QD105 - Dealing With Surgeons Save

This is QD Clinic, and I am doctor Jack Cush, and you are here because we're having fun. QD Clinic is brought to you by our coverage of ACR twenty twenty. Our case today is dealing with surgeons. So a 54 year old fellow who's got well controlled rheumatoid arthritis taking a JAK inhibitor, which he says has dramatically changed his life. He's really taking no other medicines, and he's got to go and have some neck surgery.

And, he didn't tell me of this because it was gonna it was about three or four months after I last saw him that he had it done. It was right after COVID. And so what's happened? His neck surgeon, the neurosurgeon, gave him all the instructions on how to prepare for this and what to do with his anti rheumatic medicines. They told the patient, Oh, we called Doctor.

Cush and they said that you should stop your JAK inhibitor for one month before and two months after because it impairs wound healing, or it can cause an infection, or it's because this is what I do because I'm the surgeon. My goodness, it's the most disastrous thing that can possibly happen. So, this is how I deal with it. First off, you know the research here. The literature is very clear.

All DMAR should basically be continued all throughout surgery. There's really no reason to stop. Steroids should be continued throughout surgery, and really, there's no reason to use stress doses of steroids anymore. That's been proven not to be beneficial or effective, just gives the patient more steroids than they need. Biologics, the rule is stop for one dosing interval.

So, here's some particulars. One, let's talk about nonsteroidals. That's very clear. Nonsteroidals aspirin, seven days before, and and and then they can resume them as soon as they get home. When it comes to, DMARDs, and even most biologics, I tell the patient, listen, talk to the surgeon.

Get out your pen, your paper, you know, write things down. Like when he says, do this and do that, you go, uh-huh, uh-huh, you write stuff down, and you look at it and says, I got it, doc. And then when you get home, you can take that and you can throw it away, and you call doctor Cush, and he'll tell you what to do. If it's methotrexate, sulfasalazine, whatever, I'll say, take it one week before surgery, don't take it the week of surgery, take it and then restart everything two weeks after surgery's done or when the sutures come out. That's not stopping any drug long enough to get into trouble, and it kinda makes the surgeons happy.

It's sort of a compromise between their idiocy and our being hard line and evidence based. That actually works. That also works for biologics, where the rule is, again, you don't wanna be at peak drug levels. You don't wanna take your infliximab the day before you have your hip replacement. You wanna be somewhere from the peak levels down but not washed out, because washed out means no drug and inflammation and flare with inflammation.

Inflammation drives risk for poor wound healing and or infection. So you want to be off the biologic for, I don't know, a week or two or four, one dosing interval. It's a q two week drug, be off two weeks. After the q four week, be off four weeks. And then have the surgery, and then restart the biologic when the sutures come out, assuming no infection, no complications of surgery.

These work, and the patient needs to know that you're the expert, you're the one who has a plan. Again, you're gonna you need to sound as forceful and as certain as the orthopedist does, or the general surgeon does. But we know their guidelines are not necessarily based on any evidence. So, if you're a surgeon and you don't like what I just said, I'll meet you in the parking lot, we'll discuss this. That's it.

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