Susan Goodman, MD: Pre and Perioperative Care for Patients with Rheumatic Disease

In an interview with HCPLive Rheumatology, Susan Goodman, MD, a rheumatologist at the Hospital for Special Surgery in New York, discusses her Congress of Clinical Rheumatology West presentation, “Pre and Perioperative Management of Patients with Rheumatic Disease.” She expands on the impact rheumatic disease has on perioperative care, the challenges for healthcare providers for managing this patient population, and the advancements in rheumatology as it relates to surgical care.

Susan Goodman, MD

Credit: Hospital for Special Surgery

How does a diagnosis of a rheumatic disease impact surgical and perioperative care?

It's essential to consider the patient's systemic disease when approaching surgery because of the widespread use of immune-suppressing medications like disease-modifying antirheumatic drugs (DMARDs) and biologics. Additionally, patients with rheumatic diseases may have specific comorbidities that need attention, making perioperative management crucial.

Are there particular factors that rheumatologists should keep in mind during preoperative assessments?

Certainly, one significant area of concern is modifiable risk factors. Infection risk, both at the surgical site and elsewhere, is a primary concern for patients with rheumatic diseases. One of the most modifiable risk factors is medication use. Approximately 70% of patients having surgery are on DMARDs, and another 10-20% are on glucocorticoids, both of which come with specific management requirements. It's crucial to understand that the use of DMARDs and biologics can increase the risk of infection, making their management a top priority.

In your opinion, what are the challenges or considerations for healthcare providers when managing patients with rheumatic diseases in perioperative care?

Managing patients with rheumatic diseases undergoing arthroplasty differs significantly from those with osteoarthritis. Although both groups may have polyarticular diseases, rheumatic disease patients have systemic conditions. Surgeons and anesthesiologists should be experienced in dealing with these patients. For instance, patients with rheumatoid arthritis (RA) on biologics have a higher likelihood of being colonized by staphylococcusaureus, a common bacterium causing prosthetic joint infections. Additionally, active disease and disease severity are associated with an increased infection risk. Many RA patients undergoing arthroplasty have active, longstanding disease, which is less likely to be modifiable.

Are there specific surgical procedures or types of surgeries that may pose higher risks or require specialized approaches for patients with rheumatic disease?

That’s an interesting question. While the procedures themselves may not differ significantly, studies have shown that the surgeon's experience with RA is a critical factor in reducing complications. Surgeons experienced in treating RA patients are more likely to achieve better outcomes, possibly due to their familiarity with issues such as tissue laxity, medication use, and deformities. That's one consideration that patients should bear in mind.

Are there any emerging trends or advances in the field of Rheumatology that are influencing how rheumatologists approach pre and perioperative care?

An interesting trend is the decrease in small joint procedures and soft tissue procedures, likely due to the effectiveness of current medications in treating these issues. However, larger joint and spine surgeries have not seen significant changes over time. The reasons behind this trend remain unclear.

Is there anything else you'd like our audience to know before we conclude?

I'd like to highlight the importance of medication management, as it presents a modifiable risk factor that can significantly impact perioperative care. A guideline developed in collaboration with the American College of Rheumatology and the American Association of Hip and Knee Surgeons provides valuable recommendations for managing these medications during surgery. It's a useful tool for ensuring the best possible outcomes for patients undergoing surgery while managing their rheumatic diseases.

This transcript was edited for clarity.