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Perioperative management of immunosuppression in patients with rheumatoid arthritis

George, Michael D.a; Baker, Joshua F.a,b

Current Opinion in Rheumatology: May 2019 - Volume 31 - Issue 3 - p 300–306
doi: 10.1097/BOR.0000000000000589

Purpose of review Patients with rheumatoid arthritis are at increased risk of infection after surgery. Recent literature has provided more data and updated guidelines to guide the management of immunosuppression in the perioperative period.

Recent findings Studies over the past few years have confirmed that patients with rheumatoid arthritis are at increased risk of infection after surgery. Patients treated with biologics are at greater risk of postoperative infection, but this risk might be explained by the comorbidities and greater disease severity often seen in these patients. Recent observational studies have suggested that interruption of biologic therapies before surgery may not be associated with better outcomes. Glucocorticoids, however, have consistently been found to be risk factors for infection. Recent guidelines from the American College of Rheumatology/American Association of Hip and Knee Surgeons recommend continuing conventional disease-modifying drugs and holding biologics for one dosing interval before surgery.

Summary Prolonged interruption of conventional and biologic therapies before surgery does not appear to substantially reduce infection risk. Guidelines now recommend continuing conventional DMARDs and holding biologics for just one dosing interval before surgery. Glucocorticoids are strongly associated with the risk of postoperative infection and should be minimized before surgery.

a Division of Rheumatology, University of Pennsylvania

b Division of Rheumatology, Philadelphia Veterans Affairs Medical Center, Philadelphia, USA

Correspondence to Michael D. George, MD, MSCE, Division of Rheumatology, University of Pennsylvania, 5 White Building, 3400 Spruce Street, Philadelphia, PA 19104, USA. Tel: +1 215 662 2454; e-mail:

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