The American College of Rheumatology has partnered with the American Association of Hip and Knee Surgeons to develop evidence-based guidelines for perioperative management of antirheumatic medication for patients with rheumatic diseases who undergo total joint replacement.
“Periprosthetic joint infection remains one of the most common reasons for failure of hip and knee replacement,” Bryan D. Springer, MD, co-principal investigator, orthopedic surgeon at the OrthoCarolina Hip and Knee Center, and American Association of Hip and Knee Surgeons (AAHKS) education council chair, said in a press release from the American College of Rheumatology (ACR). “Because periprosthetic joint infections are associated with such high morbidity and mortality, we felt there was a dire need for perioperative management recommendations that could be subscribed to by both disciplines in order to provide arthritis patients with better outcomes.”
Bryan D. Springer
“Prior to our study, there was little to no consensus among orthopedic surgeons or rheumatologists on the optimal way to manage anti-rheumatic medication in patients having joint replacement surgery, and this often led to uncertainty in decision-making for physicians and patients alike,” Susan M. Goodman, MD, co-principal investigator and rheumatologist at Hospital for Special Surgery, said in a press release. “Our project brought together hip and knee replacement surgeons, rheumatologists and methodologists to determine optimal medical management through a group consensus process. In addition, a panel of 11 patients provided input on their preferences.”
A panel of 31 orthopedists and rheumatologists from 20 hospitals and organizations created questions about the timing of anti-rheumatic medications and dosage of glucocorticoids for patients with rheumatic diseases, such as rheumatoid arthritis (RA), spondyloarthritis (SpA), juvenile idiopathic arthritis (JIA) and systemic lupus erythematosus (SLE), undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA). A multi-step systematic literature review was performed and evidence was collected on the continuation of anti-rheumatic treatment compared with the withholding medication during the perioperative period. The medications included disease-modifying antirheumatic drugs (DMARDs), biologic agents, tofacitinib and glucocorticoids.
Seven recommendations were created. The recommendations noted that non-biologic DMARDs should be continued in the perioperative period for patients with RA, AS, PsA, JIA and SLE undergoing TKA or THA; however, biologic therapies should be withheld “as close to one-dosing cycle as scheduling permits” before surgery and restarted after signs of wound healing. In addition, it was recommended that tofacitinib be withheld 7 days before surgery in patients with RA, SpA and JIA.
The panel recommended to continue methotrexate, mycophenolate mofetil, azathioprine, cyclosporine or tacrolimus in cases with severe SLE through the surgical period; however, mycophenolate mofetil, azathioprine, cyclosporine or tacrolimus should be withheld 1 week before patients undergo total joint replacement in cases with non-severe SLE. Biologic therapy that was withheld prior to surgery should be re-started with evidence of wound healing in patients with RA, SLE and SpA, including AS, PsA, and JIA. In cases of RA, AS, PsA, SpA or SLE, the panel recommended the continued use of daily dose of glucocorticoids for patients who were already receiving these treatments rather than “stress dosing.” – by Monica Jaramillo
Disclosures: Goodman reports no relevant financial disclosures. Springer reports he receives honoraria from CeramTec consulting fees from Stryker Orthopaedics and Convatec. Please see the full study for a list of all other authors’ relevant financial disclosures.