Elective surgery in rheumatic disease and immunosuppression: to pause or not.

A need for evidence-based approach Whether or not to stop immunosuppressive therapy in the perioperative setting is a challenge for any clinician. Exacerbation of the inflammatory process would normally require increased immunosuppression; however, in this situation, it may lead to wound infection, with local or sys-temic sepsis, and potentially even lethal consequences. Unfortunately, no data are available from randomized, double-blind, controlled clinical trials about the management of immunosuppressive therapy in the perioperative setting, making evidence-based recommendations difficult to say the least. Very limited evidence exists to determine whether the risk of infectious complications under immunosuppressive therapy differs according to the type and localization of surgery. Moreover, use of immunosuppressive co-medication such as dose of glu-cocorticoid is not adequately addressed in most studies, making their interpretation even more difficult. Decisions, therefore, must be made on an individual basis. In chronic inflammatory diseases, drugs of many types, from small molecules to biologics, with varying levels of potency and affecting the immune system at many different levels, are used. Susceptibility to infection may be determined by the specific immune mechanism targeted, as individual immune mechanisms may be important in defence against different pathogens. For instance, T-cell depleting therapies are associated with increased rates of viral and fungal infections [1]. The extent of immuno-suppression also depends on the dosage given [2]. Furthermore, combining drugs and inhibiting multiple immune mechanisms simultaneously has the potential to achieve yet greater immunosuppression—as shown by unacceptably high rates of infection and neutropenia, when combination therapy with an IL-1 receptor antagonist and a TNFi is used in patients with RA [3]. However, these pharmacological and pharmacodynamic considerations must be balanced by the often forgotten observation that chronic inflammatory processes in their own right seem to reduce defence against infection. Individuals with chronic arthritis seem to have a higher risk of infectious arthritis [4]. This increased risk may depend on the severity [4] of the underlying disease and is estimated to be up to 10-fold greater than those without [5]. When considering immunosuppressive therapy in surgery, one must also consider the effects that drugs, such as glucocorticoids, may have on wound healing. These drugs, frequently used perioperatively, mediate strong inhibitory effects on cell proliferation that, in turn, may compromise wound healing [6, 7] and increase the risk of infection. While the risk of wound infection and compromised wound healing during immunosuppressive therapy is increased, the likelihood of exacerbating underlying inflammatory disease …