Stop TNF Inhibitors, Reduce Postoperative Infections?
Stop TNF Inhibitors, Reduce Postoperative Infections?
Many practitioners are already having their patients with IRDs stop anti-TNF therapy 1 administration cycle before orthopedic surgery, and Scherrer and colleagues' findings support that practice. Certainly, we need to know more about the perioperative management of patients with IRDs who are on immunosuppressive therapy. However, given the relatively low overall rates of operative-associated infections, it would be very difficult to study the issue in an adequately powered randomized controlled trial, and therefore results from this type of retrospective study may be the best that we will get in this area.
Other issues of importance that Scherrer and colleagues did not address include how to manage specific DMARDs and other biologic agents. Furthermore, if immunosuppression is stopped before surgery, the optimal time to restart immunosuppression postoperatively is not clear. Many practitioners have patients restart their DMARDs once the surgical site appears to be healing well, but is that the optimal strategy?
The ideal management of steroid therapy is not well understood either. Do all patients require a short-term increase in their steroid dose to avoid complications of adrenal insufficiency? If increased steroids are needed, what is the optimal steroid dosing, and how may that affect surgical complications?
Moreover, the impact of preoperative cessation of immunosuppression on postoperative rehabilitation is unknown. In particular, do postoperative flares of underlying disease increase if immunomodulatory therapy is stopped before surgery? Although it might be possible to study rates of postoperative disease flares in a controlled trial, other issues are less easily studied in a controlled fashion, and we must rely on retrospective studies to inform practice.
Abstract
Viewpoint
Many practitioners are already having their patients with IRDs stop anti-TNF therapy 1 administration cycle before orthopedic surgery, and Scherrer and colleagues' findings support that practice. Certainly, we need to know more about the perioperative management of patients with IRDs who are on immunosuppressive therapy. However, given the relatively low overall rates of operative-associated infections, it would be very difficult to study the issue in an adequately powered randomized controlled trial, and therefore results from this type of retrospective study may be the best that we will get in this area.
Other issues of importance that Scherrer and colleagues did not address include how to manage specific DMARDs and other biologic agents. Furthermore, if immunosuppression is stopped before surgery, the optimal time to restart immunosuppression postoperatively is not clear. Many practitioners have patients restart their DMARDs once the surgical site appears to be healing well, but is that the optimal strategy?
The ideal management of steroid therapy is not well understood either. Do all patients require a short-term increase in their steroid dose to avoid complications of adrenal insufficiency? If increased steroids are needed, what is the optimal steroid dosing, and how may that affect surgical complications?
Moreover, the impact of preoperative cessation of immunosuppression on postoperative rehabilitation is unknown. In particular, do postoperative flares of underlying disease increase if immunomodulatory therapy is stopped before surgery? Although it might be possible to study rates of postoperative disease flares in a controlled trial, other issues are less easily studied in a controlled fashion, and we must rely on retrospective studies to inform practice.
Abstract
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