Perioperative strategies for other DMARDs, such as sulfasalazine, azathioprine, or mycophenolate mofetil (MMF), are usually keyed to the drugs’ half lives. For example, sulfasalazine is held one day prior to surgery and resumed three days afterward. Caution also dictates that biologics be held at least one dose cycle prior to surgery (one week for etanercept, two weeks for adalimumab, and six to eight weeks for infliximab), he noted, citing recommendations from the ACR and other major rheumatologic societies.
Dr. Paget concluded with a discussion of bisphosphonate use in the orthopedic surgery setting at HSS, where the drugs are stopped preoperatively before back surgery and sometimes held when treating new fractures. He also cited a study that showed that an annual infusion of zoledronic acid within 90 days of repair of a low-trauma hip fracture was associated with improved survival and a reduction in new fractures.1
Summing up, Dr. Paget proposed that rheumatologists should be the principal caregivers for their patients in the perioperative period, and that musculoskeletal perioperative medicine may be emerging as a unique subsubspecialty in the field of rheumatology.
Exercising Caution
Regarding medications for patients who are pregnant and breastfeeding—or for those who want to conceive—rheumatologists should peruse available data, make phone calls to relevant resources such as teratogen registries, and come to a decision before counseling their patients, advised Dr. Laskin. He noted that he enjoys “the good fortune” of being located next door to Toronto’s Hospital for Sick Children, a renowned teratogen and children’s research center that also sponsors the Motherisk Program (www.motherisk.org).
“When you finally do make that decision, make sure you counsel your patient appropriately,” he emphasized. “And please, do NOT tell your patient, ‘Well, it could be this, or it could be that; the choice is yours.’ Patients are not looking for that from you. You’re the expert; if you cannot come off the fence—and I know it’s hard—find somebody who can.”
Dr. Laskin urged his audience to view the Food and Drug Administration’s (FDA’s) Pregnancy Classification scheme as a series of traffic lights. “It’s not outstanding,” he says of the scheme, “but it’s the best we have.” In this model, Category A is a bright green light (okay to use in pregnant patients); Categories B and C are yellow lights (proceed with caution); Category D is a “stale” yellow light; and Category X is a red light (contraindicated and should not be used).
