title: Perioperative management of patients with rheumatoid arthritis in the era of biologic response modifiers.
abstract: OBJECTIVE
  This article provides guidelines for the perioperative management of the most commonly used antirheumatic drugs being used to treat patients with rheumatoid arthritis, with an emphasis on the relatively new addition of biologic response modifiers.
  
  
  RESULTS
  Few clinical data exist examining the perioperative management of the biologic drugs, which include the inhibitors of tumor necrosis factor-alpha (etanercept, infliximab, and adalimumab), the interleukin-1 receptor antagonist anakinra, and to a much lesser extent the CD20 inhibitor rituximab. The only human data available in that regard is based on the use of the tumor necrosis factor-alpha inhibitor infliximab in surgical patients with Crohn disease. Although quite limited, that data appeared favorable in finding that infliximab did not result in an increased risk of postoperative complications in that setting.
  
  
  CONCLUSIONS
  Perioperative guidelines have never been well established for a majority of the traditional antirheumatic drugs in use today. Recommendations for the perioperative use of nonsteroidal antiinflammatory drugs and glucocorticoids have the most evidence-based support. Data for the use of methotrexate are also available from which to generate reasonable guidelines; however, for the remaining antirheumatic drugs in current use, the available data cannot support any clear evidence-based recommendations. To provide reasonable guidelines for the use of the biologics, perhaps the best we can do is to extrapolate from the very limited data coming from the concurrent use of infliximab in patients with Crohn disease who have undergone surgery. Beyond that, we are left with animal and tissue culture data from which any recommendations would be rather tenuous.
authors.affiliation: Division of Rheumatology, Department of Medicine, Emory University School of Medicine, 49 Butler Street SE, Atlanta, GA 30303, USA.
authors.forename: Peter A
authors.initials: PA
authors.lastname: Rosandich
authors.forename: Joe T
authors.initials: JT
authors.lastname: Kelley
authors.forename: Doyt L
authors.initials: DL
authors.lastname: Conn
mesh_terms: D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D006801:Humans; D007155:Immunologic Factors / Q000627:therapeutic use*; D019990:Perioperative Care; D013514:Surgical Procedures, Operative
chemical_list: D018501:Antirheumatic Agents; D007155:Immunologic Factors