Perioperative management of disease-modifying antirheumatic drugs and other immunomodulators

We aim to summarize the relevant evidence and provide guidance for perioperative management of disease-modifying antirheumatic drugs (DMARDs) and other immunomodulators used in the treatment of the various inflammatory rheumatic diseases in patients submitted to elective surgery.

This is a review article directed towards clinical practice, based on recent literature available in PubMed database, as well as guidelines published by Rheumatology Societies.

Treatment with conventional DMARDs (methotrexate, hydroxychloroquine, sulfasalazine and leflunomide) can be continued perioperatively; targeted synthetic DMARDs should be suspended at least 3 to 7 days before surgery, depending on the drug, and restarted 3-5 days after the procedure, while biologic DMARDs should be withheld a dosing cycle prior to surgery and resumed at least 14 days after the procedure, with evidence of complete wound healing. In the case of Systemic Lupus Erythematosus (SLE), one should consider the severity of the condition to make the decision about discontinuing immunomodulators (mycophenolate mofetil, azathioprine, cyclosporine, or tacrolimus) as these should be continued in severe SLE because of the increased risk of life-threatening flares. The usual dose of glucocorticoids should be continued perioperatively; however, elective procedures with high-risk surgical site infection should be postponed in patients under ≥20 mg/day prednisone or equivalent until the inflammatory process is controlled with the minimum effective dose.

The perioperative management of patients with rheumatic disease under DMARDs or other immunomodulators is challenging but vital for achieving the best outcome possible. A multidisciplinary approach agreed upon by the anesthesiologist, surgeon and rheumatologist is the best strategy for success.