Patients with rheumatoid arthritis (RA), an inflammatory arthritis that can destroy joint structures, are often on multiple medications to control disease activity. These medications may have significant toxicities and side effects. Over the course of their lifetime, patients with this disease often require orthopedic procedures, including total joint arthroplasty, and the medications they are taking present management issues specific to the perioperative period. As many of these medications are immunosuppressive, the concern for postoperative infection and delayed wound healing are particularly worrisome. We conducted a review of the available literature pertaining to the perioperative use of the most commonly prescribed medications for RA. Although the existing data directly addressing perioperative complications in orthopedic surgery is sparse, information on relevant complications resulting from the general use of these drugs may be used as a basis for conservative recommendations.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
An YH, Friedman RJ (1996) Prevention of sepsis in total joint arthroplasty. J Hosp Infect 33:93–108
Schlaghecke R, Kornely E, Santen RT, Ridderskamp P (1992) The effect of long-term glucocorticoid therapy on pituitary-adrenal responses to exogenous corticotropin-releasing hormone. N Engl J Med 326:226–230
McPhee IB, Williams RP, Swanson CE (1998) Factors influencing wound healing after surgery for metastatic disease of the spine. Spine 23:726–732
Busti AJ, Hooper JS, Amaya CJ, Kazi S (2005) Effects of perioperative anti-inflammatory and immunomodulating therapy on surgical wound healing. Pharmacotherapy 25:1566–1591
Mathis AS, Shah NK, Mulgaonkar S (2004) Stress dose steroids in renal transplant patients undergoing lymphocele surgery. Transplant Proc 36:3042–3045
Bromberg JS, Alfrey EJ, Barker CF, et al (1991) Adrenal suppression and steroid supplementation in renal transplant recipients. Transplantation 51:385–390
Glowniak JV, Loriaux DL (1997) A double-blind study of perioperative steroid requirements in secondary adrenal insufficiency. Surgery 121:123–129
Leopold SS, Casnellie MT, Warme WJ, et al (2003) Endogenous cortisol production in response to knee arthroscopy and total knee arthroplasty. J Bone Jt Surg Am Vol 85-A:2163–2167
Bruewer M, Utech M, Rijcken EJ, et al (2003) Preoperative steroid administration: effect on morbidity among patients undergoing intestinal bowel resection for Crohns disease. World J Surg 27:1306–1310
Aberra FN, Lewis JD, Hass D, et al (2003) Corticosteroids and immunomodulators: postoperative infectious complication risk in inflammatory bowel disease patients. Gastroenterology 125:320–327
Jain A, Witbreuk M, Ball C, Nanchahal J (2002) Influence of steroids and methotrexate on wound complications after elective rheumatoid hand and wrist surgery. J Hand Surg [Am] 27:449–455
Hanssen AD, Cabanela ME, Michet CJ Jr (1987) Hip arthroplasty in patients with systemic lupus erythematosus. J Bone Jt Surg Am Vol 69:807–814
Levitsky J, Te HS, Cohen SM (2003) The safety and outcome of joint replacement surgery in liver transplant recipients. Liver Transplant 9:373–376
Cronstein BN (2005) Low-dose methotrexate: a mainstay in the treatment of rheumatoid arthritis. Pharmacol Rev 57:163–172
Choi HK, Hernan MA, Seeger JD, et al (2002) Methotrexate and mortality in patients with rheumatoid arthritis: a prospective study. Lancet 359:1173–1177
Pincus T, Yazici Y, Sokka T, et al (2003) Methotrexate as the “anchor drug” for the treatment of early rheumatoid arthritis. Clin Exp Rheumatol 21:S179–S185
Grennan DM, Gray J, Loudon J, Fear S (2001) Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery. Ann Rheum Dis 60:214–217
Sany J, Anaya JM, Canovas F et al (1993) Influence of methotrexate on the frequency of postoperative infectious complications in patients with rheumatoid arthritis. J Rheumatol 20:1129–1132
Carpenter MT, West SG, Vogelgesang SA, Casey Jones DE (1996) Postoperative joint infections in rheumatoid arthritis patients on methotrexate therapy. Orthopedics 19:207–210
Bibbo C, Anderson RB, Davis WH, Norton J (2003) The influence of rheumatoid chemotherapy, age, and presence of rheumatoid nodules on postoperative complications in rheumatoid foot and ankle surgery: analysis of 725 procedures in 104 patients. Foot Ankle Int 24:40–44
Bland KI, Palin WE, von Fraunhofer JA et al (1984) Experimental and clinical observations of the effects of cytotoxic chemotherapeutic drugs on wound healing. Ann Surg 199:782–790
Cohen SC, Gabelnick HL, Johnson RK, Goldin A (1975) Effects of antineoplastic agents on wound healing in mice. Surgery 78:238–244
Hernigou P, Thiery JP, Benoit J et al (1989) Methotrexate diffusion from acrylic cement. Local chemotherapy for bone tumours. J Bone Jt Surg Br 71:804–811
Shamberger RC, Devereux DF, Brennan MF (1981) The effect of chemotherapeutic agents on wound healing. Int Adv Surg Oncol 4:15–58
Kasdan ML, June L (1993) Postoperative results of rheumatoid arthritis patients on methotrexate at the time of reconstructive surgery of the hand. Orthopedics 16:1233–1235
Lim V, Pande I (2002) Leflunomide can potentiate the anticoagulant effect of warfarin. BMJ 325:1333
Feldmann MM, Maini RN (2002) Discovery of TNF-α as a therapeutic target in rheumatoid arthritis: preclinical and clinical studies. Joint, Bone, Spine 69:12–18
Hochberg MC, Tracy JK, Hawkins-Holt M, Flores RH (2003) Comparison of the efficacy of the tumour necrosis factor α blocking agents adalimumab, etanercept, and infliximab when added to methotrexate in patients with active rheumatoid arthritis. Ann Rheum Dis 62(Suppl 2):ii13–ii16
Lipsky PE, van der Heijde DM, St Clair EW et al (2000) Infliximab and methotrexate in the treatment of rheumatoid arthritis. Anti-Tumor Necrosis Factor Trial in Rheumatoid Arthritis with Concomitant Therapy Study Group. NEJM 343:1594–1602
Hyrich KL, Silman AJ, Watson KD, Symmons DP (2004) Anti-tumour necrosis factor alpha therapy in rheumatoid arthritis: an update on safety. Ann Rheum Dis 63:1538–1543
Fisher CJ, Agosti JM, Opal SM et al (1996) Treatment of septic shock with the tumor necrosis factor receptor:Fc fusion protein. The Soluble TNF Receptor Sepsis Study Group. NEJM 334:1697–1702
Marchal L, D'Haens G, Van Assche G et al (2004) The risk of post-operative complications associated with infliximab therapy for Crohn's disease: a controlled cohort study. Aliment Pharmacol Ther 19:749–754
Colombel JF, Loftus EV Jr, Tremaine WJ et al (2004) Early postoperative complications are not increased in patients with Crohn's disease treated perioperatively with infliximab or immunosuppressive therapy. Am J Gastroenterol 99:878–883
Bibbo C, Goldberg JW (2004) Infectious and healing complications after elective orthopaedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy. Foot Ankle Int 25:331–335
Giles JT, Bartlett SJ, Gelber AC, et al (2006) Tumor necrosis factor inhibitor therapy and risk of serious postoperative orthopedic infection in Rheumatoid Arthritis. Arthritis Care Res 55:333–337
Kawaguchi HH, Hizuta AA, Tanaka NN, Orita KK (1995) Role of endotoxin in wound healing impairment. Res Commun Mol Pathol Pharmacol 89:317–327
Doran MF, Crowson CS, Pond GR, et al (2002) Frequency of infection in patients with rheumatoid arthritis compared with controls: a population-based study. Arthritis Rheum 46:2287–2293
Edwards JC, Szczepanski L, Szechinski J, et al (2004) Efficacy of B-cell-targeted therapy with rituximab in patients with rheumatoid arthritis. NEJM 350:2572–2581
White CA, Weaver RL, Grillo-Lopez AJ (2001) Antibody-targeted immunotherapy for treatment of malignancy. Annu Rev Med 52:125–145
Sarrecchia C, Cappelli A, Aiello P (2005) HBV reactivation with fatal fulminating hepatitis during rituximab treatment in a subject negative for HBsAg and positive for HBsAb and HBcAb. J Infect Chemother 11:189–191
Law JK, Ho JK, Hoskins PJ, et al (2005) Fatal reactivation of hepatitis B post-chemotherapy for lymphoma in a hepatitis B surface antigen-negative, hepatitis B core antibody-positive patient: potential implications for future prophylaxis recommendations. Leuk Lymphoma 46:1085–1089
Tsutsumi Y, Kanamori H, Mori A, et al (2005) Reactivation of hepatitis B virus with rituximab. Expert Opin Drug Safety 4:599–608
Cambridge G, Leandro MJ, Edwards JC, et al (2003) Serologic changes following B lymphocyte depletion therapy for rheumatoid arthritis. Arthritis Rheum 48:2146–2154
The authors would like to thank C. Ronald MacKenzie, MD, for his editorial assistance in preparation of this manuscript.
Supported by the Hospital for Special Surgery Frankenthaler Fellowship in Restorative Mobility (C.R. Scanzello).
About this article
Cite this article
Scanzello, C.R., Figgie, M.P., Nestor, B.J. et al. Perioperative Management of Medications Used in the Treatment of Rheumatoid Arthritis. HSS Jrnl 2, 141–147 (2006). https://doi.org/10.1007/s11420-006-9012-5
- Rheumatoid arthritis
- perioperative management