Perioperative management of drugs commonly used in patients with rheumatic diseases: a review

Abstract

Rheumatic diseases are very prevalent, affecting about 7 million people in North America; they affect the musculoskeletal system, often with systemic involvement and potential for serious consequences and limitation on quality of life. Clinical treatment is usually long-term and includes drugs that are considered either simple or complex and are occasionally unknown to many health professionals who do not know how to manage these patients in emergency units and surgical wards. Thus, it is important for clinicians, surgeons and anesthesiologists who are involved with rheumatic patients undergoing surgery to know the basic principles of therapy and perioperative management. This study aims to do a review of the perioperative management of the most commonly used drugs in rheumatologic patients. Manuscripts used in this review were identified by surveying MEDLINE, LILACS, EMBASE, and COCHRANE databases and included studies containing i) the perioperative management of commonly used drugs in patients with rheumatic diseases: and ii) rheumatic diseases. They are didactically discussed according to the mechanism of action and pharmacokinetics; and perioperative management. In total, 259 articles related to the topic were identified. Every medical professional should be aware of the types of drugs that are appropriate for continuous use and should know the various effects of these drugs before indicating surgery or assisting a rheumatic patient postoperatively. This information could prevent possible complications that could affect a wide range of patients.

Practical Guidance in Perioperative Management of Immunosuppressive Therapy for Rheumatology Patients Undergoing Elective Surgery

“…Table 1 summarizes management recommendations for rheumatology patients during the perioperative period of elective surgeries for common immunosuppressants marketed in Canada. 3,[5][6][7][8][9][10][11][12][13][14] Canadian recommendations have been prioritized as much as possible (in Table 1, see the recommendations originating from reference 3). The information in this table applies only to rheumatology patients and does not cover other populations, such as transplant patients, who may be at risk of organ rejection if immunosuppressive therapy is stopped temporarily.…”

Principais recomendações em cuidados pré-operatórios

“…As doenças reumatológicas são prevalentes no cenário de saúde, porém, as medicações são consideradas complexas e desconhecidas por muitos profissionais, o que dificulta a gestão desses pacientes na sala cirúrgica. 11 Eles estão expostos a maior risco de infecção, impactando nas complicações perioperatórias. 11 O metotrexate deve ser continuado durante o perioperatório sem aumentar risco de infecção e comprometimento da cicatrização, porém, em pacientes com doença renal crônica e diabetes mellitus não controlado, deve-se suspender por uma semana, pois já podem aumentar esses riscos de maneira independente.…”

“…11 Eles estão expostos a maior risco de infecção, impactando nas complicações perioperatórias. 11 O metotrexate deve ser continuado durante o perioperatório sem aumentar risco de infecção e comprometimento da cicatrização, porém, em pacientes com doença renal crônica e diabetes mellitus não controlado, deve-se suspender por uma semana, pois já podem aumentar esses riscos de maneira independente. 11 A hidroxicloroquina em pacientes lúpicos reduz risco cardiovascular, resistência a insulina, eventos tromboembólicos, infecção e mortalidade ao controlar a doença de base, portanto, deve ser mantida no perioperatório.…”

Perioperative Management of Patients With Ankylosing Spondylitis Undergoing Spine Surgery

“…Since COX-2 inhibitors have little effects on platelet function, there is no need to suspend them during the perioperative period. (Leese et al, 2000;Franco et al, 2017). However, this group of drugs is associated with the risk of significant cardiovascular adverse outcomes.…”

“…Considering the average half-life of an NSAID, they must be withdrawn at some point prior to surgery. ( Franco et al., 2017 ). On the other hand, in patients, whose cardiovascular risk exceeds the intraoperative benefit (for example, patients with cardiac stents), it’s recommended to continue the aspirin during the perioperative period ( Oscarsson et al., 2010 ; Gerstein et al., 2015 ).…”