Dr. Singh points out that in severe lupus, the risk of organ failure and severe outcomes from uncontrolled disease is far worse than any risks from the drug being continued. “Some of those mortality and organ failure risks do go up just because of fluid shifts and stress from the surgery itself,” he adds, “so it’s quite critical to continue medications in those instances.” Voclosporin and anifrolumab, two new drugs for lupus, were added to this list in the updated guideline; however, we don’t currently have specific data relevant to their use in the perioperative period.
Given its six-month dosing interval and its known risk of severe infection, perioperative management of rituximab has long been a challenge. Although not technically approved for SLE by the FDA, it has increasingly been used in this context. In contrast to the previous guideline, this update separates the use of rituximab in SLE from its use in other diseases (e.g., to be held in inflammatory arthritis). For non-severe SLE, surgery should be performed in the month after the last expected dose (i.e., month 7); in severe SLE, surgery should be performed in the last month of the dosing cycle (i.e., month 6) to minimize infection risk while not skipping a dose.
Recommendation: For patients with inflammatory arthritis or SLE who are taking baseline glucocorticoids, continue this daily dose but do not administer additional glucocorticoids on the day of surgery.
This recommendation is unchanged from the previous guideline, but two new sources support it. Dr. Goodman explains that administering additional glucocorticoids on the day of surgery became commonplace after reports of severe hypotension and death in a patient who had stopped glucocorticoids several days prior to surgery. “More recently, no differences in hemodynamics have been seen when patients receive their usual dose, so that is our current recommendation,” she adds.
Putting Recommendations in Context
As always, these recommendations only provide guidance; physicians must use their own clinical judgment in combination with patient input to make decisions. For example, in a patient whose disease has been historically difficult to control, the best choice may be continuing to take a DMARD, even if a conditional recommendation in the guideline suggests holding it.
Similarly, it may make sense for some patients to temporarily hold a medication, even when conditional guidance would be to continue it. For example, this might be the case for a patient with a history of severe infections or a previous joint infection, or a patient whose disease has been very stable and not subject to flares. Dr. Singh points out that this conversation between the patient, the orthopedic surgeon and the rheumatologist is critical, so that each patient’s individual risk can be fully considered.
