Zusammenfassung
Hintergrund
Vor operativen Eingriffen stellt sich Ärzten und Patienten mit entzündlich rheumatischen Erkrankungen weiterhin die Frage nach einer Unterbrechung oder Fortsetzung der entzündungshemmenden Medikation. Die Deutsche Gesellschaft für Rheumatologie hat hierfür ihre Empfehlungen von 2014 aktualisiert.
Methoden
Nach einer systematischen Literaturrecherche mit Einschluss von Publikationen bis zum 31.08.2021 wurden die Empfehlungen zum Umgang mit Glukokortikoiden, konventionell synthetischen „disease-modifying antirheumatic drugs“ (csDMARDs) und Biologika (bDMARDs) überarbeitet und Empfehlungen zu neueren Substanzen und „targeted synthetic (ts) DMARDs“ ergänzt.
Ergebnisse
Die Glukokortikoiddosis sollte 2 bis 3 Monate vor elektiven Eingriffen so niedrig wie möglich reduziert (in jedem Fall <10 mg/Tag), 1 bis 2 Wochen vor und am Operationstag jedoch stabil gehalten werden. csDMARDs können in vielen Fällen fortgeführt werden, Ausnahmen sind eine Reduktion hoher Methotrexat-Dosierungen auf ≤15 mg/Woche und Auswaschen des Leflunomid bei hohem Infektionsrisiko. Azathioprin, Mycophenolat und Ciclosporin sollten 1 bis 2 Tage vor der Operation pausiert werden. Unter bDMARDs können Operationen zum Ende des jeweiligen Therapieintervalls geplant werden. Januskinase(JAK)-Inhibitoren sollten bei größeren Eingriffen für 3 bis 4 Tage pausiert werden. Apremilast kann fortgeführt werden. Bei notwendiger Unterbrechung gilt für alle Substanzen, die Therapie in Abhängigkeit der Wundheilung baldmöglichst wieder zu beginnen.
Schlussfolgerungen
Ob bDMARDs das Infektionsrisiko perioperativ erhöhen und welche Rolle die Absetzzeit dabei spielt, bleibt bei gegenwärtiger Evidenz noch unklar. Um das Risiko eines Krankheitsschubs unter längerer Therapiepause zu minimieren, wurde in den aktualisierten Empfehlungen die perioperative Pausierung von bDMARDs von mindestens 2 Halbwertszeiten auf ein Therapieintervall reduziert.
Abstract
Background
Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014.
Methods
After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added.
Results
The glucocorticoid dose should be reduced to as low as possible 2–3 months before elective surgery (in any case <10 mg/day) but should be kept stable 1–2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1–2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3–4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing.
Conclusion
Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.
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K. Albrecht, D. Poddubnyy, J. Leipe, P. Sewerin, C. Iking-Konert, R. Scholz und K. Krüger geben an, dass kein Interessenkonflikt besteht.
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Alle Autoren schreiben für die Kommission Pharmakotherapie der Deutschen Gesellschaft für Rheumatologie e. V. (DGRh) und den Vorstand der DGRh.
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Albrecht, K., Poddubnyy, D., Leipe, J. et al. Perioperativer Umgang mit der Therapie von Patienten mit entzündlich rheumatischen Erkrankungen. Z Rheumatol 81, 212–224 (2022). https://doi.org/10.1007/s00393-021-01140-x
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DOI: https://doi.org/10.1007/s00393-021-01140-x