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Australian recommendations on perioperative use of disease-modifying anti-rheumatic drugs in people with inflammatory
Rachelle Buchbinder1, Vanessa Glennon1, Renea V Johnston1
1School of Public Health and Preventive Medicine, Monash University, Victoria, Melbourne, Australia.
Abstract:
Disease-modifying anti-rheumatic drugs (DMARDs) are effective treatments for inflammatory arthritis but carry an increased risk of infection. For patients undergoing surgery, there is a need to consider the trade-off between a theoretical increased risk of infection with continuation of DMARDs perioperatively versus an increased risk of disease flare if they are temporarily withheld. We used the Grading of Recommendations Assessment, Development and Evaluation methodology to develop recommendations for perioperative use of DMARDs for people with inflammatory arthritis undergoing elective surgery. The recommendations form part of the National Health and Medical Research Council-endorsed Australian Living Guideline for the Pharmacological Management of Inflammatory Arthritis. Conditional recommendations were made against routinely discontinuing conventional synthetic and biologic (b) DMARDs in the perioperative period but to consider temporary discontinuation of bDMARDs in individuals with a high risk of infection or where the impact of infection would be severe. A conditional recommendation was made in favour of temporary discontinuation of targeted synthetic DMARDs in the perioperative period.
Insights
For patients with inflammatory arthritis, continuing disease-modifying anti-rheumatic drugs (DMARDs) during surgery is generally recommended. Temporary discontinuation of biologic DMARDs may be considered for high-risk patients, while targeted synthetic DMARDs may be temporarily stopped.
Area of Science:
- Rheumatology
- Pharmacology
- Surgical Medicine
Background:
- Disease-modifying anti-rheumatic drugs (DMARDs) manage inflammatory arthritis but increase infection risk.
- Perioperative management of DMARDs involves balancing infection risk against disease flare.
- Evidence-based guidelines are needed for DMARD use around elective surgery.
Purpose of the Study:
- To develop evidence-based recommendations for the perioperative use of DMARDs in inflammatory arthritis.
- To guide clinicians in managing DMARDs for patients undergoing elective surgery.
- To inform the Australian Living Guideline for Pharmacological Management of Inflammatory Arthritis.
Main Methods:
- Utilized the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.
- Systematic review of evidence on perioperative DMARD use and its outcomes.
- Formulated conditional recommendations based on the GRADE framework.
Main Results:
- Conditional recommendation against routine perioperative discontinuation of conventional synthetic and biologic DMARDs.
- Conditional recommendation to consider temporary discontinuation of biologic DMARDs in high-risk individuals or severe infection impact scenarios.
- Conditional recommendation for temporary discontinuation of targeted synthetic DMARDs perioperatively.
Conclusions:
- Routine perioperative DMARD cessation is not advised for inflammatory arthritis.
- Individualized assessment is crucial for managing biologic and targeted synthetic DMARDs around surgery.
- These recommendations support optimized perioperative care for inflammatory arthritis patients.
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