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Aktuelle Rheumatologie 2012; 37(01): 22-26
DOI: 10.1055/s-0031-1283174
Übersichtsarbeit
© Georg Thieme Verlag KG Stuttgart · New York

Perioperatives Management der medikamentösen Therapie mit Antirheumatika

Perioperative Management of Immunosuppression in Rheumatic Diseases
R. Alten
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Publication History

Publication Date:
28 July 2011 (online)

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Zusammenfassung

In der Therapie der Rheumatoiden Arthritis spielen vor allem immunsuppressive Medikamente eine bedeutende Rolle. Stehen operative Eingriffe bevor, stellt sich immer wieder die Frage, wie mit der aktuellen Medikation umgegangen werden soll. Das perioperative Beibehalten immunsuppressiver Medikamente kann sich negativ auf den geplanten Eingriff auswirken und postoperativ Wundheilungsstörungen und -infektionen nach sich ziehen. Hingegen führt ein präoperatives Absetzen der Therapeutika nicht selten zu einer Exazerbation des autoimmunen entzündlichen Geschehens. In diesem Artikel wird die aktuelle Evidenz für und wider das perioperative Absetzen von Steroiden, nicht-biologischen und biologischen Basistherapeutika zusammengestellt. Da derzeit zu den meisten in der Therapie der RA eingesetzten Medikamenten leider keine ausreichenden Daten aus klinischen kontrollierten Studien vorliegen, scheint ein individualisiertes Vorgehen d. h. die Berücksichtigung der jeweiligen Risikofaktoren der zu operierenden Patienten, adäquat zu sein.

Abstract

Immunosuppressive agents play a major role in the therapy for patients with rheumatoid arthritis. When an elective surgical intervention is pending, the question of how to deal with the current medical treatment arises. If immunosupressive treatment is maintained the surgical intervention might be complicated by wound healing disorders and infections. However, stopping the current antirheumatic treatment may lead to an exacerbation of autoimmune inflammatory activity. This article presents the pros and cons of stopping antirheumatic treatment (i. e., steroids, non-biologic and biologic DMARD therapy), prior to an elective surgery following the latest evidence. Since at present data from controlled clinical studies are insufficent and scarce, an individualised approach taking all the risk factors of the patient undergoing surgery into consideration seems to be the appropriate approach.

Schlüsselwörter

Rheumatoide Arthritis - Perioperatives Management - Biologika - DMARDs - Steroide

Key words

rheumatoid arthritis - perioperative management - biologic agents - DMARDs - steroids
 

  • Literatur

  • 1 Gluck T, Muller-Ladner U. (Do DMARDs contibute to impaired healing after surgery? Should they be discontinued before surgery?). Dtsch Med Wochenschr 2007; 132: 1901-1904 DOI: 10.1055/s-2007-985615.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 2 Weiss RJ, Ehlin A, Montgomery SM et al. Decrease of RA-related orthopaedic surgery of the upper limbs between 1998 and 2004: data from 54,579 Swedish RA inpatients. Rheumatology (Oxford) 2008; 47: 491-494 ken009 [pii] DOI: 10.1093/rheumatology/ken009.
    PubMedGoogle Scholar
  • 3 Louie GH, Ward MM. Changes in the rates of joint surgery among patients with rheumatoid arthritis in California, 1983-2007. Ann Rheum Dis 2010; 69: 868-871 ard.2009.112474 [pii] DOI: 10.1136/ard.2009.112474.
    CrossrefPubMedGoogle Scholar
  • 4 Grijalva CG, Chung CP, Stein CM et al. Changing patterns of medication use in patients with rheumatoid arthritis in a Medicaid population. Rheumatology (Oxford) 2008; 47: 1061-1064 ken193 [pii] DOI: 10.1093/rheumatology/ken193.
    CrossrefPubMedGoogle Scholar
  • 5 Soderlin MK, Lindroth Y, Jacobsson LT. Trends in medication and health-related quality of life in a population-based rheumatoid arthritis register in Malmo, Sweden. Rheumatology (Oxford) 2007; 46: 1355-1358 kem143 [pii] DOI: 10.1093/rheumatology/kem143.
    CrossrefPubMedGoogle Scholar
  • 6 Dixon WG, Kezouh A, Bernatsky S et al. The influence of systemic glucocorticoid therapy upon the risk of non-serious infection in older patients with rheumatoid arthritis: a nested case-control study. Ann Rheum Dis 2011 ard.2010.144741 [pii] DOI: 10.1136/ard.2010.144741.
    PubMedGoogle Scholar
  • 7 Jain A, Witbreuk M, Ball C et al. Influence of steroids and methotrexate on wound complications after elective rheumatoid hand and wrist surgery. J Hand Surg Am 2002; 27: 449-455 S036350230241060X [pii]
    CrossrefPubMedGoogle Scholar
  • 8 Marik PE, Varon J. Requirement of perioperative stress doses of corticosteroids: a systematic review of the literature. Arch Surg 2008; 143: 1222-1226 143/12/1222 [pii] DOI: 10.1001/archsurg.143.12.1222.
    CrossrefPubMedGoogle Scholar
  • 9 Visser K, Katchamart W, Loza E et al. Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with a focus on rheumatoid arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative. Ann Rheum Dis 2009; 68: 1086-1093 ard.2008.094474 [pii] DOI: 10.1136/ard.2008.094474.
    CrossrefPubMedGoogle Scholar
  • 10 Krüger K. Perioperatives Management der medikamentösen Therapie mit Antirheumatika – was ist gesichert?. Akt Rheumatol 2007; 318-322
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Loza E, Martinez-Lopez JA, Carmona L. A systematic review on the optimum management of the use of methotrexate in rheumatoid arthritis patients in the perioperative period to minimize perioperative morbidity and maintain disease control. Clin Exp Rheumatol 2009; 27: 856-862 2807 [pii]
    PubMedGoogle Scholar
  • 12 Heldmann F, Dybowski F, Baraliakos X et al. Perioperativer Umgang mit Biologika bei rheumatoider. Arthritis Z Rheumatol 2011; 70: 14-20 DOI: 10.1007/s00393-010-0680-7.
    PubMedGoogle Scholar
  • 13 den Broeder AA, Creemers MC, Fransen J et al. Risk factors for surgical site infections and other complications in elective surgery in patients with rheumatoid arthritis with special attention for anti-tumor necrosis factor: a large retrospective study. J Rheumatol 2007; 34: 689-695 06/13/116 [pii]
    PubMedGoogle Scholar
  • 14 Finckh A, Dehler S, Gabay C. The effectiveness of leflunomide as a co-therapy of tumour necrosis factor inhibitors in rheumatoid arthritis: a population-based study. Ann Rheum Dis 2009; 68: 33-39 ard.2007.085696 [pii] DOI: 10.1136/ard.2007.085696.
    PubMedGoogle Scholar
  • 15 Grennan DM, Gray J, Loudon J et al. Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopaedic surgery. Ann Rheum Dis 2001; 60: 214-217
    CrossrefPubMedGoogle Scholar
  • 16 Bibbo C, Anderson RB, Davis WH et al. 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 [corrected]. Foot Ankle Int 2003; 24: 40-44
    PubMedGoogle Scholar
  • 17 Escalante A, Beardmore TD. Risk factors for early wound complications after orthopedic surgery for rheumatoid arthritis. J Rheumatol 1995; 22: 1844-1851
    PubMedGoogle Scholar
  • 18 Shamberger RC, Devereux DF, Brennan MF. The effect of chemotherapeutic agents on wound healing. Int Adv Surg Oncol 1981; 4: 15-58
    PubMedGoogle Scholar
  • 19 Galloway JB, Hyrich KL, Mercer LK et al. Anti-TNF therapy is associated with an increased risk of serious infections in patients with rheumatoid arthritis especially in the first 6 months of treatment: updated results from the British Society for Rheumatology Biologics Register with special emphasis on risks in the elderly. Rheumatology (Oxford) 2011; 50: 124-131 keq242 [pii] DOI: 10.1093/rheumatology/keq242.
    CrossrefPubMedGoogle Scholar
  • 20 Listing J, Strangfeld A, Kary S et al. Infections in patients with rheumatoid arthritis treated with biologic agents. Arthritis Rheum 2005; 52: 3403-3412 DOI: 10.1002/art.21386.
    CrossrefPubMedGoogle Scholar
  • 21 Strangfeld A, Listing J, Herzer P et al. Risk of herpes zoster in patients with rheumatoid arthritis treated with anti-TNF-alpha agents. JAMA 2009; 301: 737-744 301/7/737 [pii] DOI: 10.1001/jama.2009.146.
    PubMedGoogle Scholar
  • 22 Askling J, Dixon W. The safety of anti-tumour necrosis factor therapy in rheumatoid arthritis. Curr Opin Rheumatol 2008; 20: 138-144 DOI: 10.1097/BOR.0b013e3282f4b392. 00002281-200803000-00005 [pii]
    CrossrefPubMedGoogle Scholar
  • 23 Hetland ML. DANBIO – powerful research database and electronic patient record. Rheumatology (Oxford) 2011; 50: 69-77 keq309 [pii] DOI: 10.1093/rheumatology/keq309.
    CrossrefPubMedGoogle Scholar
  • 24 Gomez-Reino JJ, Carmona L, Angel Descalzo M. Risk of tuberculosis in patients treated with tumor necrosis factor antagonists due to incomplete prevention of reactivation of latent infection. Arthritis Rheum 2007; 57: 756-761 DOI: 10.1002/art.22768.
    CrossrefPubMedGoogle Scholar
  • 25 Carmona L, Descalzo MA, Ruiz-Montesinos D et al. Safety and retention rate of off-label uses of TNF antagonists in rheumatic conditions: data from the Spanish registry BIOBADASER 2.0. Rheumatology (Oxford). 2011 50. 85-92 keq207 [pii] DOI: 10.1093/rheumatology/keq207
    PubMedGoogle Scholar
  • 26 Kawakami K, Ikari K, Kawamura K et al. Complications and features after joint surgery in rheumatoid arthritis patients treated with tumour necrosis factor-alpha blockers: perioperative interruption of tumour necrosis factor-alpha blockers decreases complications?. Rheumatology (Oxford). 2010 49. 341-347 kep376 [pii] DOI: 10.1093/rheumatology/kep376
    PubMedGoogle Scholar
  • 27 Giles JT, Bartlett SJ, Gelber AC et al. Tumor necrosis factor inhibitor therapy and risk of serious postoperative orthopedic infection in rheumatoid arthritis. Arthritis Rheum 2006; 55: 333-337 DOI: 10.1002/art.21841.
    CrossrefPubMedGoogle Scholar
  • 28 Manger B, Michels H, Nusslein HG et al. Neufassung der Empfehlungen der Kommission Pharmakotherapie der DGRh. Therapie mit Tumornekrosefaktor-hemmenden Wirkstoffen bei entzündlich-rheumatischen Erkrankungen. Z Rheumatol 2007; 66: 72-75 DOI: 10.1007/s00393-006-0132-6.
    CrossrefPubMedGoogle Scholar
  • 29 Alten R., Tocilizumab A. Novel Humanized Anti-Interleukin 6 (Il-6) Receptor Antibody for the Treatment of Patients with Rheumatoid Arthritis. Therapeutic Advances in Musculoskeletal Diseases 2011; in press
    PubMedGoogle Scholar
  • 30 >Fachinformation Deutschland RoActemra® (Tocilizumab). April 2011
    PubMed
  • 31 Smolen JS, Keystone EC, Emery P et al. Consensus statement on the use of rituximab in patients with rheumatoid arthritis. Ann Rheum Dis 2007; 66: 143-150 ard.2006.061002 [pii] DOI: 10.1136/ard.2006.061002.
    CrossrefPubMedGoogle Scholar
  • 32 Fachinformation Deutschland MabThera® (Tocilizumab). November 2010
    PubMed
  • 33 Kaufmann D, Arbogast M. Prä- und postoperatives Management von Patienten unter Rituximab-Therapie. Akt Rheumatol 2010; 35: 386-388
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 Alten R, Gram H, Joosten LA et al. The human anti-IL-1 beta monoclonal antibody ACZ885 is effective in joint inflammation models in mice and in a proof-of-concept study in patients with rheumatoid arthritis. Arthritis Res Ther 2008; 10: R67 ar2438 [pii] DOI: 10.1186/ar2438.
    CrossrefPubMedGoogle Scholar