目的:风湿病学家和骨科医生经常合作做出艰难的决定,对风湿性疾病患者进行围手术期免疫抑制治疗,平衡术后感染的风险与疾病发作的风险。当前的循证指南特别涉及关节成形术,因此,我们试图了解关节镜下使用免疫抑制的趋势和常见做法.
方法:风湿病学家和运动医学外科医生,来自纽约的各种医院,服务于广泛的人口统计数据,对接受关节镜手术的风湿性疾病患者的免疫抑制药物管理进行了调查。对于使用风险较低的半月板切除术和风险较高的前交叉韧带(ACL)重建和同种异体移植物的常见抗风湿药物,引起了医生的偏爱。医生被特别询问了关节镜下常规合成抗风湿药物(csDMARDs)的使用情况。生物制剂,和Janus激酶(JAK)抑制剂。
结果:在调查期间,25位风湿病学家和19位接受过运动医学研究金培训的骨科医生完成了问卷。对于低风险的关节镜检查,风湿病学家赞成继续进行各种csDMARDs(72%至100%),生物制剂(50%至64%)和JAK抑制剂(57%),而大多数外科医生同意所有三种药物(csDMARDs63%;生物制剂53%;JAK抑制剂58%)。对于高风险的关节镜,大多数风湿病学家倾向于患者继续使用csDMARDs(63%~100%),但较少患者支持使用生物制剂(28%~39%)或JAK抑制剂(22%).在这些高风险手术中,外科医生更不愿认可任何类型的免疫抑制抗风湿药物(22%至27%)。风湿病学家最关心的是在最后一剂利妥昔单抗后过早进行手术,建议在最后一次输注后7.7±8.8周内不进行这些高风险手术.
结论:对于低风险关节镜检查,大多数风湿病学家,但只有大约一半的整形外科医生更喜欢继续csDMARDs的患者。两组中大约有一半的患者首选持有生物制剂和JAK抑制剂。在涉及更多的关节镜检查中,大多数风湿病学家,但很少有骨科医生支持继续使用csDMARDs,共识是在可能的情况下保留所有其他免疫抑制。虽然围手术期的药物治疗在某种程度上反映了目前的关节成形术指南,有必要制定循证指南,特别是关于风湿性疾病患者关节镜下免疫抑制的指南.
OBJECTIVE: Rheumatologists and orthopedic surgeons frequently collaborate on difficult decisions regarding perioperative management of immunosuppression in rheumatic disease patients, balancing risk of postoperative infection with risk of disease flares. Current evidence-based guidelines pertain specifically to arthroplasty, thus we sought to understand the trends and common practices regarding peri-arthroscopic use of immunosuppression.
METHODS: Rheumatologists and sports medicine surgeons, from a variety of New York hospitals and serving a broad range of demographics, were surveyed on immunosuppressive medication management in rheumatic disease patients undergoing arthroscopic surgeries. Physicians\' preferences were elicited regarding the use of common anti-rheumatic medications with the lower risk meniscectomies and the higher risk anterior cruciate ligament (ACL) reconstructions and allografts. Physicians were asked specifically about peri-arthroscopic use of conventional synthetic diseasemodifying antirheumatic drugs (csDMARDs), biologics, and Janus kinase (JAK) inhibitors.
RESULTS: During the survey period, 25 rheumatologists and 19 sports medicine fellowship-trained orthopedic surgeons completed the questionnaire. For lower-risk arthroscopies, rheumatologists favored continuing various csDMARDs (72% to 100%), biologics (50% to 64%) and JAK inhibitors (57%), while a majority of surgeons concurred for all three drug classes (csDMARDs 63%; biologics 53%; and JAK inhibitors 58%). For higher-risk arthroscopies, most rheumatologists preferred that patients continue csDMARDs (63% to 100%) but fewer supported the use of biologics (28% to 39%) or JAK inhibitors (22%). Surgeons were more hesitant to endorse any class of immunosuppressive antirheumatic medications (22% to 27%) around these higher risk surgeries. The rheumatologists were most concerned about surgeries taking place too soon after the last dose of rituximab, recommending these higher risk surgeries not take place for 7.7 ± 8.8 weeks following the last infusion.
CONCLUSIONS: For lower-risk arthroscopies, most rheumatologists but only about half of orthopedic surgeons preferred patients continuing csDMARDs. Approximately half of both groups preferred patients hold biologics and JAK inhibitors. In more involved arthroscopies, most rheumatologists but few orthopedists supported the continued use of csDMARDs, and the consensus was to hold all other immunosuppression when possible. While the duration medications were held perioperatively were somewhat reflective of the current guidelines for arthroplasty, there is a need for evidencebased guidelines specifically regarding peri-arthroscopy immunosuppression in rheumatic disease patients.