Krüger K
Rheumatologisches Praxiszentrum, St. Bonifatius Str. 5, 81541, München, Deutschland.
Z Rheumatol. 2017 Nov;76(9):767-775. doi: 10.1007/s00393-017-0379-0.
The perioperative management of patients on immunosuppressive drugs is uncertain due to a lack of controlled studies. Continuation of medication without a pause may increase the risk of postoperative infections and wound healing disorders and when the pause is too long this can induce a flare of the underlying rheumatic disease. Additional factors, such as rheumatic disease activity, comorbidities, previous infections and the type of surgical procedure also modulate the risk. The highest risk of infection is associated with corticosteroids depending on the dose, so that a dosage as low as possible but stable in the perioperative period is recommended. Among the conventional disease-modifying antirheumatic drugs (DMARDs) only methotrexate has been sufficiently investigated and in this case a pause in treatment induces higher risks than continuation. Antimalarial agents and sulphasalazine should be continued due to the low risks, whereas leflunomide should be washed out before major surgical interventions. The perioperative risk of treatment with biologics is still far from clear; therefore, as a rule of thumb, withholding treatment for two serum half-lives before an intervention and restarting after completed wound healing are recommended.
由于缺乏对照研究，使用免疫抑制药物患者的围手术期管理尚不确定。不停药持续用药可能会增加术后感染和伤口愈合障碍的风险，而停药时间过长则可能引发潜在风湿性疾病的发作。其他因素，如风湿性疾病活动度、合并症、既往感染及手术类型等也会影响风险。感染风险最高与皮质类固醇有关，具体取决于剂量，因此建议围手术期尽可能使用低剂量且稳定的剂量。在传统的改善病情抗风湿药物（DMARDs）中，只有甲氨蝶呤得到了充分研究，在这种情况下，停药引发的风险高于继续用药。抗疟药和柳氮磺胺吡啶因风险较低应继续使用，而来氟米特在进行重大手术干预前应进行洗脱。生物制剂治疗的围手术期风险仍远未明确；因此，根据经验法则，建议在干预前停药两个血清半衰期，并在伤口完全愈合后重新开始用药。
