Pre-Op DMARD Use

Up to 30% of patients with rheumatoid arthritis (RA) will eventually undergo joint reconstructive surgery, yet we have limited data to guide the perioperative management of DMARDs and biologics.
Note to Orthopods: there is NO need to stop anti-TNF or other DMARDs well ahead of joint replacement surgery in rheumatic patients. They are NOT associated with serious post-surgical infection (first month) or prosthetic joint infection (first year).
These factors, however, are:
1) high RA disease activity (what you may get by stopping the anti-TNF/DMARD);
2) Prednisolone >10mg daily in the month leading up to the surgery;
3) elderly (>80);
4) with multiple comorbidities (eg DM);
5) hospitalisation in the last 1 year for infection;
6) surgeon with low surgical load (ouch).
Meds given safely within a month before arthroplasty

“…stopping therapy is not without risk, as disease flares may impair rehabilitation, adversely affect functional outcomes, or lead to excess glucocorticoid exposure that could potentially increase infection risk,” the researchers wrote.

WASHINGTON – The perioperative use of disease-modifying antirheumatic drug monotherapy or combined therapy with methotrexate and tumor necrosis factor inhibitors is not associated with increased rates of postoperative infectious…

Note to Surgeons in general: continuing biologic and conventional synthetic DMARDs through needed surgery in RA patients is NOT associated with increased post-surgical infections in general or wound infections.

Overall, the odds ratios of post-surgical infection were lower amongst those who continued their DMARDs than for those who were made to discontinue. Interestingly, infection risk was even lower amongst those who used “stronger” csDMARDs (MTX, Leflunomide) compared to those on the “milder” Hydroxychloroquine; and for those continuing combination therapy (biologic + csDMARD) and biologic alone, compared to those on MTX alone.