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Xu W, Schmiesing C, Chang J. Update on Perioperative Medication Management for the Hand Surgeon: A Focus on Diabetes, Weight Loss, Rheumatologic, and Antithrombotic Medications. J Hand Surg Am 2024:S0363-5023(24)00301-0. [PMID: 39093237 DOI: 10.1016/j.jhsa.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 05/13/2024] [Accepted: 05/22/2024] [Indexed: 08/04/2024]
Abstract
Diabetes mellitus and obesity are growing health concerns. New pharmacologic interventions have recently begun to play a more notable role in the treatment pathway of these separate but related conditions. In particular, glucagon-like peptide-1 receptor agonists, such as semaglutides (Ozempic, Wegovy) and tirzepatide (Mounjaro), and sodium glucose co-transporter 2 inhibitors, such as dapagliflozin (Farxiga) and empagliflozin (Jardiance), have emerged as treatment options. Multiple clinical trials have demonstrated their efficacy in regulating metabolism, improving glycemic control, and managing long-term weight reduction. However, glucagon-like peptide-1 receptor agonists have also been associated with gastrointestinal side effects, including delayed gastric emptying as well as regurgitation and aspiration during general anesthesia or deep sedation, and sodium glucose co-transporter 2 inhibitors have been associated with severe diabetic ketoacidosis. Therefore, discontinuation of these medications before surgery is imperative. Given the popularity of these medications among the general public, it is essential for hand surgeons, to understand how to appropriately manage them perioperatively. The objective of this article was to review these new diabetes mellitus and weight loss medications, including their mechanisms of action, indications for use, and perioperative management guidelines. Additionally, we will take this opportunity to review perioperative guidelines for other common medications relevant to patients undergoing procedures involving the hand and upper extremity such as antithrombotic medications and rheumatoid arthritis-related immunosuppressive medications. Finally, we will describe how the electronic medical record system can be used to optimize perioperative medication management in this population.
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Affiliation(s)
- Wen Xu
- Chase Hand and Upper Extremity Center, Division of Plastic Surgery, Stanford University, Palo Alto, CA
| | - Cliff Schmiesing
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA
| | - James Chang
- Chase Hand and Upper Extremity Center, Division of Plastic Surgery, Stanford University, Palo Alto, CA.
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Xiong GX, Merchan N, Ostergaard PJ, Hall MJ, Earp BE, Rozental TD. Complications After Open Reduction and Internal Fixation for Distal Radius Fractures in Patients With and Without Rheumatoid Arthritis. J Hand Surg Am 2024; 49:490.e1-490.e8. [PMID: 36216681 DOI: 10.1016/j.jhsa.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 07/14/2022] [Accepted: 08/10/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Rheumatoid arthritis (RA) can have severe impact on patients' functional abilities and increase the risk of fragility fractures. Little is known about how patients with RA fare after operative management of distal radius fractures. The purpose of this study was to compare postoperative complications after surgical fixation in patients with RA and controls, hypothesizing that patients with RA would have higher levels of postoperative complications. METHODS Patients were identified using Current Procedural Terminology and International Classification of Diseases, Ninth and Tenth Revision, codes for open treatment of distal radius fractures and RA at 3 level 1 trauma centers over a 5-year period (2015-2019). Chart abstraction provided details regarding injuries and treatment. Age- and sex-matched controls were identified in a 2:1 ratio. Postoperative complications were classified according to the Clavien-Dindo-Sink classification system and divided into early (less than 90 days) and late groups. RESULTS Sixty-four patients (21 with RA and 43 controls) were included. The patients were predominantly women, with a mean age of 62 years and a mean Charlson comorbidity index of 2.1. The RA medications at the time of injury included conventional synthetic disease-modifying antirheumatic drugs (5/21), biologic disease-modifying antirheumatic drugs (5/21), or chronic oral prednisone (6/21). Rheumatoid medications, except hydroxychloroquine, were withheld for 2-3 weeks after surgery. Rheumatoid patients were significantly more likely to sustain a complication compared with the control group, although this was no longer significant on adjusted analysis. Class I complications were the most common. The incidence of early versus late complications was similar between the groups. A high rate of early return to surgery for fixation failure occurred in the RA group compared with none in the control group. CONCLUSIONS Patients with RA undergoing operative management of distal radius fractures are at risk of postoperative complications, particularly fracture fixation failure, necessitating return to the operative room. High levels of pain, stiffness, and mechanical symptoms were noted in the RA group. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Grace X Xiong
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, MA
| | | | - Peter J Ostergaard
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, MA
| | - Matthew J Hall
- Harvard Combined Orthopedic Residency Program, Harvard Medical School, Boston, MA
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Lynch CP, Garcia VC, Grandizio LC. The Risk of Early Postoperative Complications Associated With Preoperative Immunosuppression in Patients Undergoing Total Elbow Arthroplasty. J Hand Surg Am 2023; 48:1236-1243. [PMID: 37897471 DOI: 10.1016/j.jhsa.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 09/23/2023] [Accepted: 09/27/2023] [Indexed: 10/30/2023]
Abstract
PURPOSE Patients considering total elbow arthroplasty (TEA) may be receiving immunosuppressive therapy; however, the relationship between immunosuppressive medications and postoperative complications is not well defined. Our purpose was to assess the relationship between preoperative immunosuppression and short-term complications following TEA. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was reviewed from 2005 to 2020 to identify patients undergoing TEA. Procedures indicated for malignancy or infection were excluded. Patients were grouped according to preoperative chronic immunosuppressive status. Demographic and operative characteristics were compared between groups. The 30-day incidence of complications and reoperations were compared between groups. Multiple logistic regression models, inverse-weighted by propensity scores, were used to calculate odds ratio (OR) of experiencing any complication or return to the operating room based on immunosuppression status and other demographic characteristics. RESULTS A total of 769 patients undergoing TEA were included, of whom 142 (18.5%) received chronic immunosuppression. Distribution of age, sex, race, body mass index, diabetes, and American Society of Anesthesiologists classification differed significantly between groups. Most procedures were performed on an inpatient basis, and the median operative duration was 148 minutes. Most procedures were indicated for fracture in the nonimmunosuppressed group and rheumatoid arthritis in the immunosuppressed group. Overall complication rates were 7.0% for immunosuppressed patients and 10.2% for nonimmunosuppressed patients. The incidence of complications and reoperations did not significantly differ between groups. After controlling for confounding and adjusting for patient characteristics, immunosuppressed patients were 0.52 times less likely to experience a complication. Additionally, there was no association between immunosuppression status and odds of return to the operating room. CONCLUSION Similar rates of complications were observed following TEA, regardless of preoperative immunosuppression status. Chronic immunosuppression does not appear to increase the rates of postoperative complications for patients undergoing TEA. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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Affiliation(s)
- Conor P Lynch
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA
| | - Victoria C Garcia
- Biostatistics Core, Geisinger Health System, Henry Hood Research Center, Danville, PA
| | - Louis C Grandizio
- Department of Orthopaedic Surgery, Geisinger Musculoskeletal Institute, Geisinger Commonwealth School of Medicine, Danville, PA.
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Xu Y, Huang Z, Wu G, Jin F, Lin S, Zhang C, Zheng J, Liu W, Hou J, Lu YJ. Bioinformatic assay reveal the potential mechanism of Guizhi-Shaoyao-Zhimu decoction against rheumatoid arthritis and mild-to-moderate COVID-19. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 238:107584. [PMID: 37207464 DOI: 10.1016/j.cmpb.2023.107584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 04/23/2023] [Accepted: 05/03/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND AND OBJECTIVE Patients with rheumatoid arthritis (RA) are more susceptible to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) than healthy population, but there is still no therapeutic strategy available for RA patients with corona virus disease 2019 (COVID-19). Guizhi-Shaoyao-Zhimu decoction (GSZD), Chinese ancient experience decoction, has a significant effect on the treatment of Rheumatism and gout. To prevent RA patients with mild-to-moderate COVID-19 from developing into severe COVID-19, this study explored the potential possibility and mechanism of GSZD in the treatment of this population. METHODS In this study, we used bioinformatic approaches to explore common pharmacological targets and signaling pathways between RA and mild-to-moderate COVID-19, and to assess the potential mechanisms of in the treatment of patients with both diseases. Beside, molecular docking was used to explore the molecular interactions between GSZD and SARS-CoV-2 related proteins. RESULTS Results showed that 1183 common targets were found in mild-to-moderate COVID-19 and RA, of which TNF was the most critical target. The crosstalk signaling pathways of the two diseases focused on innate immunity and T cells pathways. In addition, GSZD intervened in RA and mild-to-moderate COVID-19 mainly by regulating inflammation-related signaling pathways and oxidative stress. Twenty hub compounds in GSZD exhibited good binding potential to SARS-CoV-2 spike (S) protein, 3C-like protease (3CLpro), RNA-dependent RNA polymerase (RdRp), papain-like protease (PLpro) and human angiotensin-converting enzyme 2 (ACE2), thereby intervening in viral infection, replication and transcription. CONCLUSIONS This finding provides a therapeutic option for RA patients against mild-to-moderate COVID-19, but further clinical validation is still needed.
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Affiliation(s)
- Yongyu Xu
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China
| | - Zebin Huang
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China
| | - Guangping Wu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Fujun Jin
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China
| | - Shuojia Lin
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China
| | - Chuang Zhang
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China
| | - Jie Zheng
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China
| | - Wenjie Liu
- Department of Chemistry, Lakehead University and Thunder Bay Regional Health Research Institute, 980 Oliver Road, Thunder Bay, ON, Canada
| | - Jinqiang Hou
- Department of Chemistry, Lakehead University and Thunder Bay Regional Health Research Institute, 980 Oliver Road, Thunder Bay, ON, Canada
| | - Yu-Jing Lu
- School of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou 510006, China; Golden Health (Guangdong) Biotechnology Co., Ltd, 99 Taoyuan East Road, Shishan, District, Foshan 528225 China.
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Shao L, Pelayo A, Shi R, Ma J, Liu H, Cai Y, Prochazkova M, Somerville RP, Panch SR, Shah NN, Stroncek DF, Jin P. Identification of genomic determinants contributing to cytokine release in immunotherapies and human diseases. J Transl Med 2022; 20:338. [PMID: 35902861 PMCID: PMC9331024 DOI: 10.1186/s12967-022-03531-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 07/11/2022] [Indexed: 11/10/2022] Open
Abstract
Background Cytokine release syndrome (CRS) is a strong immune system response that can occur as a result of the reaction of a cellular immunotherapy with malignant cells. While the frequency and management of CRS in CAR T-cell therapy has been well documented, there is emerging interest in pre-emptive treatment to reduce CRS severity and improve overall outcomes. Accordingly, identification of genomic determinants that contribute to cytokine release may lead to the development of targeted therapies to prevent or abrogate the severity of CRS. Methods Forty three clinical CD22 CAR T-cell products were collected for RNA extraction. 100 ng of mRNA was used for Nanostring assay analysis which is based on the nCounter platform. Several public datasets were used for validation purposes. Results We found the expression of the PFKFB4 gene and glycolytic pathway activity were upregulated in CD22 CAR T-cells given to patients who developed CRS compared to those who did not experience CRS. Moreover, these results were further validated in cohorts with COVID-19, influenza infections and autoimmune diseases, and in tumor tissues. The findings were similar, except that glycolytic pathway activity was not increased in patients with influenza infections and systemic lupus erythematosus (SLE). Conclusion Our data strongly suggests that PFKFB4 acts as a driving factor in mediating cytokine release in vivo by regulating glycolytic activity. Our results suggest that it would beneficial to develop drugs targeting PFKFB4 and the glycolytic pathway for the treatment of CRS. Supplementary Information The online version contains supplementary material available at 10.1186/s12967-022-03531-3.
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Affiliation(s)
- Lipei Shao
- Department of Transfusion Medicine, Center for Cellular Engineering, NIH Clinical Center, Bethesda, MD, 20892, USA
| | - Alejandra Pelayo
- Department of Transfusion Medicine, Center for Cellular Engineering, NIH Clinical Center, Bethesda, MD, 20892, USA
| | - Rongye Shi
- Department of Transfusion Medicine, Center for Cellular Engineering, NIH Clinical Center, Bethesda, MD, 20892, USA
| | - Jinxia Ma
- Department of Transfusion Medicine, Center for Cellular Engineering, NIH Clinical Center, Bethesda, MD, 20892, USA
| | - Hui Liu
- Department of Transfusion Medicine, Center for Cellular Engineering, NIH Clinical Center, Bethesda, MD, 20892, USA
| | - Yihua Cai
- Department of Transfusion Medicine, Center for Cellular Engineering, NIH Clinical Center, Bethesda, MD, 20892, USA
| | - Michaela Prochazkova
- Department of Transfusion Medicine, Center for Cellular Engineering, NIH Clinical Center, Bethesda, MD, 20892, USA
| | - Robert P Somerville
- Department of Transfusion Medicine, Center for Cellular Engineering, NIH Clinical Center, Bethesda, MD, 20892, USA
| | - Sandhya R Panch
- Department of Transfusion Medicine, Center for Cellular Engineering, NIH Clinical Center, Bethesda, MD, 20892, USA
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, NIH NCI, Bethesda, MD, 20892, USA
| | - David F Stroncek
- Department of Transfusion Medicine, Center for Cellular Engineering, NIH Clinical Center, Bethesda, MD, 20892, USA.
| | - Ping Jin
- Department of Transfusion Medicine, Center for Cellular Engineering, NIH Clinical Center, Bethesda, MD, 20892, USA.
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Kim HR, Kim SH. Perioperative and anesthetic management of patients with rheumatoid arthritis. Korean J Intern Med 2022; 37:732-739. [PMID: 35811362 PMCID: PMC9271718 DOI: 10.3904/kjim.2021.555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 04/03/2022] [Indexed: 11/27/2022] Open
Abstract
Our understanding and management of rheumatoid arthritis (RA) have greatly improved, but perioperative and anesthetic management remain challenging. RA is not limited to joints; systemic evaluation is thus required when planning perioperative management. Especially, careful airway evaluation is needed; management of airway-related arthritis is challenging. A multidisciplinary approach is essential to prevent complications without exacerbating RA disease activity. Guidelines published in 2017 are available for perioperative management of anti-rheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. However, the guidelines focus only on anti- rheumatic medications, and do not consider all aspects of perioperative management (including anesthesia). Here, we discuss the perioperative and anesthetic management of patients with RA.
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Affiliation(s)
- Hae-Rim Kim
- Division of Rheumatology, Department of Internal Medicine, Research Institute of Medical Science, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul,
Korea
| | - Seong-Hyop Kim
- Department of Medicine, Institute of Biomedical Science and Technology, Konkuk University School of Medicine, Seoul,
Korea
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul,
Korea
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