides recommendations for their perioperative management.
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Affiliation(s)
- Ye Rin Koh
- Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA
| | - Kenneth C Cummings
- Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, E-31, Cleveland, OH 44195, USA.
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3
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Perioperative management of patients with inflammatory rheumatic diseases : Updated recommendations of the German Society for Rheumatology. Z Rheumatol 2023; 82:1-11. [PMID: 35235025 DOI: 10.1007/s00393-021-01150-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 01/15/2023]
Abstract
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.
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4
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Kirloskar KM, Dekker PK, Kiene J, Zhou S, Bekeny JC, Rogers A, Zolper EG, Fan KL, Evans KK, Benedict CD, Pasieka HB, Attinger CE. The Relationship Between Autoimmune Disease and Disease-Modifying Antirheumatic Drugs on Wound Healing. Adv Wound Care (New Rochelle) 2022; 11:650-656. [PMID: 34714156 DOI: 10.1089/wound.2021.0150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Objective: To evaluate the role of disease-modifying antirheumatic drugs (DMARDs) on wound healing outcomes of patients with autoimmune disease at our tertiary wound care center. Approach: Retrospective review of patients presenting to our wound care center between 2014 and 2018 with both chronic wounds and a history of inflammatory disease. Patient demographics, comorbid conditions, and progression to complete wound healing were compared between those taking DMARDs or not at the time of wound onset. The study adheres to the STROBE statement. Results: Fifty-eight patients with a total of 296 wounds were retrospectively reviewed. Patients were taking at least one DMARD at wound onset in 217 (73.3%) of these wounds. The average number of DMARDs at wound onset was 1.5 (standard deviation 1.2). Two hundred ten wounds progressed to heal (70.9%), with a median time to healing of 229.5 days (interquartile range 71.0-490.0). Of the 210 wounds that healed, patients taking at least one DMARD had a significantly shorter time to healing relative to patients who were not on any DMARDs (median 190.5 days vs. 340.0 days, p = 0.0156). Innovation: Characterizing wound healing outcomes at a tertiary hospital with a dedicated wound care center and analyzing the role of DMARDs in wound healing progression. Conclusions: The median time to healing in the studied cohort was 229.5 days, which is much longer than the healing time for noninfected diabetic foot ulcers at our institution. These findings highlight the wound healing challenges posed by underlying autoimmune disease.10.
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Affiliation(s)
- Kunal M Kirloskar
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Paige K Dekker
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Julianne Kiene
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Suzanne Zhou
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Jenna C Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Ashley Rogers
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Elizabeth G Zolper
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia, USA.,Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia, USA.,Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Carol Deane Benedict
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia, USA.,Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Helena B Pasieka
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia, USA.,Department of Dermatology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, Georgetown University School of Medicine, Washington, District of Columbia, USA.,Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
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5
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Streufert BD, Onyedimma C, Yolcu YU, Ghaith AK, Elder BD, Nassr A, Currier B, Sebastian AS, Bydon M. Rheumatoid Arthritis in Spine Surgery: A Systematic Review and Meta-Analysis. Global Spine J 2022; 12:1583-1595. [PMID: 35302407 PMCID: PMC9393968 DOI: 10.1177/21925682211057543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Systematic Review and Meta-analysis. OBJECTIVE The purpose of this study is to synthesize recommendations for perioperative medical management of RA patients and quantify outcomes after spine surgery when compared to patients without RA. METHODS A search of available literature on patients with RA and spine surgery was performed. Studies were included if they provided a direct comparison of outcomes between patients undergoing spine surgery with or without RA diagnosis. Meta-analysis was performed on operative time, estimated blood loss, hospital length of stay, overall complications, implant-related complications, reoperation, infection, pseudarthrosis, and adjacent segment disease. RESULTS Included in the analysis were 9 studies with 703 patients with RA undergoing spine surgery and 2569 patients without RA. In RA patients compared to non-RA patients undergoing spine surgery, the relative risk of infection was 2.29 times higher (P = .036), overall complications 1.61 times higher (P < .0001), implant-related complications 3.93 times higher (P = .009), and risk of reoperation 2.45 times higher (P < .0001). Hospital length of stay was 4.6 days longer in RA patients (P < .0001). CONCLUSIONS Treatment of spinal pathology in patients with RA carries an increased risk of infection and implant-related complications. Spine-specific guidelines for perioperative management of antirheumatic medication deserve further exploration. All RA patients should be perioperatively co-managed by a rheumatologist. This review helps identify risk profiles in RA specific to spine surgery and may guide future studies seeking to medically optimize RA patients perioperatively.
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Affiliation(s)
- Benjamin D. Streufert
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA,Benjamin D Streufert MD, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55901, USA.
| | | | - Yagiz U. Yolcu
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Ahmad Nassr
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Bradford Currier
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Mohamad Bydon
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
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Ponkilainen V, Karjalainen TV, Kuitunen I, Uimonen M, Johnston RV, Saarinen A, Whittle SL, Avery JC, Glennon V, Grobler L, Buchbinder R. Perioperative use of disease modifying anti-rheumatic drugs (DMARDs) in people with inflammatory arthritis. Hippokratia 2022. [DOI: 10.1002/14651858.cd015096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Ville Ponkilainen
- Department of Surgery; Central Finland Hospital Nova; Jyvaskyla Finland
| | - Teemu V Karjalainen
- Department of Surgery; Central Finland Hospital Nova; Jyvaskyla Finland
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
| | - Ilari Kuitunen
- Institute of Clinical Medicine; University of Eastern Finland; Kuopio Finland
| | - Mikko Uimonen
- Department of Surgery; Central Finland Hospital Nova; Jyvaskyla Finland
| | - Renea V Johnston
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
| | - Antti Saarinen
- Department of Surgery; Central Finland Hospital Nova; Jyvaskyla Finland
| | - Samuel L Whittle
- Rheumatology Unit; Queen Elizabeth Hospital; Woodville South Australia
| | - Jodie C Avery
- Adelaide Medical School, Robinson Research Institute; The University of Adelaide; North Adelaide Australia
| | - Vanessa Glennon
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
| | - Liesl Grobler
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences; Stellenbosch University; Cape Town South Africa
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University; Monash-Cabrini Department of Musculoskeletal Health and Clinical Epidemiology; Cabrini Health; Melbourne Australia
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7
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Perioperative Management of Immunosuppressive Medications for Rheumatoid Arthritis. J Hand Surg Am 2022; 47:370-378. [PMID: 35184919 DOI: 10.1016/j.jhsa.2021.09.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/09/2021] [Accepted: 09/17/2021] [Indexed: 02/02/2023]
Abstract
Operations in patients with rheumatoid arthritis are complicated by the fact that most drugs used in medical management have immunosuppressive mechanisms of action, including corticosteroids and conventional synthetic and biologic disease-modifying antirheumatic drugs. In deciding to continue or discontinue these medications perioperatively, surgeons must weigh the relative risk of infection from immunosuppression against the risk of rheumatoid arthritis symptom flares from reduced medical disease control. The objective of this article is to review the existing evidence regarding perioperative management of immunosuppressive rheumatoid arthritis medications, with a specific focus on relevance to hand and upper-extremity procedures.
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Mamaril-Davis JC, Aguilar-Salinas P, Avila MJ, Villatoro-Villar M, Dumont TM. Perioperative management of disease-modifying antirheumatic drugs for patients undergoing elective spine surgery: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:815-829. [PMID: 35132461 DOI: 10.1007/s00586-021-07080-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 11/26/2021] [Accepted: 11/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND In preparation for surgery, patients being treated with disease-modifying antirheumatic drugs (DMARDs) are recommended to either continue or withhold therapy perioperatively. Some of these drugs have known effects against bone healing, hence the importance of adequately managing them before and after surgery. OBJECTIVE We aim to assess the current evidence for managing conventional synthetic and/or biologic DMARDs in the perioperative period for elective spine surgery. METHODS A systematic review of four databases was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The included manuscripts were methodically scrutinized for quality, postoperative infections, wound healing characteristics, bone fusion rates, and clinical outcomes. RESULTS Six studies were identified describing the management of conventional synthetic and/or biologic DMARDs. There were 294 DMARD-treated patients described undergoing various spine surgeries such as craniovertebral junction fusions. Three of the studies involved exclusive continuation of DMARDs in the perioperative window; one study involved exclusive discontinuation of DMARDs in the perioperative window; and two studies involved continuation or discontinuation of DMARDs perioperatively. Of patients that continued DMARDs in the perioperative period, 13/50 patients (26.0%) had postoperative surgical site infections or wound dehiscence, 2/19 patients (10.5%) had delayed wound healing, and 32/213 patients (15.0%) had secondary revision surgeries. A fusion rate of 14/19 (73.6%) was described in only one study for patients continuing DMARDs perioperatively. CONCLUSIONS The available published data may suggest a higher risk of wound healing concerns and lower than average bone fusion, although this may be under-reported given the current state of the literature.
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Affiliation(s)
- James C Mamaril-Davis
- Department of Neurosurgery, University of Arizona, 1501 N Campbell Avenue, Room 4303, Tucson, AZ, 32207, USA
| | - Pedro Aguilar-Salinas
- Department of Neurosurgery, University of Arizona, 1501 N Campbell Avenue, Room 4303, Tucson, AZ, 32207, USA
| | - Mauricio J Avila
- Department of Neurosurgery, University of Arizona, 1501 N Campbell Avenue, Room 4303, Tucson, AZ, 32207, USA
| | | | - Travis M Dumont
- Department of Neurosurgery, University of Arizona, 1501 N Campbell Avenue, Room 4303, Tucson, AZ, 32207, USA.
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9
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Albrecht K, Poddubnyy D, Leipe J, Sewerin P, Iking-Konert C, Scholz R, Krüger K. [Perioperative management of treatment of patients with inflammatory rheumatic diseases : Updated recommendations of the German Society of Rheumatology]. Z Rheumatol 2021; 81:212-224. [PMID: 34928422 DOI: 10.1007/s00393-021-01140-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2021] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
| | - Denis Poddubnyy
- Rheumatologie am Campus Benjamin Franklin - Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - Jan Leipe
- Sektion Rheumatologie, Medizinische Klinik V, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - Philipp Sewerin
- Uniklinik Düsseldorf Poliklinik, Funktionsbereich & Hiller Forschungszentrum für Rheumatologie, UKD, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
| | - Christof Iking-Konert
- Sektion Rheumatologie, Medizinische Klinik und Poliklinik III, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Roger Scholz
- Orthopädie und Unfallchirurgie, Collm Klinik Oschatz, Oschatz, Deutschland
| | - Klaus Krüger
- Rheumatologisches Praxiszentrum München, St.-Bonifatius-Str. 5, 81541, München, Deutschland.
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10
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Active rheumatoid arthritis in a mouse model is not an independent risk factor for periprosthetic joint infection. PLoS One 2021; 16:e0250910. [PMID: 34398899 PMCID: PMC8366981 DOI: 10.1371/journal.pone.0250910] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 07/29/2021] [Indexed: 01/16/2023] Open
Abstract
INTRODUCTION Periprosthetic joint infection (PJI) represents a devastating complication of total joint arthroplasty associated with significant morbidity and mortality. Literature suggests a possible higher incidence of periprosthetic joint infection (PJI) in patients with rheumatoid arthritis (RA). There is, however, no consensus on this purported risk nor a well-defined mechanism. This study investigates how collagen-induced arthritis (CIA), a validated animal model of RA, impacts infectious burden in a well-established model of PJI. METHODS Control mice were compared against CIA mice. Whole blood samples were collected to quantify systemic IgG levels via ELISA. Ex vivo respiratory burst function was measured via dihydrorhodamine assay. Ex vivo Staphylococcus aureus Xen36 burden was measured directly via colony forming unit (CFU) counts and crystal violet assay to assess biofilm formation. In vivo, surgical placement of a titanium implant through the knee joint and inoculation with S. aureus Xen36 was performed. Bacterial burden was then quantified by longitudinal bioluminescent imaging. RESULTS Mice with CIA demonstrated significantly higher levels of systemic IgG compared with control mice (p = 0.003). Ex vivo, there was no significant difference in respiratory burst function (p = 0.89) or S. aureus bacterial burden as measured by CFU counts (p = 0.91) and crystal violet assay (p = 0.96). In vivo, no significant difference in bacterial bioluminescence between groups was found at all postoperative time points. CFU counts of both the implant and the peri-implant tissue were not significantly different between groups (p = 0.82 and 0.80, respectively). CONCLUSION This study demonstrated no significant difference in S. aureus infectious burden between mice with CIA and control mice. These results suggest that untreated, active RA may not represent a significant intrinsic risk factor for PJI, however further mechanistic translational and clinical studies are warranted.
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11
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Saunders NE, Holmes JR, Walton DM, Talusan PG. Perioperative Management of Antirheumatic Medications in Patients with RA and SLE Undergoing Elective Foot and Ankle Surgery: A Critical Analysis Review. JBJS Rev 2021; 9:01874474-202106000-00002. [PMID: 34101706 DOI: 10.2106/jbjs.rvw.20.00201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Recent literature has shown that continued use rather than discontinuation of various antirheumatic agents throughout the perioperative period may present an opportunity to mitigate the risks of elective surgery. » For patients with rheumatoid arthritis and systemic lupus erythematosus, perioperative management of medication weighs the risk of infection against the risk of disease flare when immunosuppressive medications are withheld. » Broadly speaking, current evidence, although limited in quality, supports perioperative continuation of disease-modifying antirheumatic drugs, whereas biologic drugs should be withheld perioperatively, based on the dosing interval of the specific drug. » For any withheld biologic drug, it is generally safe to restart these medications approximately 2 weeks after surgery, once the wound shows evidence of healing, all sutures and staples have been removed, and there is no clinical evidence of infection. The focus of this recommendation applies to the optimization of wound-healing, not bone-healing. » In most cases, the usual daily dose of glucocorticoids is administered in the perioperative period rather than administering "stress-dose steroids" on the day of surgery.
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Affiliation(s)
- Noah E Saunders
- The University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - James R Holmes
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - David M Walton
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Paul G Talusan
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, Michigan
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12
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Madanipour S, Prinja A, Lee M, Rashid A. Shoulder arthroplasty for juvenile idiopathic arthritis. J Orthop Surg (Hong Kong) 2020; 28:2309499019890615. [PMID: 31916484 DOI: 10.1177/2309499019890615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
There is limited literature to guide shoulder surgeons in the management of juvenile idiopathic arthritis (JIA). We aim to help clinicians to formulate an approach to the surgical management of the condition through a review of the available literature on arthroplasty in JIA, general considerations when operating on patients with inflammatory arthropathy and recommendations based on the authors' experience. Four articles report formal data on arthroplasty in JIA with favourable improvements in post-operative pain and function scores after the long-term follow-up. Significant heterogeneity in treatment and a lack of standardisation in quantitative outcomes highlights the need for further larger scale and higher quality research. The aim of this study is to review the evidence and provide information on preoperative evaluation of surgical candidates, operative techniques, choice of implant design and to evaluate functional outcomes in patients who undergo shoulder arthroplasty.
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Affiliation(s)
- Suroosh Madanipour
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK
| | - Aditya Prinja
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK
| | - Marcus Lee
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK
| | - Abbas Rashid
- Department of Trauma and Orthopaedic Surgery, University College Hospital, London, UK
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13
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Abstract
STUDY DESIGN Narrative review. OBJECTIVE To provide an overview on the diagnosis and surgical management of rheumatoid involvement of the lumbar spine. Rheumatoid arthritis (RA) is a chronic inflammatory disease of synovial joints, most commonly appendicular followed by axial. Although cervical spine involvement of RA is well documented, data on lumbar spine involvement and surgical management remains limited. METHODS Using PubMed, studies published prior to November 2018 with the keywords "RA, etiology"; "RA, spine management"; "RA, surgical management"; "RA, treatment"; "RA, DMARDs"; "RA, lumbar spine"; "RA, spine surgical outcomes"; "RA, imaging" were evaluated. RESULTS The narrative review addresses the epidemiology, manifestations, imaging, surgical complications, and operative and nonoperative management of RA involvement of the lumbar spine. CONCLUSIONS Rheumatoid involvement of the lumbar spine can present with lower back pain, neurogenic claudication, radiculopathy, spinal deformity, and instability. Patients with RA have significantly higher rates of vertebral fractures and complications following surgical intervention. However, in the setting of instability and spinal deformity, thoughtful surgical planning in conjunction with optimal medical management is recommended.
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Affiliation(s)
- Peter Joo
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Laurence Ge
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Addisu Mesfin
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA,Addisu Mesfin, Department of Orthopaedics and Rehabilitation, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA.
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14
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[Periprosthetic and interprothetic fractures in patients with rheumatism : Characteristics of conservative and surgical treatment]. Unfallchirurg 2020; 123:597-606. [PMID: 32666164 DOI: 10.1007/s00113-020-00838-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Periprosthetic fractures in patients with underlying rheumatic diseases can be a special challenge depending on the extent, bone quality and septic complications. OBJECTIVES Does the underlying rheumatic disease influence the treatment strategy for periprosthetic fractures? What effect do the many extra-articular and local joint-specific rheumatic involvement patterns have on the surgical strategy? How should the potential immunosuppressive side effects of continuously new biologicals be perioperatively taken into account? How can less conspicuous infections under immunosuppression be recognized clinically and using laboratory parameters? MATERIAL AND METHODS Rheumatic disease manifestations that must be perioperatively considered are presented based on the literature. The results are supplemented by many years of experience in a hospital with more than 1500 operations on patients with an underlying rheumatic disease. RESULTS The treatment of periprosthetic fractures with underlying rheumatic diseases necessitates the specific consideration of the multiple accompanying conditions. In general, extra-articular manifestations, average younger age, increased susceptibility to infections, multiple joint involvement and the basic medication must be taken into consideration. The local poorer bone quality can require an adaptation of the surgical technique. These factors are summarized in a treatment algorithm for periprosthetic fractures in patients with rheumatism taking the stability of the prosthesis, the infection status, the etiology, the localization and extent of the fracture into consideration.
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15
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[Perioperative management in the treatment of trauma for rheumatics under immunosuppression]. Unfallchirurg 2020; 123:588-596. [PMID: 32661554 DOI: 10.1007/s00113-020-00826-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
With an almost 3.5% manifestation rate in Germany, rheumatoid arthritis is a relatively frequent disease. Due to the involvement of diverse locations on the skeleton and often multiple comorbidities, treatment of these patients in cases of acute trauma potentially represents a substantial risk. The anti-inflammatory drug treatment harbors dangers, such as delayed wound healing and infections in the perioperative management of these patients. In an emergency a modification of the basic anti-inflammatory medication is hardly possible, so that the postoperative phase after trauma surgery is of special importance. If necessary, orthopedic or internist rheumatologists should be consulted for additional support. Absolute and urgent surgical interventions do not constitute a contraindication with respect to the antirheumatic medication but should be considered in the assessment of the perioperative risk profile. A close cooperation with anesthesia, the meticulous control of intraoperative positioning and postoperative management are of particular importance.
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Impact of Chronic DMARD Therapy in Patients With Rheumatoid Arthritis Undergoing Surgery of the Craniovertebral Junction: A Multi-center Retrospective Study. Spine (Phila Pa 1976) 2020; 45:930-936. [PMID: 32039944 DOI: 10.1097/brs.0000000000003402] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A multi-centered retrospective review from five institutions. OBJECTIVE The aim of this study was to determine whether continuing or withholding disease-modifying antirheumatoid drugs (DMARDs) in the perioperative period affect outcomes in rheumatoid arthritis (RA) patients undergoing arthrodesis at the craniovertebral junction SUMMARY OF BACKGROUND DATA.: RA is a chronic systemic inflammatory disease that affects the cervical spine and is treated with DMARDs. Some advocate withholding DMARDs in the perioperative period due to concern for the cytotoxic effects of these medications. However, the impact of DMARDs in the perioperative period is not well understood. METHODS A multicenter retrospective study from five affiliated institutions was performed. Adult patients with RA on chronic DMARDs undergoing posterior arthrodesis of the craniovertebral junction (occipital-cervical or atlanto-axial arthrodesis) were identified. Patients were stratified based on whether DMARD therapy was continued (C group) or discontinued (DC group) in the perioperative period. The primary outcome was the need for reoperation and reason for reoperation. RESULTS Thirty-nine patients met inclusion criteria, 19 in C group and 20 in DC group. Average follow-up time was 42 months. Four patients (three in DC group and one in C group) required reoperation. Two patients from the DC group required readmission secondary to RA flare-up. CONCLUSION Our cohort of RA patients who underwent occipital-cervical and C1/C2 posterior arthrodesis showed no significant differences in surgical complications when DMARD therapy was continued or discontinued in the perioperative period. The decision to continue or discontinue DMARD therapy in the perioperative period is at the discretion of the treating physician, but we encourage physicians to counsel patients regarding this theoretical risk and their tolerance of the medications as well as the risk of RA flare-up. Factors such as overall health, disease burden, nutrition, bone quality, smoking status, and other comorbid conditions are likely to have a larger influence on perioperative complications. LEVEL OF EVIDENCE 3.
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O'Shaughnessy MA, Kannas S, Ernste F, Rizzo M. Team Approach: Role of Medical and Surgical Management in Rheumatoid Arthritis of the Hand and Wrist. JBJS Rev 2019; 7:e10. [PMID: 31460989 DOI: 10.2106/jbjs.rvw.18.00196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Maureen A O'Shaughnessy
- Departments of Orthopedic Surgery (M.A.O. and M.R.), Physical Medicine and Rehabilitation (S.K.), and Rheumatology (F.E.), Mayo Clinic, Rochester, Minnesota
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Dougherty CD, Hung YY, Weintraub MLR, Patel S, King CM. Osseous and Soft Tissue Complications Associated With Foot and Ankle Surgery in Patients With Rheumatoid Arthritis Taking a Variety of Antirheumatic Medications. J Foot Ankle Surg 2019; 58:508-513. [PMID: 30885450 DOI: 10.1053/j.jfas.2018.09.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Indexed: 02/03/2023]
Abstract
There are multiple antirheumatic drug modalities available to patients with symptomatic rheumatoid arthritis (RA) that function to suppress the overactive immune system, but the inflammatory and immune suppression may contribute to postoperative complications. The purpose of this study was to determine if antirheumatic medications increased the risk of both soft tissue and osseous postoperative complications in patients with RA who underwent foot and ankle surgery. We reviewed patients with RA, aged 18years and older, who underwent either an elective or a nonelective foot or ankle surgery involving an osseous procedure between 2009 and 2014. Chart review was conducted to document procedure type, active medications, and postoperative complications. Of the final 110 subjects meeting inclusion criteria, 31 (28%) patients had a postoperative complication (13 soft tissue, 9 osseous, and 9 both soft tissue and osseous). There was no statistically significant association between taking antirheumatic medications in the perioperative period and postoperative complications. Increased surgery duration and peripheral neuropathy were associated with a statistically significant increase in postoperative complications. Every 15 minutes of increased surgery time led to a 1.2-fold increase in complication risk. Nonelective procedures had a higher risk of soft tissue complications than did elective procedures (odds ratio 4.2, 95% confidence interval 1.1 to 16.0). Although there was no statistically significant association between the specific medication and complications, some medications trended toward statistical significance. When working with patients with RA, our findings suggest the importance of considering the risk of surgery duration and the potential risk of antirheumatic medications in the perioperative period.
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Affiliation(s)
- Colten D Dougherty
- Third-Year Resident, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser San Francisco Bay Area Foot and Ankle Residency, San Francisco, CA
| | - Yun-Yi Hung
- Third-Year Resident, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser San Francisco Bay Area Foot and Ankle Residency, San Francisco, CA
| | - Miranda L Ritterman Weintraub
- Senior Research Project Manager, Graduate Medical Education, Kaiser Permanente Oakland Medical Hospital, Oakland, CA
| | - Sandeep Patel
- Attending Staff, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Department of Orthopedics, Kaiser Foundation Hospital, Walnut Creek, CA
| | - Christy M King
- Residency Director, Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Foundation Hospital, Oakland, CA.
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Abstract
Rheumatoid arthritis is a complex disease state with multiple associated comorbidities. Perioperative evaluation of the rheumatoid patient from a multidisciplinary approach is necessary to achieve favorable outcomes. A complete history and physical, laboratory, cervical, cardiovascular, pulmonary, and medication assessment before surgery should be performed. Educating the patient on potential complications, such as wound dehiscence, infection, and venous thromboembolism, as well as general postoperative expectations, is essential when evaluating the rheumatoid patient for surgery.
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Affiliation(s)
- Jesse Wolfe
- Foot and Ankle Surgery Residency, SSM Health DePaul Hospital, 12303 DePaul Drive, Suite B1, St Louis, MO 63044, USA
| | - Joshua Wolfe
- Foot and Ankle Surgery Residency, SSM Health DePaul Hospital, 12303 DePaul Drive, Suite B1, St Louis, MO 63044, USA
| | - H John Visser
- Foot and Ankle Surgery Residency, SSM Health DePaul Hospital, 12303 DePaul Drive, Suite B1, St Louis, MO 63044, USA.
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20
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[Perioperative management of immunosuppressive treatment in patients undergoing joint surgery]. Z Rheumatol 2018; 76:767-775. [PMID: 28913596 DOI: 10.1007/s00393-017-0379-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The perioperative management of patients on immunosuppressive drugs is uncertain due to a lack of controlled studies. Continuation of medication without a pause may increase the risk of postoperative infections and wound healing disorders and when the pause is too long this can induce a flare of the underlying rheumatic disease. Additional factors, such as rheumatic disease activity, comorbidities, previous infections and the type of surgical procedure also modulate the risk. The highest risk of infection is associated with corticosteroids depending on the dose, so that a dosage as low as possible but stable in the perioperative period is recommended. Among the conventional disease-modifying antirheumatic drugs (DMARDs) only methotrexate has been sufficiently investigated and in this case a pause in treatment induces higher risks than continuation. Antimalarial agents and sulphasalazine should be continued due to the low risks, whereas leflunomide should be washed out before major surgical interventions. The perioperative risk of treatment with biologics is still far from clear; therefore, as a rule of thumb, withholding treatment for two serum half-lives before an intervention and restarting after completed wound healing are recommended.
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Bause L. [Complications in orthopedic rheumatology-characteristics of operative procedures]. DER ORTHOPADE 2018; 47:949-957. [PMID: 30327820 DOI: 10.1007/s00132-018-3648-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The introduction of biologics has led to a great improvement in the treatment options for inflammatory rheumatic diseases. Nevertheless, surgical interventions are still necessary in many patients but a change in surgical indications could be observed. The previously predominant synovectomy of inflamed rheumatic joints is now reduced to a few so-called rebellious joints with persistent inflammation. Joint-preservation and tenoplasty are standard surgical procedures requiring a specific approach including potential complications. The basic immunosuppressive medication has to be considered for all rheumatological interventions. Recommendations extensively evaluate the risk profile of immunosuppressants. The available clinical data are difficult to assess and incomplete. Advances in modern joint replacement procedures have increased the quality of life of patients. Compared to degenerative osteoarthritis, patients with rheumatism tend to present at a lower age, with poorer bone quality and have an increased risk for bacterial joint infections. In cases of a multilocular rheumatoid manifestation including all joints of the extremities, joint replacement specifics need to be taken into account. In patients with rheumatic diseases the mechanical stability of joint replacements, revision options, potential risk of joint infections and periprosthetic fractures vary sometimes considerably from patients with degenerative osteoarthritis. Missing clinical signs of joint infection despite a life-threatening, possibly multilocular dissemination of the disease due to immunosuppressants represents a particular challenge with respect to the diagnostics and treatment. The confusion of this with a rheumatic exacerbation might lead to general septicemia with a high mortality.
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Affiliation(s)
- L Bause
- CA Klinik für Rheumaorthopädie, St. Josef-Stift Sendenhorst, Westtor 7, 48324, Sendenhorst, Deutschland.
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Gualtierotti R, Parisi M, Ingegnoli F. Perioperative Management of Patients with Inflammatory Rheumatic Diseases Undergoing Major Orthopaedic Surgery: A Practical Overview. Adv Ther 2018; 35:439-456. [PMID: 29556907 PMCID: PMC5910481 DOI: 10.1007/s12325-018-0686-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Indexed: 02/06/2023]
Abstract
Patients with inflammatory rheumatic diseases often need orthopaedic surgery due to joint involvement. Total hip replacement and total knee replacement are frequent surgical procedures in these patients. Due to the complexity of the inflammatory rheumatic diseases, the perioperative management of these patients must envisage a multidisciplinary approach. The frequent association with extraarticular comorbidities must be considered when evaluating perioperative risk of the patient and should guide the clinician in the decision-making process. However, guidelines of different medical societies may vary and are sometimes contradictory. Orthopaedics should collaborate with rheumatologists, anaesthesiologists and, when needed, cardiologists and haematologists with the common aim of minimising perioperative risk in patients with inflammatory rheumatic diseases. The aim of this review is to provide the reader with simple practical recommendations regarding perioperative management of drugs such as disease-modifying anti-rheumatic drugs, corticosteroids, non-steroidal anti-inflammatory drugs and tools for a risk stratification for cardiovascular and thromboembolic risk based on current evidence for patients with inflammatory rheumatic diseases.
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Sindhu K, Cohen B, Gil JA. Perioperative Management of Rheumatoid Medications in Orthopedic Surgery. Orthopedics 2017; 40:282-286. [PMID: 28530768 DOI: 10.3928/01477447-20170518-04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 11/15/2016] [Indexed: 02/03/2023]
Abstract
Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disorder known to cause progressive joint destruction. Over time, untreated RA can lead to pain and increasing disability, making orthopedic intervention necessary. The treatment of RA revolves around a variety of medications that blunt the overall immune response. However, this may increase the risk of infection and impair wound healing. Given the nature of this disease, orthopedists frequently encounter patients with RA in the operative setting. To optimize surgical outcomes, orthopedists must carefully manage and pay special attention to the adverse side effects of the complicated medication regimens of these patients perioperatively. [Orthopedics. 2017; 40(5):282-286.].
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Abstract
INTRODUCTION Methotrexate (MTX) is one of the most commonly used disease modifying drugs administered for wide spectrum of conditions. Through the expansion of the indications of MTX use, an increasing number of patients nowadays attend orthopaedic departments receiving this pharmacological agent. The aim of this manuscript is to present our current understanding on the effect of MTX on bone and wound healing. Areas covered: The authors offer a comprehensive review of the existing literature on the experimental and clinical studies analysing the effect of MTX on bone and wound healing. The authors also analyse the available literature and describe the incidence of complications after elective orthopaedic surgery in patients receiving MTX. Expert opinion: The available experimental data and clinical evidence are rather inadequate to allow any safe scientific conclusions on the effect of MTX on bone healing. Regarding wound healing, in vitro and experimental animal studies suggest that MTX can adversely affect wound healing, whilst the clinical studies show that lose-dose MTX is safe and does not affect the incidence of postoperative wound complications.
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Affiliation(s)
- Ippokratis Pountos
- a Academic Department of Trauma & Orthopaedics, School of Medicine , University of Leeds , Leeds , United Kingdom
| | - Peter V Giannoudis
- a Academic Department of Trauma & Orthopaedics, School of Medicine , University of Leeds , Leeds , United Kingdom.,b NIHR Leeds Biomedical Research Unit , Chapel Allerton Hospital , Leeds , UK
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Meyr AJ, Mirmiran R, Naldo J, Sachs BD, Shibuya N. American College of Foot and Ankle Surgeons ® Clinical Consensus Statement: Perioperative Management. J Foot Ankle Surg 2017; 56:336-356. [PMID: 28231966 DOI: 10.1053/j.jfas.2016.10.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Indexed: 02/07/2023]
Abstract
A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.
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Affiliation(s)
- Andrew J Meyr
- Committee Chairperson and Clinical Associate Professor, Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
| | | | - Jason Naldo
- Assistant Professor, Department of Orthopedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Brett D Sachs
- Private Practice, Rocky Mountain Foot & Ankle Center, Wheat Ridge, CO; Faculty, Podiatric Medicine and Surgery Program, Highlands-Presbyterian St. Luke's Medical Center, Denver, CO
| | - Naohiro Shibuya
- Professor, Department of Surgery, Texas A&M, College of Medicine, Temple, TX
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Marculescu CE, Mabry T, Berbari EF. Prevention of Surgical Site Infections in Joint Replacement Surgery. Surg Infect (Larchmt) 2016; 17:152-7. [PMID: 26855288 DOI: 10.1089/sur.2015.258] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Prosthetic joint infections (PJI), although rare, represent a serious complication of total joint arthroplasty as they pose not only a direct financial burden to the patient but also an indirect burden related to psychosocial impact that PJI incur on the patient. Treatment of PJI is complex and requires a combined surgical and medical approach. Patients are often subjected to multiple surgical procedures and prolonged courses of antimicrobial therapy. Therefore, all efforts should be directed toward maximizing the prophylactic measures in the peri-operative and post-operative phases in order to prevent the occurrence of surgical site infections. This article explores primarily the prophylactic measures that target the host and the operative theater environment. Implementation of such preventive measures requires a multi-disciplinary approach and is crucial for a successful outcome of the total joint arthroplasty.
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Affiliation(s)
- Camelia E Marculescu
- 1 Department of Infectious Diseases, Medical University of South Carolina , Charleston, South Carolina
| | - Tad Mabry
- 2 Department of Orthopedic Surgery, Mayo Clinic , Rochester, Minnesota
| | - Elie F Berbari
- 3 Department of Infectious Diseases, Mayo Clinic , Rochester, Minnesota
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Abstract
Rheumatoid arthritis is an autoimmune disease mediated by a widespread chronic systematic inflammatory process that causes joint deterioration, which leads to pain, disability, and poor quality of life. The increased use of disease-modifying antirheumatic drugs has been shown to markedly slow disease progression, which has translated into a decrease in the need for orthopaedic intervention in this population. However, a substantial percentage of patients with the disease fail optimal pharmacologic treatment and still require surgical intervention. A thorough understanding of medical considerations in these patients and improved knowledge of the medical complications caused by the disease process and the pharmacologic therapy used to treat it may lead to improved preoperative planning and medical clearance, which may ultimately improve the overall postoperative outcome.
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Goodman SM, Figgie MA. Arthroplasty in patients with established rheumatoid arthritis (RA): Mitigating risks and optimizing outcomes. Best Pract Res Clin Rheumatol 2015; 29:628-42. [DOI: 10.1016/j.berh.2015.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Goodman SM. Rheumatoid arthritis: Perioperative management of biologics and DMARDs. Semin Arthritis Rheum 2015; 44:627-32. [DOI: 10.1016/j.semarthrit.2015.01.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 01/02/2015] [Accepted: 01/23/2015] [Indexed: 12/20/2022]
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Goodman SM. Optimizing Perioperative Outcomes for Older Patients with Rheumatoid Arthritis Undergoing Arthroplasty: Emphasis on Medication Management. Drugs Aging 2015; 32:361-9. [DOI: 10.1007/s40266-015-0262-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Wiewiorski M, Barg A, Hoerterer H, Voellmy T, Henninger HB, Valderrabano V. Risk factors for wound complications in patients after elective orthopedic foot and ankle surgery. Foot Ankle Int 2015; 36:479-87. [PMID: 25550453 DOI: 10.1177/1071100714565792] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of this study was to quantify the incidence of postoperative wound complications in elective foot and ankle surgery as well as the risk factors for postoperative wound complications. METHODS Two hundred ninety-five elective orthopaedic foot and ankle operative procedures were performed in 290 patients between January 2006 and June 2010. A logistic multiple regression model was used to identify independent risk factors for postoperative wound healing complications/infection. RESULTS The overall prevalence of postoperative wound complications within our cohort was 16.9%. In 4 patients (1.4%) deep infection was diagnosed requiring operative irrigation and debridement. Using a logistic multiple regression model we identified the following statistically independent risk factors: age ≥ 60 years (OR = 8.98, 95% CI = 3.55 to 25.02), tobacco use (OR = 48.77, 95% CI = 15.55 to 139.71), and tourniquet time ≥ 90 minutes (OR = 7.02, 95% CI = 2.77 to 19.32). CONCLUSION Patients at risk for postoperative wound healing complications following elective orthopaedic foot and ankle surgery include those with higher age, tobacco use, and prolonged use of tourniquet. LEVEL OF EVIDENCE Prognostic Level III, comparative study.
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Affiliation(s)
- Martin Wiewiorski
- Orthopaedic Department, University Hospital of Basel, Basel, Switzerland
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Hubert Hoerterer
- Orthopaedic Department, University Hospital of Basel, Basel, Switzerland
| | - Thomas Voellmy
- Orthopaedic Department, University Hospital of Basel, Basel, Switzerland
| | - Heath B Henninger
- Department of Orthopaedics, Harold K. Dunn Orthopaedic Research Laboratory, University of Utah, Salt Lake City, UT, USA
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Update on the surgical treatment for rheumatoid arthritis of the wrist and hand. J Hand Ther 2014; 27:134-41; quiz 142. [PMID: 24530143 DOI: 10.1016/j.jht.2013.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 11/29/2013] [Accepted: 12/01/2013] [Indexed: 02/03/2023]
Abstract
Surgical procedures for the treatment of rheumatoid arthritis are aimed at restoring function and decreasing pain. Over the past four decades multiple procedures have been described in the management of early and late disease. This article will review the most common forms of surgery used in the treatment of rheumatoid arthritis.
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Krüger K, Albrecht K, Rehart S, Scholz R. [Recommendations of the German Society for Rheumatology on the perioperative approach under therapy with DMARDs and biologicals in inflammatory rheumatic diseases]. Z Rheumatol 2014; 73:77-84. [PMID: 24310229 DOI: 10.1007/s00393-013-1301-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The perioperative administration of antirheumatic medication can lead to an increased risk of infection and to a malfunction in wound healing up to a manifest infection; however, the termination of antirheumatic therapy can result in a flare up of the disease. Both situations can endanger the success of the operation, particularly in arthroplasty. METHOD The recommendations have been developed and approved by the Pharmacotherapy Commission of the German Society for Rheumatology following a systematic literature search (as of 30 April 2013) and a consensus process. RESULTS As very little data with sufficiently high evidence are available, the present recommendations should be considered as having an advisory quality and an individual risk assessment should always be carried out. Classical disease-modifying antirheumatic drugs (DMARD), such as methotrexate can be continued in normal cases but whether this is also true for leflunomide is still undecided. For biologicals a break of two half-life periods before the operation is recommended. The therapy can be continued after wound healing has been completed and when there are no signs of infection.
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Affiliation(s)
- K Krüger
- Niedergelassener Rheumatologe, Praxiszentrum, Sankt-Bonifatius, 81541, München, Deutschland,
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Krause ML, Matteson EL. Perioperative management of the patient with rheumatoid arthritis. World J Orthop 2014; 5:283-291. [PMID: 25035831 PMCID: PMC4095021 DOI: 10.5312/wjo.v5.i3.283] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 03/20/2014] [Accepted: 05/08/2014] [Indexed: 02/06/2023] Open
Abstract
A multidisciplinary approach is required to care for patients with rheumatoid arthritis (RA) in the perioperative period. In preparation for surgery, patients must have a cardiovascular risk assessment performed due to the high risk of heart disease in patients with RA. Treatment of RA is with immunomodulatory medications, which present unique challenges for the perioperative period. Currently, there is no consensus on how to manage disease modifying antirheumatic drug (DMARD) therapy in the perioperative setting. Much of the data to guide therapy is based on retrospective cohort data. Choices regarding DMARDs require an individualized approach with collaboration between surgeons and rheumatologists. Consensus regarding biologic therapy is to hold the therapy in the perioperative period with the length of time dictated by the half-life of the medication. Special attention is required at the time of surgery for potential need for stress dose steroids. Further, there must be close communication with anesthesiologists in terms of airway management particularly in light of the risk for cervical spine disease. There are no consensus guidelines regarding the requirement for cervical spine radiographs prior to surgery. However, history and exam alone cannot be relied upon to identify cervical spine disease. Patients with RA who undergo joint replacement arthroplasty are at higher risk for infection and dislocation compared to patients with osteoarthritis, necessitating particular vigilance in postoperative follow up. This review summarizes available evidence regarding perioperative management of patients with RA.
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Abstract
The risk of infection accompanies the benefits of surgery. Immunomodulatory chronic illnesses may increase the risk of surgical infections. Surgical patients with rheumatologic illness need close preoperative assessment regarding their infection risks (fixed and modifiable), which vary on the basis of the proposed procedure, specific rheumatologic illness, and underlying comorbidities. Modification of the medication regimens in the preoperative period may decrease risk and enhance healing. Intraoperative antisepsis and antibiotic prophylaxis remain critical in this patient population. Postoperative fevers within 3 days of surgery are usually noninfectious but require vigilance and attention. The principles of surgical infection reduction are not different in the rheumatologic and general patient populations, but best practice depends on expertise in caring for patients with these illnesses.
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Goodman SM, Paget S. Perioperative Drug Safety in Patients with Rheumatoid Arthritis. Rheum Dis Clin North Am 2012; 38:747-59. [DOI: 10.1016/j.rdc.2012.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Rheumatoid arthritis is often accompanied by massive destruction of the smaller and larger joints even with early therapy using antirheumatic drugs. In these cases total joint arthroplasty is the only surgical option, especially for the knee and hip joint. Knowledge of the specific disease-related postoperative characteristics is a prerequisite for the successful treatment of patients with rheumatoid arthritis. As dislocation of the arthroplastic joint does not occur more often in rheumatoid arthritis, the risk of periprosthetic infection is increased due to the use of biologicals. Therefore, a perioperative optimization is obligatory. In order to facilitate independence in daily living physiotherapy in combination with aids such as arthritis crutches, gripping pliers or raised toilet seat need to be started as soon as possible after surgical treatment. To achieve this goal it is recommended to refer patients with inflammatory arthritis to inpatient rehabilitation facilities. With respect to the specific postoperative treatment after joint replacement the long-term results are comparable with those from patients with primary osteoarthritis.
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Affiliation(s)
- S Seitz
- Klinik für Orthopädie und Orthopädische Rheumatologie, Klinikum Bad Bramstedt, Oskar-Alexander Str. 26, 24576, Bad Bramstedt, Deutschland.
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Wise DM. Suppressed wound healing in a patient with rheumatoid arthritis taking leflunomide (arava). Perm J 2012; 15:70-4. [PMID: 22319420 DOI: 10.7812/tpp/11-044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Although patients with rheumatoid arthritis taking disease-modifying antirheumatic drugs (DMARDs) are monitored for various medication adverse events, DMARDs, and leflunomide in particular, have effects that are not observed clinically, specifically adverse effects on wound healing.
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Perioperative management of rheumatoid medications. J Hand Surg Am 2012; 37:1928-31. [PMID: 22652181 DOI: 10.1016/j.jhsa.2012.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Revised: 03/04/2012] [Accepted: 04/07/2012] [Indexed: 02/02/2023]
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Perioperative management of disease modifying anti-rheumatic drugs: Recommendations based on a meta-analysis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2012. [DOI: 10.1016/j.recote.2012.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Del Olmo L, Hernández B, Galindo-Izquierdo M, Tébar D, Balsa A, Carmona L. [Peri-operative management of disease modifying anti-rheumatic drugs: recommendations based on a meta-analysis]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2012; 56:393-412. [PMID: 23594897 DOI: 10.1016/j.recot.2012.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 04/20/2012] [Accepted: 05/02/2012] [Indexed: 01/30/2023] Open
Abstract
The objective of this paper is make recommendations for the perioperative management of antirheumatic treatment based on the best available evidence. A systematic review was performed including studies in which patients with rheumatic diseases treated with biological and non-biological disease-modifying antirheumatic drugs (DMARDs) had undergone surgery. A total of 5,285 studies were recorded, of which 27 were finally included. These contained information on 5,268 patients and 7,933 surgeries. The majority were women (mean age 55 years) were diagnosed with rheumatoid arthritis, and the most studied drug was methotrexate (MTX). The final recommendations include: maintaining treatment with MTX or leflunomide in the perioperative period in the absence of other risk factors for postoperative complications (Level of Evidence 1c, Grade D recommendation). Biological DMARDs should be temporarily suspended, or the surgery scheduled as far as possible from the last dose, and, if there were other risk factors a space at least two doses (Level of Evidence 2c; Grade D recommendation).
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Affiliation(s)
- L Del Olmo
- Servicio de Reumatología, Hospital Universitario La Paz, Madrid, España.
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Wise DM. Suppressed wound healing in a patient with rheumatoid arthritis taking leflunomide (arava). Perm J 2012. [PMID: 22319420 DOI: 10.7812/tpp/11-044.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Although patients with rheumatoid arthritis taking disease-modifying antirheumatic drugs (DMARDs) are monitored for various medication adverse events, DMARDs, and leflunomide in particular, have effects that are not observed clinically, specifically adverse effects on wound healing.
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Goodman SM, Figgie MP, MacKenzie CR. Perioperative management of patients with connective tissue disease. HSS J 2011; 7:72-9. [PMID: 22294961 PMCID: PMC3026116 DOI: 10.1007/s11420-010-9180-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Accepted: 06/29/2010] [Indexed: 02/07/2023]
Abstract
Diseases of the connective tissue are a varied group of disorders with major musculoskeletal manifestations such as joint pain and loss of function. As a consequence of the accompanying inflammatory joint disease, such patients often require surgery. Due to the protean organ-related consequences of these conditions, patients who suffer from chronic connective tissue disease are a highly challenging population in the perioperative context. This paper reviews the management of such patients in this clinical setting.
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Affiliation(s)
- Susan M. Goodman
- Department of Rheumatology, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021 USA
| | - Mark P. Figgie
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021 USA
| | - C. Ronald MacKenzie
- Department of Rheumatology, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021 USA
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Jones PBB, White DHN. Reappraisal of the clinical use of leflunomide in rheumatoid arthritis and psoriatic arthritis. Open Access Rheumatol 2010; 2:53-71. [PMID: 27789998 PMCID: PMC5074775 DOI: 10.2147/oarrr.s9448] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Leflunomide is a disease-modifying antirheumatic drug (DMARD) that has been in routine clinical use for the treatment of rheumatoid arthritis (RA) and psoriatic arthritis for a decade. In RA, clinical trials of up to two years' duration showed that leflunomide monotherapy was equivalent to methotrexate in clinical and radiographic disease outcomes (tender and swollen joint counts, physician and patient global assessments, American College of Rheumatology and Disease Activity Score responses, slowing or halting of radiographic progression). In a number of studies, quality of life measurements indicated that leflunomide is superior to methotrexate. Leflunomide has been studied in combination with methotrexate and shows efficacy in patients only partly responsive to this agent. Recent trials have shown that leflunomide can be used safely with biologic DMARDs, including antitumor necrosis factor agents and rituximab as part of the treatment algorithm in place of methotrexate as a cotherapy. Leflunomide has demonstrated efficacy as a monotherapy in psoriatic arthritis, and it also has a beneficial effect in psoriasis. Postmarketing studies have shown that retention on treatment with leflunomide is equal to methotrexate and superior to other DMARDs. In general, its side effect profile is acceptable compared with other DMARDS, with nausea, diarrhea, and hair fall occurring commonly, but only rarely leading to discontinuation. Liver toxicity is the most significant problem in clinical use although it is uncommon. Peripheral neuropathy, hypertension, pneumonitis, and cytopenia occur more rarely. Leflunomide is contraindicated in pregnancy and should be used with caution in women during child-bearing years. In this review, the place of leflunomide in therapy is discussed and practical advice informed by evidence is given regarding dosing regimens, safety monitoring, and managing side effects. Leflunomide remains one of the most useful of the nonbiologic DMARDs.
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Affiliation(s)
- Peter BB Jones
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland
- Rheumatology Department, Waikato Hospital, Hamilton, New Zealand
| | - Douglas HN White
- Rheumatology Department, Waikato Hospital, Hamilton, New Zealand
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Balasanthiran A, Vakilgilani T, Darzy K, Axon J. A case of severe staphylococcal septicaemia: septic arthritis and a mediastinal abscess following leflunamide therapy for rheumatoid arthritis. BMJ Case Rep 2010; 2010:bcr0720092082. [PMID: 22766573 PMCID: PMC3029350 DOI: 10.1136/bcr.07.2009.2082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This highly unusual case illustrates how a potentially life-threatening complication may develop insidiously in the context of immunosuppression. A 46-year-old woman presented with increasing malaise and a marked inflammatory response in the context of immunosuppressive therapy for rhueumatoid arthritis. On the basis of microbiological findings, the patient was treated for systemic staphylococcal infection with a prolonged antibiotic course. In addition, incision and drainage procedures were performed on associated, non-resolving abscesses at various sites. One particular lesion in the breast was slow to heal and was monitored with ultrasound imaging. Subsequent cross-sectional imaging revealed that this was, in fact, a large mediastinal abscess, eroding the manubrium and lying within close proximity of the aorta. The patient was eventually referred to a cardiothoracic unit for complete evacuation of this lesion. Following a prolonged illness and treatment period, the patient recovered well and successfully resumed employment.
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