Disclosures: The authors report no relevant financial disclosures.
June 22, 2022
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ACR/AAHKS: Decision to withhold drugs before arthroplasty must weigh flare vs infection

Disclosures: The authors report no relevant financial disclosures.
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Patients with autoimmune rheumatic diseases who are undergoing elective hip or knee arthroplasty should maintain their usual doses of methotrexate, leflunomide, hydroxychloroquine, sulfasalazine and apremilast , according to new guidelines.

Meanwhile, tofacitinib (Xeljanz, Pfizer), baricitinib (Olumiant, Eli Lilly & Co.) and upadacitinib (Rinvoq, AbbVie), should all be withheld 3 days prior to surgery in patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis or juvenile idiopathic arthritis.

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“The main takeaway from the guideline is that the decision to withhold a medication versus continuing it in the perioperative period weighs the risk of a disease flare with the risk of infection, as the majority of anti-rheumatic medications are immunosuppressants,” Susan Goodman, MD, told Healio.

The guidelines, a joint effort from the American College of Rheumatology and the American Association of Hip and Knee Surgeons, were first announced in February. The full guidance document, which includes recommendations for patients with RA, PsA, JIA, systematic lupus erythematosus and AS, was later published simultaneously in Arthritis Care & Research and the Journal of Arthroplasty in June.

Susan Goodman

“The ACR updates its guidelines regularly as new research adds to our clinical database,” Susan Goodman, MD, of the Hospital for Special Surgery and Weill Cornell Medicine, in New York, told Healio. “This is especially important in practice guidelines so that recommendations for new medications can be included.”

To draft the new recommendations, Goodman and colleagues created a panel of rheumatologists, orthopedic surgeons and infectious disease specialists. Three teams, including a leadership team, literature review team and a voting team, were established to carry out the duties of the panel. The core leadership team was responsible for confirming that the questions used for the new recommendation list matched the questions used in the 2017 recommendations. Additionally, the leadership team updated the medications list to include those approved for use through Aug. 21, 2021.

The literature review team updated the systematic literature review for each population, intervention, comparator and outcome (PICO) question, evaluated evidence quality and produced the evidence report. The review team updated the review to include articles published between March 6, 2016, and Aug. 26, 2021.

The voting panel, meanwhile, was responsible for reviewing evidence summaries originating from the 2017 and 2022 systematic literature reviews, as well as discussing and voting on recommendation statements. The panel included two patients who underwent prior arthroplasty surgery and who participated in the 2017 review. Consensus for recommendations required 70% or greater agreement on both direction and strength of recommendation.

The guidelines include a conditional recommendation for patients with RA, AS, PsA, JIA or SLE undergoing total hip or knee arthroplasty to continue receiving their usual dose of methotrexate, leflunomide, hydroxychloroquine, sulfasalazine and apremilast.

In addition, patients with RA, AS, PSA or JIA are conditionally recommended to withold biologics, including rituximab (Rituxan, Genentech), prior to and during the planning of surgery.

Another conditional recommendations counsels that tofacitinib (Xeljanz, Pfizer), baricitinib (Olumiant, Eli Lilly & Co.) and upadacitinib (Rinvoq, AbbVie), should be withheld 3 days prior to surgery in patients with RA, AS, PsA or JIA. Patients with not-severe SLE should conditionally withhold mycophenolate mofetil, mycophenolic acid, azathioprine, cyclosporine, mizoribine or tacrolimus 1 week before surgery. Those with not-severe SLE should also conditionally withhold belimumab (Benlysta, GlaxoSmithKline) and rituximab.

Meanwhile, for patients with severe SLE who have been approved for surgery, the guidelines conditionally recommend continuing mycophenolate mofetil, mycophenolic acid, azathioprine, mizoribine, cyclosporine, or tacrolimus, anifrolumab, and voclosporin.

Other conditional recommendations include:

  • Patients with severe SLE should continue receiving belimumab and have surgery planned for the last month of the rituximab dosing cycle.
  • Patients with RA, AS, PsA or SLE who had antirheumatic therapy withheld leading up to surgery should have it restarted as soon as possible — once the wound shows evidence of healing, sutures are removed, significant swelling is absent and there is no ongoing, nonsurgical site infection.
  • Patients with RA, AS, PsA or SLE who receive glucocorticoids should continue receiving their standard dose instead of the supraphysiologic dose on the day of surgery.

“The main takeaway from the guideline is that the decision to withhold a medication versus continuing it in the perioperative period weighs the risk of a disease flare with the risk of infection, as the majority of anti-rheumatic medications are immunosuppressants,” Goodman said. “Given the paucity of clear data on this subject, the patients perspective should be included in a shared decision-making process, weighing the risks and benefits.”