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Area of Science:

  • Rheumatology
  • Orthopedic Surgery
  • Immunology

Background:

  • Biologic and immunomodulatory therapies, including TNF inhibitors and interleukin-targeting drugs, are crucial for managing autoimmune diseases.
  • Perioperative management of these therapies in orthopedic surgery presents a challenge due to the increased risk of postoperative infections.
  • Abrupt discontinuation can lead to disease flare-ups and potential drug tolerance, complicating treatment efficacy.

Purpose of the Study:

  • To review the challenges and considerations in the perioperative management of biologic and immunomodulatory therapies for orthopedic surgery patients.
  • To highlight the balance between infection risk and disease flare-ups associated with these medications.
  • To emphasize the need for individualized patient management and multidisciplinary collaboration.

Main Methods:

  • Review of current literature and guidelines on the management of biologic and immunomodulatory drugs around orthopedic surgery.
  • Analysis of the risks associated with continuing or discontinuing these therapies, including infection and disease activity.
  • Discussion of factors influencing perioperative drug management, such as drug pharmacokinetics, surgical procedure type, and patient comorbidities.

Main Results:

  • Ongoing biologic therapy during major orthopedic surgery, especially with implants, is associated with an elevated risk of surgical site infections (SSIs).
  • Withholding biological disease-modifying antirheumatic drugs (bDMARDs) for at least one dosing cycle before surgery is generally recommended when feasible.
  • Non-biologic DMARDs can often be continued, and decisions regarding biologics require individualization based on multiple clinical factors.

Conclusions:

  • Individualized perioperative management is essential, considering drug properties, surgical complexity, patient health, and disease status.
  • Close collaboration between rheumatologists, orthopedic surgeons, and infectious disease specialists is critical for optimizing patient outcomes and minimizing complications.
  • Balancing the risks of infection and disease exacerbation is key to safe and effective perioperative care for patients on these therapies.