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Purpose of Review: This article provides guidelines for the perioperative management of the most commonly used antirheumatic drugs being used to treat patients with rheumatoid arthritis, with an emphasis on the relatively new addition of biologic response modifiers., Recent Findings: Few clinical data exist examining the perioperative management of the biologic drugs, which include the inhibitors of tumor necrosis factor-alpha (etanercept, infliximab, and adalimumab), the interleukin-1 receptor antagonist anakinra, and to a much lesser extent the CD20 inhibitor rituximab. The only human data available in that regard is based on the use of the tumor necrosis factor-alpha inhibitor infliximab in surgical patients with Crohn disease. Although quite limited, that data appeared favorable in finding that infliximab did not result in an increased risk of postoperative complications in that setting., Summary: Perioperative guidelines have never been well established for a majority of the traditional antirheumatic drugs in use today. Recommendations for the perioperative use of nonsteroidal antiinflammatory drugs and glucocorticoids have the most evidence-based support. Data for the use of methotrexate are also available from which to generate reasonable guidelines; however, for the remaining antirheumatic drugs in current use, the available data cannot support any clear evidence-based recommendations. To provide reasonable guidelines for the use of the biologics, perhaps the best we can do is to extrapolate from the very limited data coming from the concurrent use of infliximab in patients with Crohn disease who have undergone surgery. Beyond that, we are left with animal and tissue culture data from which any recommendations would be rather tenuous.

There has been a renewed interest in the use of low doses of prednisone in the treatment of early rheumatoid arthritis. This is because it has been conclusively shown that low doses of prednisone retard bone damage, and physicians use prednisone because it helps control tender and swollen joints. Two studies appeared in 2002, one by van Everdingen et al. and one by Landewe et al. demonstrating the reduction of bone damage in early RA with the use of prednisone. Van Everdingen used 10 mg/day of prednisone and Landewe used an initial high dose of 60 mg/day of prednisone for a week, tapering off by 6 months. The bone sparing effect was still evident at 5 years. Low doses of prednisone are well tolerated, with documented side effects including weight gain, ecchymosis, and osteopenia.

There are few controlled trials of immunosuppressive therapy for vasculitis, making the further study of long-term outcome of these diseases with contemporary modes of management necessary. Relapse is frequent in many forms of vasculitis. The consequences of immunosuppressive therapy, including opportunistic infection, have been emphasized. Novel forms of therapy have been described in small series and case reports, although the precise role of such therapies in the treatment of vasculitis in general is far from certain in the absence of collaborative, multicenter controlled studies. The relationship between vasculitis and hepatitis C virus has prompted the use of interferon therapy in the treatment of vasculitic complications resulting from this infection.

A large variety of vasculopathic syndromes are uncommonly associated with malignancies. Vasculitis is usually manifested by skin lesions and is generally associated with hematologic malignancies rather than solid tumors. Evidence of autoantibodies, immune complexes, and complement consumption is typically absent. Myelodysplastic syndromes can be confidently linked to vasculitis on the basis of recent literature. The temporal relationship of malignancy to vasculitis development is variable except that vasculitis generally follows the discovery of hairy cell leukemia and splenectomy. Vasculitis may occasionally be a complication of chemotherapy, radiation therapy, and bone marrow transplantation. Occasionally, malignant disorders may mimic vasculitic syndromes. The etiopathogenesis of vasculitis in patients with malignant disorders is unknown. The recent literature on vasculitis and malignancy addresses predominantly case reports and small patient cohorts and identifies clinical characteristics rather than pathogenic mechanisms.