Perioperative Management of DMARDs and Biologics (Rheumatology)

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A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Introduction

This Guideline is intended to be used by clinical staff within Rheumatology and/or Orthopaedic Surgery to assist in the management of rheumatology patients undergoing elective orthopaedic surgery who may be receiving disease-modifying anti-rheumatic drugs (DMARDs) or biologic agents.

Disease-modifying anti-rheumatological drugs (DMARDs)

Table 1:Timing of stopping and starting of disease-modifying anti-rheumatological drugs (DMARDs) in patients with rheumatological disease in the perioperative period for orthopaedic surgery.
Name Dosing Interval Continue/Withdraw Clinical Considerations
Methotrexate Weekly Continue Consider witholding 2 weeks prior to surgery for old, frail patients or with renal insufficiency
Sulfasalazine Once or twice diaily Continue  
Hydroxychloroquine Once or twice daily Continue  
Leflunomide Daily Consider witholding 2 weeks prior to surgery in higher risk patients. Restart with wound healing (2 weeks)

Risk of infection.

Risk of bone marrow suppression.

Azathioprine Daily or twice daily Consider witholding 2 weeks prior to surgery.  Restart with wound healing (2 weeks)

Risk of infection.

Risk of bone marrow suppression.

Mycophenolate mofetil Twice daily Consider witholding 2 weeks prior to surgery.  Restart with wound healing (2 weeks)

Risk of infection.

Risk of bone marrow suppression.

Cyclosporine Twice daily Consider witholding 2 weeks prior to surgery.  Restart with wound healing (2 weeks)

Risk of infection.

Risk of bone marrow suppression.

Biological Drugs

Table 2: Timing of stopping and starting of biological drugs in patients with rheumatological disease in the perioperative period

References

  1. Goodman SM, Springer B, Guyatt G et al. 2017 American College of Rheumatology/ American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Arthritis Care & Research Vol. 69, No. 8, August 2017, pp 1111–1124 DOI 10.1002/acr.23274
  2. N. Maiden, N. Liggett, V. McGoldrick, S. Walker, R Stewart. Clinical Guidelines published by SHSCT Rheumatological Service November 2018.

Last reviewed: 12 May 2021

Next review: 31 May 2024

Author(s): Raj Kumar, Roderick Kong, Martin Perry

Version: 1

Author Email(s): [email protected], [email protected]

Approved By: Medicines Utilisation Subcommittee of ADTC

Document Id: 918