Perioperative management of biologic agents used in treatment of rheumatoid arthritis

Patients with rheumatoid arthritis, an inflammatory arthritis that can destroy joint structures, are often on multiple disease-modifying antirheumatic medications to control disease activity. These medications have significant toxicities, most notably immunosuppression leading to increased risk of infection. Furthermore, certain disease-modifying antirheumatic medications have been reported to affect the healing process. Over the course of their lifetime, patients with rheumatoid arthritis may undergo many surgical procedures, often orthopedic interventions, including total joint arthroplasty, reconstructive surgeries, or cervical stabilization. How to manage antirheumatic medications and their toxicities in the perioperative period is a challenging question, especially with regard to the biologic therapies such as antitumor necrosis factor alpha agents. We conducted a review of the available literature pertaining to the perioperative use of biologic agents used to treat rheumatoid arthritis. Although existing data directly addressing complications during specific orthopedic procedures are sparse, information on general surgical complications in rheumatic and other patient populations may be used as a basis for conservative recommendations.