The need for cervical spine surgery in rheumatoid patients has decreased dramatically over the past few decades due to increased use of DMARDs. These medications have resulted in much less disease progression in patients with inflammatory arthritis, though some patients taking these medications still need spine or other orthopaedic procedures. While these potent medications have revolutionized the treatment of rheumatoid disease, they are also immunosuppressant agents that theoretically increase the risk of wound healing problems and surgical site infection. In order to better understand the need for stopping DMARDs in the perioperative period, Dr. Elia and colleagues from Kaiser Permanente in California retrospectively identified 39 patients who had upper cervical spine fusion (involving either the occipitocervical junction or C1-C2) who were taking DMARDs preoperatively. Twenty patients stopped their DMARDs perioperatively and nineteen continued on them through surgery. The groups were similar at baseline, though the group that continued had a higher proportion with diabetes. The discontinued group had a slightly longer average fusion length (3.7 levels vs. 2.3 levels), though this difference was not significant. There was also a trend for more of the discontinued patients to be on a DMARD and steroids (65% vs. 42%). The authors found no difference in the rate of reoperation for wound dehiscence or surgical site infection, with only one patient in the discontinued group requiring this at 6 weeks out from surgery. Three other patients required revision surgery at later time points for adjacent segment degeneration or pseudarthrosis (one in the continued DMARD group and two in the discontinued group). Two patients in the discontinued group required readmission due to an arthritis flare after surgery. Based on these data, the authors recommended continuing DMARD treatment in the perioperative period.
Spine surgeons and rheumatoid patients are fortunate that DMARDs have resulted in better disease control and markedly decreased the rate of cervical spine surgery in this population. However, some patients on DMARDs still require surgery, and surgeons have limited and oftentimes conflicting evidence regarding the need to stop these agents perioperatively. Many surgeons do stop DMARDs in the perioperative period as they believe the morbidity associated with a disease flare is relatively low compared to the morbidity of a surgical site infection. The American College of Rheumatology collaborated with the American Association of Hip and Knee Surgeons to review the literature on the topic and issue guidelines about which DMARDs to stop perioperatively.1 They suggested holding the biologic DMARDs (i.e. adalimumab, etanercept) for one dosing cycle prior to surgery and post-operatively until the wound had healed. They also recommended continuing non-biologics (i.e. methotrexate, hydroxychloroquine, leflunomide) and steroids (at a dose of less than 20 mg prednisone per day) through the perioperative period. The current study is limited by its small sample size and the fact that only about 25% of patients in each group were taking a biologic agent. Only 4 patients continued their biologic agent perioperatively compared to 5 who stopped it. Clearly, it is not possible to make any meaningful comparisons between groups of this size. The majority of the patients in both groups were on nonbiologic agents, and there is a reasonable consensus that these can be continued perioperatively. In this cohort, only 1/39 patients required a reoperation for a wound problem or surgical site infection. With rates of wound complications this low, a very large sample size would be needed to answer the question at hand. The success of DMARDs probably makes such a study impossible. In order to generate 39 patients, the authors needed to review 9 years of records at 4 hospitals. Based on the data presented, their conclusion that all DMARDs, including biologics, should be continued perioperatively is too strong of a conclusion. Until better data is available, surgeons should probably stick to the recommendations in the American College of Rheumatology guidelines.
Please read Dr. Elia's article on this topic in the July 1 issue. Does this change your views regarding stopping DMARDs perioperatively?
Adam Pearson, MD, MS
Associate Web Editor
1. Goodman SM, Springer B, Guyatt G, et al. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Arthritis Care Res (Hoboken) 2017;69:1111-24.