SAN FRANCISCO—With little clinical evidence to guide them, rheumatologists often struggle to select appropriate treatments for their patients with special issues, noted moderator Peter J. Embi, MD, MS, assistant professor of medicine at the University of Cincinnati, as he introduced presenters in the 2008 ACR/ARHP Annual Scientific Meeting session, “Practical Pharmacotherapy: Special Problems in Special Patient Populations.” Accordingly, he and co-moderator Michael H. Weisman, MD, director of the Division of Rheumatology at Cedars-Sinai Medical Center in Los Angeles, chose two knowledgeable presenters: Stephen A. Paget, MD, physician-in-chief and chairman of the Division of Rheumatology at the Hospital for Special Surgery (HSS) in New York; and Carl A. Laskin, MD, Rheumatic Disease Unit, University of Toronto, and director, LifeQuest Centre for Reproductive Medicine. Both offered guidance from their own experience.
Perioperative Care: A Balancing Act
In patients with arthritis undergoing joint replacements, physicians must balance the medications taken to control disease processes with the need to ensure optimal wound healing, Dr. Paget emphasized. Preventing flareups may help to ensure successful postsurgical rehabilitation. With nearly 1 million combined total knee and total hip replacements performed in the United States each year, these benefit–risk challenges are apt to increase.
At the HSS, rheumatologists are members of a multidisciplinary team. Decisions about continuing or withdrawing drug therapy are considered in the context of such questions as: Will the medications affect healing of soft tissues and bone? Will they increase the risk of infection? Will the medication improve overall short- and long-term outcome of the surgery—and does this effect differ with different types of surgery?
Dr. Paget combined a literature review with the HSS experience regarding use of antirheumatic therapies—nonsteroidal antiinflammatory drugs (NSAIDs), corticosteroids, and biologic and non-biologic disease-modifying antirheumatic drugs (DMARDs)—in the perioperative setting and included a discussion of bisphosphonates and osteoporosis medications. He acknowledged that some of his advice may not be within the comfort zone of some rheumatologists. For instance, he said, “At the HSS, we do not avoid or discontinue NSAIDs of any kind before surgery—except for spine surgery, where they carry a risk of non-union.” Perioperative aspirin is also usually continued for primary coronary prevention as well as pain management. Results with this approach have been uniformly positive, he said, with no increased incidence of bleeding problems.
Dr. Paget also presented practical guidance regarding perioperative steroid coverage for patients on chronic steroid therapies ranging from 5 mg or less per day to 5 to 7.5 mg per day. As corticosteroids may predispose the patient to wound healing problems, this risk must be carefully balanced with the need for stress doses, he said. Wound healing issues also surface in patients taking methotrexate. Most prospective and retrospective studies suggest that the drug can be continued during the perioperative period without impairing wound healing or increasing infection risk. However, patients with diabetes or a history of infection demand a different approach—for example, stopping the drug two weeks prior to surgery and resuming two weeks afterwards, providing there is good wound healing.