Rheumatism patients with immunosuppressive drugs undergo surgery, preoperative medication management recommendations at a glance!

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The increasing complexity of patients undergoing surgery makes perioperative medication management challenging
.

In August 2022, the Society for Perioperative Assessment and Quality Improvement (SPAQI) published a consensus statement
on the preoperative management of drugs for rheumatology and AIDS treatment.

1.

Preoperative advice: Continue to use before surgery, including on the day of surgery

Other considerations: the drug can affect multiple organ systems (eg, heart, kidneys, lungs, liver, hematologic system); Fluctuations in renal function may produce toxic reactions

Adjunctive tests: complete blood count (CBC), creatinine, and liver function tests (LFTs)

2.

Preoperative advice: Continue to use before surgery, including on the day of surgery

Other considerations: may reduce the white blood cell count

Auxiliary tests: CBC

3.

Preoperative advice: Continue to use before surgery, including on the day of surgery

Other considerations: can lead to prolongation of the QT interval, hypoglycemia, pancytopenia

Auxiliary tests: CBC, electrocardiogram (ECG)

4.

Preoperative advice: discontinue 4 weeks before surgery

Other considerations: may lead to increased risk of infection, bone marrow suppression, cardiac and bladder toxic effects, syndrome of improper secretion of antidiuretic hormone (SIADH)

Auxiliary tests: CBC, electrolytes, urinalysis

5.

Preoperative advice: Continue to use before surgery, including on the day of surgery

Other considerations: associated with hyperglycemia and an increased risk of infection; Long-term use is associated with increased postoperative complications (including infection), therefore, preoperative should be reduced to the lowest dose as possible

Ancillary test: rapid blood glucose test

6.
Apost

Preoperative advice: Continue to use before surgery, including on the day of surgery

Other considerations: can cause headache, dizziness, diarrhea, nausea/vomiting

7.
Sulfasalazine

Preoperative advice: Continue to use before surgery, including on the day of surgery

Other considerations: in combination with NSAIDs increases the risk of bleeding

Adjunctive tests: CBC, LFTs, creatinine

8.
Leflunomide

Preoperative advice: Continue to use before surgery, including on the day of surgery

Other considerations: can cause respiratory infections, headaches, rashes and liver enzyme abnormalities; There is an interaction with several oral hypoglycemic drugs, which increases the risk of hypoglycemia

Auxiliary tests: CBC, LFTs,

9.
Mycophenolate mofetil

Preoperative recommendations:

➤ Severe systemic lupus erythematosus (SLE) – continued preoperatively, including on the day of surgery

➤ Non-severe SLE – discontinued 7 days before surgery

Other considerations: toxic effects may occur if renal function declines postoperatively

Adjunctive tests: CBC, electrolytes, and creatinine

10.
Azoprine

Preoperative recommendations:

➤ Severe SLE — Continue to use before surgery, including on the day of surgery

➤ Non-severe SLE – discontinued 7 days before surgery

Other considerations: 3-5 days after surgery, as long as there are no wound healing or infection problems at the surgical site or other sites, you can start using again

Adjunctive tests: CBC, LFTs, and creatinine

11.
Cyclosporine

Preoperative recommendations:

➤ Severe SLE — Continue to use before surgery, including on the day of surgery

➤ Non-severe SLE – discontinued 7 days before surgery

Other considerations: neurotoxic effects (paresthesias, delirium, seizures) and nephrotoxic effects; Multiple drug-drug interactions with inhibition/induction of CYP34A drugs, many of which are used in the perioperative period, requiring close monitoring of cyclosporine levels; 3-5 days after surgery, as long as there are no wound healing or infection problems at the surgical site or other areas, you can start using again

Auxiliary tests: CBC, electrolytes, magnesium, glucose levels and creatinine

12.
Tacrolimus

Preoperative recommendations:

➤ Severe SLE — Continue to use before surgery, including on the day of surgery

➤ Non-severe SLE – discontinued 7 days before surgery

Other considerations: can lead to nephrotoxic and neurotoxic effects, prolongation of the QT interval, new diabetes mellitus, as well as pure red blood cell aplasia; The presence of multiple drug-drug interactions with inhibition/induction of CYP34A drugs, many of which are used in the perioperative period, requires close monitoring of tacrolimus levels; 3-5 days after surgery, as long as there are no wound healing or infection problems at the surgical site or other areas, you can start using again

Auxiliary tests: ECG, CBC, electrolytes, magnesium, glucose levels and creatinine

13.
Voclosporin

Preoperative advice: continue to apply according to the treatment cycle, and arrange surgery at the end of the treatment cycle

Other considerations: can lead to nephrotoxic and neurotoxic effects, prolongation of the QT interval, hypertension; There are multiple drug-drug interactions with inhibition/induction of CYP34A drugs

Auxiliary tests: ECG, CBC, electrolytes, magnesium and creatinine

Oprea AD, Keshock MC, et al.
Preoperative Management of Medications for Psychiatric Diseases: Society for Perioperative Assessment and Quality Improvement Consensus Statement.
Mayo Clin Proc.
2022 Feb; 97(2):397-416.
doi: 10.
1016/j.
mayocp.
2021.
11.
011.
PMID: 35120702.