Use of biologic DMARDs (bDMARDs) in the perioperative period for elective procedures
It is generally recommended to plan for surgery at the end of the dosing cycle for each specific bDMARD. The bDMARD should be restarted once there are signs of good wound healing, no signs of infection, and sutures/staples have been removed; this is typically approximately 14 days after surgery.
High-Risk Populations with Prosthetic Joints that may Require Antibiotic Prophylaxis Prior to Dental Procedures
|Severe immunocompromised states (e.g., AIDS, cancer patients with febrile neutropenia, rheumatoid arthritis patients on biologic DMARDs or prednisone >10 mg daily) a|
|Known diabetes, especially if poorly controlled|
|History of prosthetic joint infection requiring an operation|
|Arthroplasty within the last year|
|Dental procedures with manipulation of gingival tissue, the periapical region of teeth, or perforation of oral mucosa b|
DMARD, Disease-modifying antirheumatic drug.
a The American Academy of Orthopedic Surgeons and the American Dental Association guideline considers methotrexate and hydroxychloroquine as non-immunocompromising agents and makes no specific mention of other nonbiologic DMARDs.
b Of importance, less invasive procedures (routine dental cleaning, etc.) do not mandate antibiotic prophylaxis regardless of other patient-specific risk factors.
Regarding rituximab, one should be aware of potential hypogammaglobulinemia in those patients who have received repeated cycles of rituximab. Although specific guidelines are not available, one could consider replacing immunoglobulin (Ig) G if levels are low (typically <500 mg/dL).