How should patients currently using disease-modifying antirheumatic drugs (DMARDs) be managed in the perioperative period?

Author: Taolin Fang

RECOMMENDATION: Spine surgeons caring for patients with rheumatic diseases must be aware that there are specifi c issues involved in their perioperative management. The optimal strategy for managing DMARD medications during the perioperative period of spine surgery is unknown due to the lack of evidence and it is largely based on low-quality evidence and expert opinion. A rheumatologist should be involved in the medication management around the time of surgery. 1. For nonbiologic DMARDs such as methotrexate (MTX), lefl unomide, hydroxychloroquine and/or sulfasalazine, continuation of the current dose throughout the perioperative period is recommended. 2. For biologic DMARDs such as etanercept, we recommend that physicians withhold the biologic medication and plan elective surgery at the end of the dosing cycle for that specifi c medication. As an example, patients taking a weekly dose should schedule the surgery in the second week after the fi rst withheld dose. These agents should not be restarted until external wound healing is complete, which is typically around two weeks. Exception: In patients taking  tofacitinib (twice daily dose), withholding of tofacitinib for at least one week prior to surgery is recommended. 3. For medications typically used for systemic lupus erthematosus (SLE) patients, such as mycophenolate mofetil, azathioprine, cyclosporine and tacrolimus, the decision to withhold medications prior to surgery should be made on an individual basis.

LEVEL OF EVIDENCE: Moderate

DELEGATE VOTE: Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus)

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