title: 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.
abstract: OBJECTIVE
  To examine the use of metho-trexate (MTX) in rheumatoid arthritis (RA) patients during the perioperative period.
  
  
  METHODS
  Systematic review of studies retrieved by a sensitive search strategy in Medline (1961-July 2007), Embase (1961-July 2007), Cochrane Library (up to July 2007), and from the abstracts of the ACR (2005, 2006) and EULAR (2005-2007) annual scientific meetings.
  
  
  METHODS
  (population) studies had to include patients with RA undergoing surgery; (intervention and control) studies had to test continuing MTX versus stopping MTX; and (outcomes), studies had to report complications within a year after the surgery including infections, wound morbidity, surgery complications, and RA flares. Only randomized controlled trials (RCT) or high quality cohort studies with a control group were included.
  
  
  RESULTS
  Patients from the four included studies were mostly women with mean ages around 60. All of them underwent elective orthopaedic surgery and were taking MTX doses mainly from 5 mg/week to 10 mg/week. By order of level of evidence, we found two RCTs, in which continuing on MTX was not associated with increasing risk of surgery complications, but it was statistically associated with less RA flares. In a prospective cohort study, four infections were observed in the MTX group while none were observed in the control group. No disease flare was reported in any group. A retrospective study showed that patients on MTX reported fewer cases of wound morbitity (p=0.038), RA flares (p=0.050), and no differences related to infections compared to those who stopped MTX.
  
  
  CONCLUSIONS
  Continuing with low doses of MTX seems to be a safe option during the perioperative period in RA patients without relevant comorbidities and/or risk factors of infections, undergoing elective orthopaedic surgery, while maintaining disease control.
authors.affiliation: Hospital Clinico San Carlos, Madrid, Spain. eloza.hcsc@salud.madrid.org
authors.forename: E
authors.initials: E
authors.lastname: Loza
authors.forename: J A
authors.initials: JA
authors.lastname: Martinez-Lopez
authors.forename: L
authors.initials: L
authors.lastname: Carmona
mesh_terms: D018501:Antirheumatic Agents / Q000008:administration & dosage*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000601:surgery; D000075202:Contraindications; D004334:Drug Administration Schedule; D005260:Female; D006801:Humans; D008297:Male; D008727:Methotrexate / Q000008:administration & dosage*; D008875:Middle Aged; D019637:Orthopedic Procedures; D019990:Perioperative Care
chemical_list: D018501:Antirheumatic Agents; D008727:Methotrexate