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Perioperativer Umgang mit immunsuppressiver Therapie

Perioperative handling of immunosuppressive therapy

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Zusammenfassung

Pro Jahr werden in Deutschland ca. 16 Mio. operative Eingriffe durchgeführt. Eine ganze Reihe von Patienten hat eine Autoimmunerkrankung, z. B. rheumatoide Arthritis, Psoriasis, chronisch-entzündliche Darmerkrankungen, die einer Therapie bedarf. Hier werden vor allem Immunsuppressiva eingesetzt. Im klinischen Alltag ist der operativ tätige Arzt mit der Frage konfrontiert, ob diese perioperativ fortgeführt werden können oder pausiert werden sollten und wenn ja, mit welchem Risiko. Der perioperative Umgang mit dieser Medikamentengruppe ist äußerst relevant, da viele Patienten z. B. mit rheumatoider Arthritis im Verlauf eine totale Knie- oder Hüftendoprothese benötigen oder auch Patienten mit chronisch-entzündlichen Darmerkrankungen aufgrund ihrer Erkrankung operiert werden müssen. Das Pausieren einer immunsuppressiven Therapie sollte im interdisziplinären Konsens anhand der zugrunde liegenden Erkrankung diskutiert werden, da es bei einer Fortführung zu einer erhöhten Rate an Komplikationen, vor allem Wundheilungsstörungen, kommen kann. Bekommt ein Patient Glukokortikoide zur Immunsuppression, muss berücksichtigt werden, dass es in der perioperativen Phase zu einer vermehrten Stressreaktion des Körpers kommt, bei der ein erhöhter Bedarf an Glukokortikoiden vorhanden ist. Bei einer exogenen Zufuhr (ab 7,5 mg/Tag Prednisolonäquivalent) wird diese Stressantwort inhibiert. Daher wird in diesen Fällen in der perioperativen Phase eine Hydrokortisonsubstitution empfohlen.

Abstract

Every year 16 million operations are performed in Germany. Many patients have an autoimmune disorder, for example rheumatoid arthritis, psoriasis or chronic inflammatory bowel disease, which requires treatment. Immunosuppressants are widely applied. Physicians must make a risk-adapted decision whether the immunosuppressant medication can be continued perioperatively or if certain drugs must be paused and if so, with what risks. The handling of immunosuppressants during the perioperative period is very relevant as many patients, for example with rheumatoid arthritis are in need of a hip or knee replacement or patients with inflammatory bowel disease need an operation due to the chronic illness. The interruption of an immunosuppressant therapy should be discussed in an interdisciplinary board according to the underlying disease, because the continuation of immunosuppressants perioperatively can lead to an increased rate of complications, especially wound healing disorders. If a patient is on a glucocorticoid therapy the following must be considered: during the perioperative period the body has an increased demand for glucocorticoids due to the stress reaction. If glucocorticoids are administered in a dosage of more than 7.5 mg/day equivalent of prednisolone this stress reaction is inhibited. Thus, in these cases a perioperative substitution with hydrocortisone is recommended.

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Authors and Affiliations

  1. Klinik für Allgemein‑, Viszeral‑, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Oberduerrbacherstr. 6, 97080, Würzburg, Deutschland

    J. Wagner, J. F. Lock, U. A. Dietz, S. Lichthardt, N. Matthes, K. Krajinovic, C.‑T. Germer &  A. Wiegering

  2. Klinik für Innere Medizin II, Universitätsklinikum Würzburg, Würzburg, Deutschland

    V. Luber & S. Knop

  3. Comprehensive Cancer Center Mainfranken, Universitätsklinikum Würzburg, Würzburg, Deutschland

    C.‑T. Germer & S. Knop

  4. Institut für Biochemie und Molekularbiologie, Universität Würzburg, Würzburg, Deutschland

    A. Wiegering

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J. Wagner, V. Luber, J. F. Lock, U.A. Dietz, S. Lichthardt, N. Matthes, K. Krajinovic, C.‑T. Germer, S. Knop und A. Wiegering geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Wagner, J., Luber, V., Lock, J.F. et al. Perioperativer Umgang mit immunsuppressiver Therapie. Chirurg 89, 116–121 (2018). https://doi.org/10.1007/s00104-017-0529-6

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  • DOI: https://doi.org/10.1007/s00104-017-0529-6

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