Perioperative management of patients with rheumatoid arthritis in the era of biologic response modifiers

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Abstract
This article provides guidelines for the perioperative management of the most commonly used antirheumatic drugs being used to treat patients with rheumatoid arthritis, with an emphasis on the relatively new addition of biologic response modifiers. Few clinical data exist examining the perioperative management of the biologic drugs, which include the inhibitors of tumor necrosis factor-α (etanercept, infliximab, and adalimumab), the interleukin-1 receptor antagonist anakinra, and to a much lesser extent the CD20 inhibitor rituximab. The only human data available in that regard is based on the use of the tumor necrosis factor-α inhibitor infliximab in surgical patients with Crohn disease. Although quite limited, that data appeared favorable in finding that infliximab did not result in an increased risk of postoperative complications in that setting. Perioperative guidelines have never been well established for a majority of the traditional antirheumatic drugs in use today. Recommendations for the perioperative use of nonsteroidal antiinflammatory drugs and glucocorticoids have the most evidence-based support. Data for the use of methotrexate are also available from which to generate reasonable guidelines; however, for the remaining antirheumatic drugs in current use, the available data cannot support any clear evidence-based recommendations. To provide reasonable guidelines for the use of the biologics, perhaps the best we can do is to extrapolate from the very limited data coming from the concurrent use of infliximab in patients with Crohn disease who have undergone surgery. Beyond that, we are left with animal and tissue culture data from which any recommendations would be rather tenuous.