Perioperative use of methotrexate--a survey of clinical practice in the UK.

SUMMARY We have surveyed the use of methotrexate in the perioperative period in patients with rheumatoid arthritis (RA) undergoing surgery. A total of 200 consultant rheumatologists and 200 consultant orthopaedic surgeons in the UK were sent a postal questionnaire. Thirty-five per cent of rheumatologists and 46% of orthopaedic surgeons were concerned that the drug may increase the risk of post-operative complications, although significantly less ‘always’ stopped the drug around the time of surgery. There was great variation in the timing of stopping the drug with most stopping treatment within 2 weeks before surgery and restarting within 2 weeks after surgery. The majority of clinicians surveyed (70%) felt that national guidelines for the perioperative use of methotrexate would be helpful. METHOTREXATE (MTX) is a folate antagonist that is widely used as a second-line agent in patients with rheumatoid arthritis (RA). It is a potent cellular antimetabolite with eAects on several intracellular folatedependent systems involved in the synthesis of purines, pyrimidines and proteins. The mechanism of action of MTX in RA is incompletely understood; however, an array of eAects on immune cells have been documented (reviewed in [1] and [2]). Infectious complications have been reported during the course of treatment, although the majority were not serious [3, 4]. Rarely, severe life-threatening infection may occur [3, 5‐7]. Patients with RA are also at increased risk of infection during and after major surgery, in particular joint replacement. There is, therefore, concern that the combination of MTX treatment and major surgery may magnify the infection risk. In addition, there is some evidence that MTX may delay wound healing [8]. Whether either of these concerns is true is unknown. Several small studies have been published [9‐14], but there have been no large controlled trials of post-operative complications in this group of patients and no consensus has emerged. The aim of the current study was to assess the attitude of clinicians to the use of MTX in patients with RA in the perioperative period.