Perspectives on Rheumatoid Arthritis for the Orthopedic Surgeon: Overview of Non-Tumor Necrosis Factor Biologic Drugs and Perioperative Management

Early use of disease-modifying antirheumatic drug (DMARD) therapy has become the stan­dard of care in the treatment of rheumatoid arthritis (RA). Methotrexate remains the DMARD of choice in patients without contraindications for its use. The addition of a tumor necrosis factor-α antagonist to methotrexate makes clinical remission more likely. Despite the effectiveness of this approach, some patients continue to have active disease. In these patients, the use of rituximab, abatacept, or tocilizum­ab provides additional options when first-line therapies inadequately control RA. For orthopedic surgeons and rheumatologists, additional therapeutic options increase the complexity of perioperative medical man­agement. No consensus has been reached by rheuma­tology societies as to the optimal approach for the use of biologic and traditional DMARDs around the time of surgery. Therefore, perioperative medication manage­ment should be individualized and based on a discus­sion of potential risks and benefits involving patients, surgeons, and rheumatologists.