SLR - October 2022 - Jennifer So, DPM
Reference: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(6):10.2106/JBJS.RVW.20.00201. Published 2021 Jun 8. doi:10.2106/JBJS.RVW.20.00201
Level of Evidence: 3
Reviewed By: Jennifer So, DPM
Residency Program: University of Florida College of Medicine Jacksonville. Jacksonville, FL.
Podiatric Relevance: Foot and ankle surgeons must understand the proper management of immunosuppressive drugs during the perioperative setting in patients with rheumatologic disease. Decision making is key in balancing the risk of infection and the risk of disease flare. This article aims to outline current recommendations of continuing, withholding, and restarting immunosuppressive drugs in patients undergoing elective foot and ankle surgery with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE).
Methods: The authors conducted a literature review of perioperative medication management of rheumatologic medications in foot and ankle surgery. The authors modeled their work on the current guidelines by the American College of Rheumatology and the American Association of Hip and Knee Surgeons in 2017 and those of the British Society for Rheumatology in 2019. They had summarized current evidence-based guidelines and determined recommendations as there are no prior randomized controlled trials or level I studies.
Results:
RA and SLE medical management require understanding the dosing regimen of biologics, disease modifying antirheumatic drugs, Janus kinase (JAK) inhibitors, SLE drugs, and steroids. Biologics may be withheld perioperatively based on dosing and restart 2 weeks after surgery with proper wound healing and no clinical signs of infection while disease modifying antirheumatic drugs (DMARDs) such as methotrexate may be continued. Holding methotrexate has been found to increase the risk of disease flare within 6 weeks after elective surgery. Among the JAK inhibitors, tofactinib is held 1 week before surgery but restarting this drug is based on an individual case basis as there are no postoperative recommendations in the literature. Instead of stress dosing steroids, it is now recommended to continue the usual daily dosing of steroids the day of surgery. Interestingly, the spectrum of severity impacts medication guidelines for lupus drugs. For patients with non-severe SLE, medications such as azathioprine are to be held for 1 week and restarted 3-5 days after surgery whereas these drugs may continue in patients with severe SLE. In elective orthopedic surgery, foot and ankle surgery yields a higher postoperative infection rate of 2.0% to 4.5% compared to hip and knee surgeries
Conclusions: RA and SLE patients pose heightened risk of infection and more challenging perioperative medical management. Foot and ankle surgeons should especially pay attention to holding and restarting biologics while DMARDs and SLE drugs for severe SLE may be continued.