DMARD Management in the Perioperative Period

Michael M. Alexiades, MD, met with Rheumatology Advisor to discuss the surgical management of inflammatory arthritides.

Michael M. Alexiades, MD, associate attending orthopedic surgeon at Hospital for Special Surgery and associate professor of clinical orthopedic surgery at Weill Cornell Medical College in New York City, met with Rheumatology Advisor to discuss the surgical management of inflammatory arthritides.  

This is part 3 of a video series on this topic. To view the first video dealing with timely referral of patients to orthopedic surgeons, please click here.  To view the second video covering the surgical staging of multijoint inflammatory arthritides, click here.

Please scroll down to view the text transcript beneath the video

Video Transcript

Typically, a lot of [patients with inflammatory arthritides who are potentially operative candidates] are on disease-modifying antirheumatic drugs (DMARDs). The immune system for patients with rheumatoid arthritis (RA) is very active and these drugs essentially knock down the immune system to a degree so that their own body does not attack their own joints.  These agents have been very successful in decreasing the severity of disease in most patients.  I think the overall incidence for the need of joint replacement or joint reconstruction has dropped off dramatically as a result of that, although there are patients who are nonresponsive or who start treatment too late to save joints that have already gone on to fairly extensive destruction.

The question of whether to use these drugs immediately or delay depending on the need for surgery is something that should be discussed.  Certainly, patients who are new to a physician who may need treatment for the disease with the disease-modifying agents but who also look like they might need surgery in the near future.

In some cases it is preferable to go ahead and do the surgical intervention first, do the joint reconstruction, and then start them on the disease-modifying agents, because these disease-modifying agents – the so-called TNF blockers such as etanercept (Enbrel®, Amgen) and infliximab (Remicade®, Janssen) being two of the prototypes —  significantly affect the ability to fight infection.

Therefore, the infection rate for patients who are on these DMARDs certainly is increased, and we want to prevent infection of the joint replacement, because that often results in multiple surgeries, loss of the implant for at least a period of time ,and sometimes longer, and some of these infections can be life-threatening in patients who are on these DMARDs.

Generally, if they are already on the DMARD when they are seen by the surgeon, they usually need to stop that drug at some point prior to surgery.  Depending on how long that medication lasts inside the body, the timeframe as to when it has to be stopped has to be individualized.

There are certain drugs that we typically do not stop at the time of surgery.  If patients are on prednisone, which thankfully they are not on it as much as they used to be because of the side effects, but if they are still on prednisone, we keep them on that.  The other drug  is methotrexate.  It is a very commonly used drug in patients with rheumatoid arthritis.  It helps modify the immune system, but it does not have the increased risk of infection like some of the other drugs do. So, common we continue the methotrexate because of the risk of a flare, where the arthritis suddenly becomes very active after surgery and impairs their ability to do their rehabilitation.

So, we do have to temper our holding back on these drugs because of the risk for flares.  So, for a patient in whom we stopped the Enbrel prior to surgery, we typically will restart it as soon as the wound is healed.  This is typically within a couple of weeks after the surgery, when we know that the wound is healed, there is no drainage, and the risk of infection has significantly decreased. We can then restart those particular drugs and hopefully prevent a flare, in which all of their joints would start to act up

If, however, a flare occurs prior to that, then we typically try to treat that with prednisone.

The immunosuppression risk is real.  And patients who have had joint replacements, even remotely, who are on these drugs are always at higher risk for infection.  The surgeon and the rheumatologist need to constantly be alerted to the fact that some of these patients may start to develop joint pain, joint swelling, fevers, even years after their hip or knee replacement, and it may be due to their immune system being so debilitated by the rheumatoid arthritis itself, as well as the immunosuppressant drugs that they are on, so much so that in some cases, we  have seen patients with multiple total joint infections:  both of their hips get infected or both their knees.

To eradicate the infection, typically we have to remove the implant and treat them with intravenous antibiotics before we can reimplant them.  But some patients knee an even longer period of time before re-implantation of their total joint. That will affect function if the joint is left out for a prolonged period of time.

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