Background/Purpose: The use of disease-modifying anti-rheumatic drugs (DMARDs) in the treatment of autoimmune rheumatic diseases, including rheumatoid arthritis (RA), has significantly improved disease and functional outcomes. However, large joint replacements remain relatively common in this population (Nikiphorou et al 2014) and concerns remain regarding the optimal method for balancing the risks and benefits of the use of DMARDs in the perioperative period. The aim of this review is to compare existing clinical practice guideline recommendations for the perioperative management of DMARDs in patients with rheumatic diseases.

Methods: A scoping review was performed. We searched Medline and EMBASE and performed a hand search of references to identify guidelines published since 2014 by national or international academic societies in rheumatology that addressed perioperative management of DMARDs in any of adult RA, Ankylosing Spondylitis (AS), Psoriatic Arthritis (PsA), juvenile idiopathic arthritis (JIA) or systemic lupus erythematosus (SLE). Target drugs were csDMARDs (methotrexate, sulfasalazine, leflunomide, hydroxychloroquine, minocycline), bDMARDs (adalimumab, etanercept, infliximab, golimumab, certolizumab, abatacept, tocilizumab, rituximab, sarilumab, anakinra), tsDMARDs (tofacitinib, baricitinib, upadacitinib, filgotinib). In the case of multiple versions of the same guideline, only the most recent guideline was included. Data extraction was performed in duplicate by two authors.

Results: We included 12 guidelines (5 European, 1 North American, 1 South American, 5 Asia-Pacific; publication year range 2014-2024). 2 (17%) were a standalone guideline for the use of DMARDs in the perioperative period; the remaining 10 (83%) incorporated a recommendation within a broader guideline. RA was the sole rheumatic condition covered in 7 (58%) guidelines. Recommendations for csDMARDs were included in 8 (67%), bDMARDs in 8 (67%) and tsDMARDs in 5 (42%). Overall, low to moderate quality evidence supported these recommendations and most were based on evidence from studies of participants undergoing elective orthopaedic surgery. Guidelines varied in development process, format, the choice of evidence system, level of evidence, and strength of recommendation. Similar themes for recommendations for bDMARDs and tsDMARDs were observed, however variations in the recommendations for csDMARDs were noted between guidelines.  

Conclusion: Although guidelines for the use of DMARDs in the perioperative period are widely available, the development process and the presentation of recommendations varies between guidelines. There is a lack of high quality evidence to support recommendations for non-elective, non-orthopaedic surgery cases. Variations in recommendations were more common for csDMARDs compared to b/tsDMARDs, potentially leading to more practice variation in csDMARD use in the perioperative period.  

Nikiphorou E, Carpenter L, Morris S, et al. Hand and Foot Surgery Rates in Rheumatoid Arthritis Have Declined From 1986 to 2011, but Large‐Joint Replacement Rates Remain Unchanged: Results From Two UK Inception Cohorts. Arthritis & Rheumatology. 2014 May;66(5):1081–9.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/recommendations-for-the-perioperative-use-of-dmards-in-rheumatic-diseases-a-scoping-review/