Perioperative management of immunosuppression

Many rheumatologists are concerned about the complications of maintaining immunosuppression at the time of elective surgery. Complications may be increased risk of infection, or a slow healing of the surgical wound. On the other hand, stopping medication may place the patient at undesirable levels of disease activity. Many rheumatologists actually act on art, stopping the drug perioperatively depending on blood count, drug type and dose, previous postoperative complications, type of surgery, and other factors. The timing of stopping treatment preoperatively and restarting after surgery also significantly differ among rheumatologists. All in all, there is a great variability in clinical practice related to the perioperative use of immunosuppressants. This chapter reviews the evidence on methotrexate, glucocorticoids, and biological therapies related to the perioperative period, and it proposes some recommendations on the management of immunosuppressant drugs in rheumatic diseases. Factors that may be related to complications will also be reviewed.