Should anti-TNF therapy be discontinued in rheumatoid arthritis patients undergoing elective orthopaedic surgery? A systematic review of the evidence

Abstract

Anti-tumour necrosis factor (TNF) therapies have revolutionized the management of rheumatoid arthritis (RA). A high proportion of RA patients are now established users of anti-TNF agents. Unfortunately, many RA patients with longstanding disease still require elective orthopaedic procedures. Published studies on the influence of TNF antagonist on infection rates in RA patients undergoing surgery are conflicting. However, national registries of RA patients on anti-TNF reported an increased risk of infection. The risk of anti-TNF-related infection is highest at the start of treatment with frequent involvement of the skin and subcutaneous tissue. Infection at these sites could negatively influence the healing of surgical wound. Current guidelines suggest that treatment with biologics should be discontinued prior to surgery. Patients with established disease are more likely to flare compared to those with early disease on stopping treatment. Consequently, TNF blockers need to be reinstated promptly after surgery to avoid the risk of RA flare.

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

“…However, for major surgeries, their interruption is recommended for at least twice their half-lives before surgery and may be resumed from 10 to 14 days after surgery 9,39–43, since all of these agents increase the risk of infections. Some drugs, as rituximab, an anti-CD20 monoclonal antibody that depletes populations of B lymphocytes, have a longstanding effect, beginning 2 to 3 weeks after drug introduction and lasting up to 12 months after withdrawal.…”

Évaluation du rapport bénéfice-risque de la suspension des anti-TNF alpha en chirurgie orale

“…Risque de complications cicatricielles post-opératoires chez les patients sous anti-TNF. En cas d'intervention chirurgicale, les patients atteints de PR pourraient présenter un retard de cicatrisation et les patients sous anti-TNF auraient un risque majoré de complications cicatricielles [43]. En effet, le TNF alpha est essentiel au bon déroulement de la cicatrisation.…”

Perioperative Surgical Site Infections and Complications in Elective Orthopedic Surgery in Patients with Rheumatoid Arthritis Treated with Anti-Tumor Necrosis Factor-Alpha Agents − Discontinue or Not, Clinical Dilemma

“…Thus, many orthopaedic surgeons consider the risk of wound healing complication to be high in RA patients, especially treated with TNF blockers [36]. Wound healing is a complex process and TNF-α is required for normal wound healing.…”

“…Because perioperative discontinuation of anti-TNF therapy is basically temporary, and the therapy is restarted promptly after confirmation of good wound healing and no evidence of infection. Therefore, if TNF blockers are withheld prior to surgery, those with longer disease duration need to be monitored carefully for features of relapse [36].…”