[Peri-operative management of disease modifying anti-rheumatic drugs: recommendations based on a meta-analysis]

Characteristics of rheumatoid arthritis patients undergoing reverse shoulder arthroplasty

The risks and complication profile of reverse total shoulder arthroplasty (RSA) in rheumatoid arthritis (RA) patients has yet to be clearly defined as most studies have small cohorts. Using a large inpatient database, the purpose on our study was to determine the overall demographics, hospitalization characteristics, and early complication rates in rheumatoid patients and compared these to rotator-cuff arthropathy patients without RA undergoing RSA. Utilizing United States Nationwide Inpatient Sample from 2010 to 2013, we evaluated a total of 919 RA RSA and compared them to 8097 patients without RA undergoing RSA. The outcomes included demographic characteristics like age, race, sex, Deyo comorbidity score, perioperative complications, and mean length-of-stay. The RA cohort had 81% females versus 60% in the comparison cohort. This cohort was younger (p = 0.006) and had longer hospitalization time (p = 0.001), but the total inpatient costs were not significantly different (p = 0.15). In regards to Deyo index, rheumatoid patients had significantly higher scores (p < 0.001). The inpatient complication rates for infection (p = 0.9), nerve injury (p = 0.9), and instability (p = 0.19) were similar, but the RA cohort had more prosthetic-related (p = 0.001) and greater tuberosity-related (p = 0.008) complications. The mortality rates were also similar (p = 0.625). In RSA for RA patients, surgeons should be mindful of preoperative risk factors and demographic characteristics that may influence their outcomes. Caution should specifically be paid to the possibility of longer hospitalization time and increased incidence of certain complications, including intraoperative fracture, when compared to non-rheumatoid patients. Close collaboration between rheumatologists, surgeons, and primary care physicians is a must for optimizing and managing these patients.

Consensus statement on a framework for the management of comorbidity and extra-articular manifestations in rheumatoid arthritis

The objective of the study was to develop evidence-based and practical recommendations for the detection and management of comorbidity in patients with rheumatoid arthritis (RA) in daily practice. We used a modified RAND/UCLA methodology and systematic review (SR). The process map and specific recommendations, based on the SR, were established in discussion groups. A two round Delphi survey permitted (1) to prioritize the recommendations, (2) to refine them, and (3) to evaluate their agreement by a large group of users. The recommendations cover: (1) which comorbidities should be investigated in clinical practice at the first and following visits (including treatments, risk factors and patient's features that might interfere with RA management); (2) how and when should comorbidities and risk factors be investigated; (3) how to manage specific comorbidities, related or non-related to RA, including major adverse events of RA treatment, and to promote health (general and musculoskeletal health); and (4) specific recommendations to assure an integral care approach for RA patients with any comorbidity, such as health care models for chronic inflammatory patients, early arthritis units, relationships with primary care, specialized nursing care, and self-management. These recommendations are intended to guide rheumatologists, patients, and other stakeholders, on the early diagnosis and management of comorbidity in RA, in order to improve disease outcomes.

Perioperative management of patients with rheumatic diseases

This paper aims to explore the assessment of patients with rheumatologic diseases, especially rheumatoid arthritis (RA), before undergoing orthopedic surgery. Perioperative assessment ensures an early diagnosis of the patient's medical condition, overall health, medical co-morbidities, and the assessment of the risk factors associated with the proposed procedures. Perioperative assessment allows for proper postoperative management of complications and of the management of drugs such as disease-modifying anti-rheumatic drugs (DMARD) and anti-platelets, and corticosteroids. The assessment also supports follow up plans, and patient education. Perioperative assessment enables the discussion of the proposed treatment plans and the factors associated with them in each case among the different specialists involved to facilitate an appropriate early decision-making about the assessment and treatment of patients with rheumatologic diseases. It also enables the discussion of both condition and procedure with the patient to ensure a good postoperative care. The article identifies the components of perioperative medical evaluation, discusses perioperative management of co-morbidities and the management of specific clinical problems related to RA, systemic lupus erythematosus, the management of DMARDs, like methotrexate (MTX) and biologic therapies, prophylactic antibiotics, and postoperative follow up, including patient education and rehabilitation.