# Perioperative Management of Biologic and Targeted Synthetic DMARDs in Orthopedic Surgery: Balancing Infection Risk and Disease Control

## TL;DR

This paper discusses managing biologic drugs before orthopedic surgery to balance infection risk and disease control.

## Contribution

It provides updated guidelines for individualized drug management based on drug type, surgery, and patient factors.

## Key findings

- Withholding biologics before surgery reduces infection risk but may increase disease flare-ups.
- Pharmacokinetics and surgery type are critical in deciding drug discontinuation timing.
- Multidisciplinary coordination is essential to optimize patient outcomes.

## Abstract

The perioperative management of biologic and immunomodulatory therapies in patients undergoing orthopedic surgery poses a clinical challenge, primarily due to the increased risk of postoperative infections. Biologic agents, particularly TNF inhibitors and interleukin-targeting drugs, may impair host immune responses, potentially increasing the risk of surgical site infections (SSIs), delayed wound healing, and systemic infections. However, abrupt discontinuation of these therapies can lead to disease flare-ups, which themselves may complicate recovery and rehabilitation. In addition, discontinuation of biologics can lead to drug tolerance and unresponsiveness when they are restarted and thereby need switching to another biologic. Recent studies suggest that the infection risk is particularly elevated with ongoing biologic therapy during major surgeries, especially in procedures involving prosthetic implants. Guidelines generally recommend withholding biological disease-modifying antirheumatic drugs (bDMARDs) for at least one dosing cycle prior to surgery, when feasible, while maintaining non-biologic DMARDs in most cases. The decision must be individualized, taking into account the pharmacokinetics of each drug, the type of surgery, the patient’s comorbidities, and the activity of the underlying disease. Close coordination among rheumatologists, orthopedic surgeons, and infectious disease specialists is essential to minimize perioperative complications and optimize patient outcomes.