Anesthesia Management in Rheumatoid Arthritis Patients
Continue nonbiologic DMARDs (methotrexate, leflunomide, hydroxychloroquine, sulfasalazine) through surgery, withhold all biologic agents until one dosing cycle before surgery, and maintain current glucocorticoid doses without stress-dosing. 1
Preoperative Airway Assessment
Cervical spine involvement is the most critical anesthetic concern in RA patients. 2, 3
- Evaluate for atlantoaxial subluxation (C1-C2 instability) which occurs in up to 30% of RA patients and can cause spinal cord compression during intubation. 2, 3
- Assess for temporomandibular joint involvement causing limited mouth opening (normal >3 fingerbreadths or 4-5 cm). 2, 3
- Examine cricoarytenoid joint arthritis which manifests as hoarseness, stridor, or dyspnea and can cause difficult intubation or complete airway obstruction. 2, 3
- Document Mallampati score and thyromental distance as these predict difficult intubation risk. 3
- Prepare for fiber-optic intubation in patients with cervical spine instability, severe temporomandibular limitation, or cricoarytenoid involvement. 4
Common pitfall: Cervical spine radiographs are frequently incomplete or not obtained; however, radiographic findings often do not change airway management decisions, which are primarily driven by clinical airway examination findings. 4
Perioperative Medication Management
Nonbiologic DMARDs
Continue methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine at current doses throughout the perioperative period. 1, 5
- Continuing these medications reduces infection risk (RR 0.39,95% CI 0.17-0.91) compared to withholding them. 1, 5
- Continuing DMARDs prevents disease flares (RR 0.06,95% CI 0.0-1.10) postoperatively. 1, 6
Biologic Agents
Withhold all biologic agents (TNF inhibitors, IL-6 inhibitors, B-cell depleting agents, T-cell costimulation inhibitors) prior to surgery and schedule the procedure at the end of the dosing cycle. 1
- Timing examples: For adalimumab (every 2 weeks), schedule surgery 2 weeks after last dose; for infliximab (every 8 weeks), schedule surgery 8 weeks after last dose. 1
- Rationale: Biologic agents increase serious infection risk (most odds ratios ≥1.5, range 0.61-8.87) in non-surgical populations. 1
- Resume biologics only after wound healing is confirmed (minimum 14 days postoperatively) and absence of both surgical site and systemic infection. 1, 5, 6
JAK Inhibitors
Withhold tofacitinib, baricitinib, and upadacitinib for at least 3 days prior to surgery. 5
Glucocorticoids
Continue the patient's current daily glucocorticoid dose through surgery; do not use supraphysiologic "stress doses." 1, 5, 6
- Optimal preoperative dosing is <20 mg/day prednisone equivalent when disease control permits. 1, 7
- Doses >15 mg/day increase infection risk following total joint arthroplasty. 1
- Stress-dosing protocols increase complication risk without demonstrated benefit. 6
Systemic Manifestations Requiring Evaluation
Cardiovascular System
RA patients have elevated cardiovascular risk comparable to diabetes mellitus. 2, 8
- Screen for coronary artery disease, heart failure, and valvular disease (particularly aortic regurgitation from aortitis). 2, 8
- Assess for pericardial effusion which occurs in up to 50% of RA patients and can cause tamponade under positive pressure ventilation. 2
- Evaluate for conduction abnormalities as RA can cause heart block. 2
Pulmonary System
Pulmonary involvement occurs in 30-40% of RA patients. 2, 3
- Identify interstitial lung disease through history (dyspnea, dry cough) and chest imaging, as it increases perioperative respiratory complications. 2, 3
- Assess for pleural effusions which are common and may require drainage if large. 2
- Evaluate for cricoarytenoid arthritis (see airway section above). 2, 3
Renal System
Screen for renal insufficiency from chronic NSAID use, amyloidosis, or vasculitis, as this affects drug dosing and fluid management. 2, 8
Hematologic System
Anemia of chronic disease occurs in 30-60% of RA patients. 2, 8
- Optimize hemoglobin preoperatively to reduce transfusion requirements. 8
- Thrombocytopenia may occur from Felty's syndrome or medication effects. 2
Intraoperative Management
Positioning
Use extreme caution with neck positioning in patients with cervical spine involvement. 2, 3
- Maintain neutral cervical alignment during intubation and throughout surgery. 2, 3
- Pad all pressure points meticulously as RA patients have increased risk of pressure ulcers from joint deformities and chronic steroid use. 2
Anesthetic Technique Selection
Regional anesthesia is preferred when feasible to avoid airway manipulation in patients with cervical spine or temporomandibular involvement. 3, 9
- Neuraxial anesthesia may be technically difficult due to spinal involvement, ligamentous calcification, or positioning limitations. 3, 9
- Peripheral nerve blocks are excellent alternatives for extremity surgery. 3
Postoperative Management
Medication Resumption
Resume all antirheumatic therapy once wound healing is confirmed, typically around 14 days postoperatively. 5, 6
- Verification criteria: Sutures/staples removed, no significant swelling/erythema/drainage, no ongoing infection. 5
- Use visiting nurse services, telemedicine, or smartphone photography for wound assessment if in-person visits are not feasible. 6
Pain Management
Multimodal analgesia is essential to minimize opioid requirements. 3, 8
- Continue baseline NSAIDs if renal function permits (though many RA patients have contraindications). 8
- Regional anesthesia techniques (peripheral nerve catheters, neuraxial analgesia) provide superior pain control. 3, 8
Special Surgical Considerations
Cervical Spine Surgery
Absolutely contraindicated: High-velocity thrust spinal manipulation in RA patients with spinal fusion or advanced osteoporosis due to catastrophic risks of spine fractures, spinal cord injury, and paraplegia. 6
Total Joint Arthroplasty
RA patients have 2-fold increased risk of postoperative infection and 1.5-fold increased risk of deep infection compared to osteoarthritis patients. 1, 5
- Optimize disease control preoperatively as uncontrolled disease activity increases perioperative complications. 5
- Young RA patients require counseling about implant survival concerns and potential need for revision surgery given longer life expectancy. 5
Multidisciplinary Coordination
Close communication between anesthesiologist, surgeon, and rheumatologist is mandatory. 6, 3, 9