Perioperative management of the patient with rheumatoid arthritis

Abstract

A multidisciplinary approach is required to care for patients with rheumatoid arthritis (RA) in the perioperative period. In preparation for surgery, patients must have a cardiovascular risk assessment performed due to the high risk of heart disease in patients with RA. Treatment of RA is with immunomodulatory medications, which present unique challenges for the perioperative period. Currently, there is no consensus on how to manage disease modifying antirheumatic drug (DMARD) therapy in the perioperative setting. Much of the data to guide therapy is based on retrospective cohort data. Choices regarding DMARDs require an individualized approach with collaboration between surgeons and rheumatologists. Consensus regarding biologic therapy is to hold the therapy in the perioperative period with the length of time dictated by the half-life of the medication. Special attention is required at the time of surgery for potential need for stress dose steroids. Further, there must be close communication with anesthesiologists in terms of airway management particularly in light of the risk for cervical spine disease. There are no consensus guidelines regarding the requirement for cervical spine radiographs prior to surgery. However, history and exam alone cannot be relied upon to identify cervical spine disease. Patients with RA who undergo joint replacement arthroplasty are at higher risk for infection and dislocation compared to patients with osteoarthritis, necessitating particular vigilance in postoperative follow up. This review summarizes available evidence regarding perioperative management of patients with RA.

Keywords: Rheumatoid arthritis, Perioperative management, Disease modifying antirheumatic drugs, Tumor necrosis factor inhibitors, Postsurgical complications

Core tip: Patients with rheumatoid arthritis (RA) require specialized care in the perioperative setting. Special attention must be given to management of immunomodulatory therapies, temporarily suspending their administration in the perioperative period. Patients on corticosteroids may require stress doses. Anesthesiologists should be aware of the possibility of cervical spine disease and appropriate measures, including obtaining cervical spine radiographs preoperatively. Patient with RA are at heightened infection risk because of their disease and its treatment, requiring particular vigilance in the postoperative period.