J Korean Rheum Assoc.  2009 Sep;16(3):175-180.

TNF Inhibitor Use during the Perioperative Period

• Ko HJ
• Park SH

Abstract

Tumor necrosis factor (TNF) inhibitors are now established as therapeutic agents for treating active rheumatoid arthritis (RA) that is resistant to conventional drug treatment. However, TNF Inhibitors decrease resistance to infection, including unusual infections such as tuberculosis, and they have been shown to impair wound healing in an experimental setting. To date, there is limited data on patients with RA regarding their infections or the complications of surgery performed while taking TNF inhibitors and there is no professional consensus about this. This problem emphasizes a need for awareness and communication between patients, the rheumatologist and the surgeon when treating patients with RA. We reviewed the effects of TNF inhibitors on the incidence of surgical site infection (SSI) and the risk factors for SSIs after performing elective surgery in patients with RA. TNF inhibitors should not be used during the perioperative period until conclusive evidence to the contrary is available.

Keyword

TNF inhibitor; Rheumatoid arthritis; Surgery

MeSH Terms

Arthritis, Rheumatoid
Consensus
Humans
Incidence
Perioperative Period
Risk Factors
Tuberculosis
Tumor Necrosis Factor-alpha
Wound Healing
Tumor Necrosis Factor-alpha

Reference

References

1. Choy EH, Panayi GS. Cytokine pathways and joint inflammation in rheumatoid arthritis. N Engl J Med. 2001; 344:907–16.

2. Olsen NJ, Stein CM. New drugs for rheumatoid arthritis. N Engl J Med. 2004; 350:2167–79.

3. Furst DE, Breedveld FC, Kalden JR, Smolen JS, Burmester GR, Dougados M. Updated consensus statement on biological agents for the treatment of rheumatoid arthritis and other immune mediated inflammatory disease. Ann Rheum Dis. 2003; 62(Suppl 2):2–9.

4. Giles JT, Bathon JM. Serious infections associated with anticytokine therapies in the rheumatic diseases. J Intensive Care Med. 2004; 19:320–34.

5. Verstappen SMM, Hoes JN, Jacobs JWG, ter Borg EJ, Bijlsma JWJ. Occurrence and predictors of joint surgery in the Utrecht rheumatoid arthritis cohort [abstract]. Ann Rheum Dis. 2005; 64:216.

6. Da Silva E, Doran MF, Crowson CS, O'Fallon WM, Matteson EL. Declining use of orthopadic surgery in patients with rheumatoid arthritis? Results of a longterm, population-based assessment. Arthritis Rheum. 2003; 49:216–20.

7. Wolfe F, Zwillich SH. The longterm outcomes of rheumatoid arthritis: a 23-year prospective longitudinal study of total joint replacement and its predictors in 1600 patients with rheumatoid arthritis. Arthritis Rheum. 1998; 41:1072–82.

8. Grennan DM, Gray J, Loudon J, Fear S. Methotrexate and early postoperative complications in patients with rheumatoid arthritis undergoing elective orthopedic surgery. Ann Rheum Dis. 2001; 60:214–7.

9. Hamalainen M, Raunio P, Von Essen R. Postoperative wound infection in rheumatoid arthritis surgery. Clin Rheumatol. 1984; 3:329–35.

10. Bongartz T, Halligan CS, Osmon DR, Hanssen AD, Bamlet WR, Matteson EL. Incidence and risk factors for prosthetic joint infections in patients with rheumatoid arthritis following total knee and total hip replacement [abstract]. Arthritis Rheum. 2005; 52(Suppl):1449.

11. Colombel JF, Loftus EV, Tremaine WJ. Perioperative infliximab and/or immunomodulator therapy is not associated with increased postoperative complications in Crohn's disease. Digestive Diseases Week, Orlando, FL; May 18–21, 2003. Abstract no. 102323.

12. Brzezinski A, Armstrong L, DelReal GA. Infliximab dose not increase the risk of complications in the perioperative period in patients with Crohn's disease. Digestive Diseases Week. San Francisco, CA; May 19–22, 2002. Abstract no. 104783.

13. Marchal L, D'Haens G, Van Assche G. Infliximab dose not increase postoperative rates in patients with Crohn's disease. Digestive Diseases Week, Orlando, FL; May 18–21, 2003. Abstract no. 100519.

14. Rosandich PA, Kelly JT III, Conn DL. Perioperative management of patients with rheumatoid arthritis in the era of biologic response modifiers. Curr Opin Rheumatol. 2004; 16:192–8.

15. Bibbo C, Goldberg JW. Infection and healing complications after elective orthopedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy. Foot Ankle Int. 2004; 25:331–5.

16. Wendling D, Balblanc JC, Brousse A, Lohse A, Lehuede G, Garbuio P, et al. Surgery in patients receiving anti-tumour necrosis factor α treatment in rheumatoid arthritis: an observational study on 50 surgical procedures. Ann Rheum Dis. 2005; 64:1378–9.

17. Den Broeder AA, Creemers MCW, Fransen J, De Jong E, De Rooij DRAM, Wymenga ATE, et al. Risk factors for surgical site infections and other complications in elective surgery in patients with rheumatoid arthritis with special attention for antitumor necrosis factor: a large retrospective study. J Rheumatol. 2007; 34:689–95.

18. Giles JT, Bartlett SJ, Gelber AC, Nanda S, Fontaine K, Ruffing V, et al. Tumor necrosis factor inhibitor therapy and risk of serious postoperative orthopedic infection in rheumatoid arthritis. Arthritis Rheum. 2006; 55:333–7.

19. Hultgren O, Eugster HP, Sedgwick JD, Korner H, Tarkowski A. TNF/Lymphotoxin-alpha double-mutant mice resist septic arthritis but display increased mortality in response to Staphylococcus aureus. J Immunol. 1998; 161:5937–42.

20. Phillips K, Husni ME, Karlson EW, Coblyn JS. Experience with etanercept in an academic medical center: are infection rates increased? Arthritis Rheum. 2002; 47:17–21.

21. Ruyssen-Witrand A, Gossec L, Salliot M, Luc M, Duclos M, Guignard S, et al. Complication rates of 127 surgical procedures performed in rheumatic patients receiving tumor necrosis factor alpha blockers. Clin Exp Rheumatol. 2007; 25:430–6.

22. Club rhumatismes et inflammation: Fishes practiques: conduite a tenir chez les patients sous anti-TNF de-vant une chirurgie, avis d'experts. http;//. www.CRI-net.com.

23. Lee YA, Hong SJ, Lee SH, Yang HI. Perioperative medication management in arthritic patients. J Korean Rheum Assoc. 2008; 15:101–9.

24. Saag KG, Teng GG, Patkar NM, Anuntiyo J, Finney C, Curtis JR, et al. American college of rheumatology 2008 recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arhtirtis. Arthritis Rheum. 2008; 59:762–84.