O Doente Reumatológico Proposto para Cirurgia: Manuseamento dos Agentes Antirreumáticos no Perioperatório

Abstract

Inflammatory rheumatic diseases are functional disorders of the musculoskeletal system whose signs and symptoms are inflammatory. Progressive and chronic situations that require surgery, especially orthopedic surgery, total hip and/or knee arthroplasty, are exposed to a high risk of surgical wound infection, aggravated by immunosuppressive treatment with antirheumatic drugs to which these patients are submitted. The aim of this article is to summarize the most recent and available evidence on perioperative management of these drugs in patients proposed for surgery, their maintenance versus suspension in the preoperative period and their resumption in the postoperative.A narrative literature review was conducted with the terms “antirheumatic agents/perioperative management”, “disease modifying antirheumatic drugs” and “rheumatic disease/postoperative adverse events” in different electronic data bases such as: MEDLINE, EMBASE, Cochrane Library and SciELo. We included articles in Portuguese and English, according to pre-defined selection criteria. Continuation of methotrexate, leflunomide, sulfasalazine and hydroxychloroquine in patients with inflammatory rheumatic diseases appears to be safe in the preoperative period. In severe systemic lupus erythematosus, azathioprine, cyclosporine A, tacrolimus and mycophenolate mofetil should be maintained and its suspension one week before surgery should only be done in situations of non-serious systemic lupus erythematosus. Tofacitinib should also be discontinued for one week prior to the surgical procedure and therapy should be resumed 3 to 5 days postoperatively, in the absence of complications of the surgical wound. For biological agents, the preoperative withdrawal time depends on the drug dosing cycle, therefore surgery should be planned for the end of each therapeutic cycle. Restarting should be done when the surgical wound shows signs of healing and there is no evidence of infection, usually on the 14th postoperative day. The literature on the perioperative management of antirheumatic drugs is scarce. Continuing therapy may hamper wound healing and predispose to infections and discontinuation may induce a flare of the disease, which may increase the need for corticosteroids for control and limit mobilization and rehabilitation after surgery. Due to the associated risks and to improve all perioperative care of the patient, an effective communication between the anesthesiologist and the rheumatologist and more scientific evidence on the subject are imperative.