Perioperative medikamentöse Therapie rheumatischer Erkrankungen

Zusammenfassung

Die Handhabung antirheumatisch wirkender Medikamente bei anstehenden operativen Eingriffen verursacht z. T. erhebliche Probleme, da es sehr wenige Untersuchungen zu diesem wichtigen Einsatzbereich gibt. Erhöhtes Infektionsrisiko und Wundheilungsstörungen zählen zu den potenziellen Risiken für viele Substanzen, wenn deren Einsatz nicht perioperativ unterbrochen wird. Umgekehrt droht bei Pausieren ein Schub der Grunderkrankung, der seinerseits das Risiko erhöhen kann. Zu den Substanzen ohne Unterbrechungsbedarf zählen nichtsteroidale Antiphlogistika, Antimalariamittel und Sulfasalazin. Methotrexat ist die einzige Substanz mit Vorliegen mehrerer randomisiert-kontrollierter Studien, die ein signifikant höheres Risiko bei Unterbrechung der Therapie im Vergleich zu einer Fortführung gezeigt haben. Glukokortikoide sollten perioperativ in möglichst niedriger, aber stabiler Dosierung gegeben werden, Leflunomid wegen seiner langen Halbwertszeit bei größeren Eingriffen und erhöhtem Risiko ausgewaschen werden. Bei Azathioprin, Ciclosporin und Mycophenolat-Mofetil reicht eine Unterbrechung von einigen Tagen. Die meisten Biologika werden bei größeren Eingriffen und erhöhtem Risiko zwei Halbwertszeiten vor Eingriff pausiert.

Summary

Management of perioperative use of antirheumatic drugs is not well studied and, therefore, difficult to handle for the rheumatologist as well as the surgeon. Many antirheumatic drugs cover the risk of a higher rate of postoperative infections or wound healing deficits on the one hand, stopping treatment before surgical intervention harbours the risk of exacerbation of the disease on the other hand. Pausing treatment seems to be unnecessary with drugs like nonsteroidal antirheumatic drugs, chloroquine/hydroxychloroquine and sulphasalazine. For methotrexate several randomized-controlled studies show a significantly higher risk in case of stopping treatment before intervention in comparison to continuous medication. Dosage of glucocorticoids should generally be as low as possible but nevertheless maintained constantly in the perioperative period. Data on leflunomide are scarce and conflicting, because of the very long drug half-life a wash-out procedure has to be carried out in case of high risk interventions and high risk patients. A short break of a few days seems to be sufficient with azathioprine, cyclosporine and mycophenolat-mofetil. For most of the biologics a break of two drug half-lives before intervention is recommended.

Schlüsselwörter

Perioperative medikamentöse Therapie - Glukokortikoide - DMARD - Biologika

Keywords

Perioperative drug treatment - glucocorticoids - DMARD - biologicals

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