Perioperative biologic use and postoperative outcomes in patients with inflammatory arthritis: a systematic review

OBJECTIVES: To evaluate the impact of continuing versus stopping biologic disease-modifying anti-rheumatic drugs (bDMARDs) during the perioperative period on surgical site infections (SSIs), delayed wound healing, and disease flares in patients with inflammatory arthritis (IA) undergoing elective non-orthopaedic surgery. METHODS: We conducted a systematic review of observational studies assessing the perioperative management of bDMARDs in IA patients undergoing elective non-orthopaedic surgery. Searches were conducted across seven databases and trial registries from the year 2000 onwards. Eligible studies compared outcomes in patients who continued versus stopped biologic therapy. Risk of bias was assessed using the ROBINS-I tool and due to heterogeneity data were synthesised narratively. RESULTS: Eight observational studies met the inclusion criteria. All studies were at moderate or serious risk of bias. Four studies compared infections with two suggesting higher infection rates in the stop biologic group. Two studies assessed delayed wound healing, both suggesting higher rates in the stop group. Disease flares were more common in patients who stopped biologics in all three of the studies reporting this outcome. No studies assessed health-related quality of life. CONCLUSIONS: The available observational evidence does not demonstrate a consistent increase in postoperative infection or wound complications related to biologic continuation, however, confidence in these findings is limited by serious risk of bias and outcome heterogeneity. High-quality randomised controlled trials are needed to inform the perioperative management guidelines for IA patients undergoing elective non-orthopaedic procedures.