What is the optimal anaesthetic management plan for a patient with Rheumatoid Arthritis (RA) undergoing surgery, considering their disease activity, medication regimen, and potential comorbidities?

Anaesthetic Management in Rheumatoid Arthritis

For RA patients undergoing surgery, continue non-biologic DMARDs (methotrexate, leflunomide, hydroxychloroquine, sulfasalazine) through the perioperative period, withhold biologic agents for one dosing cycle before surgery, maintain current glucocorticoid doses without stress-dosing, and prioritize meticulous airway assessment due to high risk of difficult intubation from cervical spine and temporomandibular joint involvement. 1, 2

Preoperative Medication Management

Non-Biologic DMARDs

• Continue methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, and apremilast at usual doses throughout surgery without interruption 1, 3
• Continuing these medications reduces infection risk (RR 0.39,95% CI 0.17-0.91) and prevents disease flares postoperatively (RR 0.06,95% CI 0.0-1.10) 4
• Exception: Patients with history of severe/recurrent infections or prior prosthetic joint infection may elect to withhold these medications 1

Biologic Agents

• Withhold all biologic agents (TNF inhibitors, IL-6 inhibitors, rituximab, etc.) prior to surgery and schedule the procedure when the next dose would be due 1, 3
• This timing minimizes infection risk while limiting time off medication 3
• The dosing interval varies by medication—plan surgery at the end of each specific biologic's dosing cycle 1

JAK Inhibitors

• Withhold tofacitinib, baricitinib, and upadacitinib for at least 3 days prior to surgery 1, 3

Glucocorticoids

• Continue the patient's current daily glucocorticoid dose through surgery rather than administering supraphysiologic "stress doses" 1, 4
• Optimal preoperative dosing is <20 mg/day prednisone equivalent when possible, as doses >15 mg/day increase infection risk 4

Critical Airway Considerations

Cervical Spine Assessment

• Evaluate for atlantoaxial subluxation and cervical spine instability before any airway manipulation 2, 5
• RA affects the cervical spine in up to 80% of patients with longstanding disease, creating risk of spinal cord injury during intubation 2
• Obtain flexion-extension cervical spine radiographs or CT imaging preoperatively if cervical involvement is suspected 5

Temporomandibular Joint Involvement

• Assess mouth opening and jaw mobility, as TMJ arthritis causes reduced mouth opening and difficult laryngoscopy 2, 6
• Cricoarytenoid joint arthritis can cause vocal cord dysfunction, stridor, and airway obstruction 2, 5

Intubation Planning

• Prepare for difficult intubation with video laryngoscopy or fiberoptic bronchoscopy readily available 2, 5
• Consider awake fiberoptic intubation in patients with severe cervical spine disease or significantly limited mouth opening 5, 7
• Avoid excessive neck manipulation during intubation to prevent neurological injury 7

Systemic Manifestations Requiring Assessment

Cardiovascular System

• Screen for accelerated atherosclerosis and elevated cardiovascular risk, which is comparable to diabetes mellitus in RA patients 5, 8
• Evaluate for pericardial effusion, valvular disease, and conduction abnormalities with ECG and echocardiography if clinically indicated 5
• RA patients have higher perioperative cardiac event rates than the general population 2

Pulmonary System

• Assess for interstitial lung disease, pleural effusions, and restrictive lung disease with pulmonary function tests and chest imaging 5, 8
• Cricoarytenoid arthritis may cause upper airway obstruction requiring postoperative monitoring 2
• Consider arterial blood gas analysis in patients with significant pulmonary involvement 5

Renal Function

• Evaluate renal function as RA patients may have renal impairment from disease, NSAIDs, or DMARD therapy 8
• Adjust anesthetic drug dosing based on creatinine clearance 5

Anesthetic Technique Selection

Regional vs General Anesthesia

• Prefer regional anesthesia when feasible to avoid airway manipulation and reduce perioperative complications 2, 6
• Neuraxial anesthesia may be technically difficult due to spinal deformities, ankylosis, or osteoporosis 6, 7
• Ultrasound guidance improves success rates for regional blocks in patients with anatomical distortion 2

General Anesthesia Considerations

• Use short-acting agents to facilitate rapid emergence and early airway assessment 5
• Avoid succinylcholine in patients with severe muscle wasting or hyperkalemia risk 5
• Position patients carefully to prevent pressure injuries on deformed joints 6, 7

Postoperative Management

Medication Resumption

• Resume all antirheumatic therapy once wound healing is evident, sutures/staples are removed, there is no significant swelling/erythema/drainage, and no ongoing infection—typically around 14 days postoperatively 1, 3
• Use visiting nurse services, photographs, or telemedicine to assess wound healing before restarting biologics 1

Monitoring

• Monitor closely for both surgical site infection and rheumatic disease flare in the postoperative period 9
• RA patients have higher rates of infection, dislocation, and readmission compared to osteoarthritis patients 1, 3

Pain Management

• Use multimodal analgesia to minimize opioid requirements 2
• NSAIDs should be used cautiously given renal and cardiovascular risks in this population 8

Common Pitfalls to Avoid

• Never assume normal cervical spine anatomy—always assess for instability before intubation 2, 5
• Do not administer stress-dose steroids routinely—continue current glucocorticoid dose only 1, 4
• Avoid withholding non-biologic DMARDs perioperatively, as this increases flare risk without reducing infection risk 1, 3
• Do not restart biologic agents before confirming adequate wound healing and absence of infection 1

Multidisciplinary Coordination

• Ensure close communication between orthopedic surgeon, rheumatologist, and anesthesiologist regarding medication timing and disease optimization 3, 7
• Optimize RA disease control before proceeding to elective surgery, as uncontrolled disease activity increases perioperative complications 3, 8