echemi logo
Product
  • Product
  • Supplier
  • Inquiry
    Home > Active Ingredient News > Immunology News > For RA patients using hormones or immunosuppressive agents, should the drug be stopped before surgery?

    For RA patients using hormones or immunosuppressive agents, should the drug be stopped before surgery?

    • Last Update: 2021-06-17
    • Source: Internet
    • Author: User
    Search more information of high quality chemicals, good prices and reliable suppliers, visit www.echemi.com
    *It is only for medical professionals to read the reference medicine.
    You can stop it if you want to! Immunosuppressants are one of the most commonly chosen treatments for patients with rheumatism and immunosuppressive diseases.
    Patients benefit
    .

    Arthritis is the most common type of disease in the field of rheumatism and immunity.
    For patients who unfortunately suffer from this disease, a long career in disease management is tantamount to suffering
    .

    In addition to the various dangers and surging undercurrents lurking under the surface of the water, the reality often adds waves to the sea, making the treatment that is not smooth sailing face difficulties
    .

    In the 2021 European Union Against Rheumatism (EULAR) Conference on the topic of arthritis, Pennsylvania scholars Nikhil Jiwarajka and Michael D.
    George shared with the world that the treatment of rheumatoid arthritis (RA) had to be done during the perioperative period.
    A typical case of decision-making
    .

    Can elderly female RA patients undergo surgery? The patient was 54 years old, an elderly female, with positive serology (rheumatoid factor and anti-cyclic citrullinated peptide antibody), combined with type 2 diabetes and hypertension
    .

    The patient's medication status was: methotrexate (25 mg, 1 time/week, subcutaneous); infliximab (10 mg/kg, 1 time/6 weeks, intravenous infusion); prednisone (7.
    5 mg, 1 time) /Day, oral)
    .

    The patient's overall assessment is 4 points (out of 10), the physician's overall assessment is 2 points (out of 10).
    There is 1 joint swelling and 3 joint tenderness all over the body, and the clinical disease activity index is 10
    .

    The most significant symptom of the patient is chronic, non-inflammatory pain in the right knee, and the symptoms continue to progress after oral medication, physical therapy, and intra-articular hormone injections.

    .

    Figure 1: Overview of the basic situation of the patient in Case 1 When the patient consulted an orthopedic surgeon and learned that a total joint replacement of the right knee was needed, a lot of questions were raised: Does the patient's medical history affect the outcome of the surgery? Will its medication and disease activity affect the outcome of the operation? How should patients use immunosuppressants during the perioperative period, and how to strike a balance between disease activity and perioperative preparation? …If you are the attending doctor in the rheumatology department of this patient in front of the screen, facing the concerns of orthopedic colleagues and the patient’s surgical needs, which option do you think is the most important factor affecting the prognosis of the patient’s knee arthroplasty? Figure 2: Six potential factors affecting the prognosis of this patient's surgery.
    Professor George discussed and explained the above doubts and pointed out that the rate of joint replacement in RA patients is very high
    .

    Studies have shown that compared with other patients, the rate of joint replacement in RA patients is 4 times higher.
    In the past few decades, the 10-year orthopedic surgery rate of RA patients was as high as 27.
    3% (1980-1994), even if the treatment concept continues Alterations, this ratio is still 19.
    5% (1995-2007), in which the proportion of small joint operations has declined relatively while the proportion of large joint operations has remained unchanged
    .

    Moreover, surgery itself is a high-risk factor for infection.
    Data shows that the probability of infection after joint replacement is about 5%, while the incidence of infection in artificial joints is about 0.
    5%-1%
    .

    Compared with patients with osteoarthritis, patients with RA have a relatively higher risk of infection after surgery
    .

    Can surgery be done? These 5 points must be considered! Therefore, he believes that in order to give fully considered recommendations for patients with such complex conditions, the awareness of the doctor in charge should be improved from five aspects: The timing of preoperative adjustments to improve the condition of anti-rheumatic drugs (DMARDs) is different from that of traditional DMARDs.
    Words: ① Methotrexate: Studies have shown that perioperative withdrawal of methotrexate or use of methotrexate has no difference in the occurrence of infection or the effect of surgical wound healing; and a small randomized controlled trial (RCT) proved that it was stopped More complications (15% vs.
    2%) occur in patients with chlorin; and in the well-known cardiovascular inflammation reduction test (CIRT), the use of methotrexate in patients without RA has no effect on severe infections, and for non-severe infections Less affected
    .

    ②Leflunomide: A small-scale RCT showed that there was no difference in the effects of drug withdrawal or use on the occurrence of infection
    .

    Therefore, Professor George believes that it is almost safe to use traditional DMARDs during the perioperative period
    .

    So how does the DMARDs of biological agents perform? Some studies have found that patients who use biological agents have more infections after surgery.
    Researchers believe that this is related to the severity of the disease and the use of glucocorticoids
    .

    A registered study in the Danish Rheumatism Database (DANBIO) included 3,913 hip/knee replacement subjects.
    Although the use of biological agents had more infections, it was not statistically significant
    .

    In addition, the study also showed that disease activity and glucocorticoid use are strongly correlated with the occurrence of infection
    .

    These contradictory studies really puzzled scholars: Can stopping biologics during the perioperative period reduce the risk of infection? An observational study analyzed data from US health insurance and found that 4288 hip/knee replacement patients who used infliximab had no risk of infection within a short period of time (<12 weeks) after stopping the biologics.
    Difference
    .

    Professor George cited similar studies by European and American research teams on biological agents such as abatacept and rituximab, and found that short-term withdrawal between surgery and the last treatment did not increase the risk of infection
    .

    These studies all show that: perioperative discontinuation of biologics is not associated with improved prognosis
    .

    Figure 3: The influence of infliximab on the occurrence of infection during the perioperative period.
    Figure 4: The related research on the influence of several other biological agents on the occurrence of infection.
    The occurrence of serious infections is related, and this correlation is dose-dependent and treatment course dependent, especially when the dosage is> 10 mg/day, its correlation with the occurrence of infection is stronger than that of biological agents
    .

    In addition, multiple observational studies have found that high-dose glucocorticoids are related to the occurrence of postoperative infections
    .

    In addition to hip/knee replacement surgery, the researchers also observed RA patients undergoing other operations (such as groin, cardiovascular, or fractures, etc.
    ) and found that regardless of the timing of use, biological agents did not increase the postoperative 90-day mortality rate.
    Or the 30-day readmission rate, and the use of glucocorticoids will increase the risk of these two indicators, and the increase in risk increases with increasing dose
    .

    Guidelines for the management of immunosuppressants in surgical patients According to the 2017 perioperative guidelines of the American Academy of Rheumatology/American Society of Hip and Knee Surgeons (ACR/AAHKS), scholars often We will weigh the pros and cons of disease outbreaks and postoperative infections, and believe that from the interests of patients, avoiding postoperative infections should be prioritized to avoiding disease outbreaks
    .

    But this concept raises another practical question: Will the disease outbreak worsen the prognosis of postoperative infection or lead to increased use of glucocorticoids? In response to this problem, ACR/AAHKS recommends the following principles during the perioperative period: traditional DMARDs should continue to be used; biological agents should be discontinued for one dose interval before surgery and can be used again 14 days after surgery; it is worth noting that JAK inhibitors It was stopped for 7 days before the operation, and the re-use of other biological agents followed the same principle after the operation
    .

    The British Society of Rheumatology (BSR) also made relevant recommendations in 2019, which are generally the same as those mentioned above, but the difference is that BSR is more balanced in the risk of disease outbreaks caused by drug withdrawal, and pays attention to potential benefits.
    For patients with high-risk disease, BSR recommends stopping the drug for 3-5 half-lives before surgery
    .

    In addition to these two guidelines, other guidelines summarize the factors that affect the occurrence of postoperative infections as the basic condition of the patient (especially age and gender), the disease itself (such as the activity of inflammatory arthritis), and medication (different types of DMARDs and glucocorticoids).
    Hormones), complications (diabetes, obesity, anemia, coagulopathy, etc.
    ) and surgery-related factors (experience of the surgeon and the duration of surgery, etc.
    )
    .

    Make individualized decisions based on existing guidelines and evidence.
    In combination with the foregoing, Professor George believes that both direct and indirect evidence prove that traditional DMARDs can continue to be used in the perioperative period, and the short-term discontinuation of biologics before surgery has no effect on the prognosis of surgery.
    Clearly, but the perioperative application of glucocorticoids has a relatively worse impact on the prognosis of surgery than biological agents, and other factors that may have a significant impact on the prognosis of surgery, such as concurrent diabetes and the level of the surgeon’s business, should be considered
    .

    Regarding this issue, Professor George recommended his own decision-making ideas: Figure 5: Preoperative drug management ideas for RA patients [1] Caution or even taboo use of "stress doses of glucocorticoids" Professor George specifically pointed out about stress doses of glucocorticoids The application of hormones, there are few clinical data to support this approach.
    The ACR perioperative guidelines believe that if patients with hip/knee replacement are receiving hormone therapy and the dose is less than 16mg/day, then the hormone dose for perioperative patients will not be maintained.
    Change
    .

    In particular, it should be noted that if the patient develops refractory hypotension, treat it with hydrocortisone
    .

    And, for patients with primary adrenal insufficiency, hormone therapy is not given
    .

       Conclusion So, back to the beginning of the problem, Professor George believes that the important factors affecting the prognosis of the patient's surgery are: the use of prednisone in the medication history, the active status of RA disease, the relevant options for surgery, and the status of glycosylated hemoglobin indicators
    .

    For this patient, Professor George suggested that she: choose a senior and experienced orthopedic surgeon for knee replacement; at the same time, consult an endocrinologist to adjust and optimize blood sugar control; reduce the dosage of prednisone to 5mg, and no longer Continue to reduce the dose and maintain until the day of surgery; continue to use methotrexate; stop infliximab 6 weeks before surgery, and resume medication 14 days after surgery
    .

    References: [1]George MD,Baker J F.
    Perioperative management of immunosuppression in patients with rheumatoid arthritis[J].
    Current opinion in rheumatology,2019,31(3):300-306.
    This article is an English version of an article which is originally in the Chinese language on echemi.com and is provided for information purposes only. This website makes no representation or warranty of any kind, either expressed or implied, as to the accuracy, completeness ownership or reliability of the article or any translations thereof. If you have any concerns or complaints relating to the article, please send an email, providing a detailed description of the concern or complaint, to service@echemi.com. A staff member will contact you within 5 working days. Once verified, infringing content will be removed immediately.

    Contact Us

    The source of this page with content of products and services is from Internet, which doesn't represent ECHEMI's opinion. If you have any queries, please write to service@echemi.com. It will be replied within 5 days.

    Moreover, if you find any instances of plagiarism from the page, please send email to service@echemi.com with relevant evidence.