ACR/AAHKS present guidelines for perioperative management of antirheumatic drugs in hip, knee replacement

WASHINGTON — At the American College of Rheumatology Annual Meeting, the American College of Rheumatology, in partnership with the American Association of Hip and Knee Surgeons, presented joint guidelines for perioperative management of antirheumatic medication use for patients undergoing total hip or knee replacement.

Jasvinder A. Singh, MD, MPH, professor of medicine and epidemiology in the Division of Clinical Immunology and Rheumatology at the University of Alabama in Birmingham, provided an overview of the methods and literature used to develop the guidelines. Susan M. Goodman, MD, associate professor of medicine at Weill Cornell Medical College in New York and co-principal investigator for the guideline, presented highlights of the document. Bryan Springer, MD, of the Ortho Hip and Knee Center in Charlotte, N.C., moderated the session.

In general terms, the recommendations offer insight on the treatment of high-risk and low-risk patients with ankylosing spondylitis (AS), rheumatoid arthritis (RA), psoriatic arthritis (PsA), juvenile idiopathic arthritis (JIA) and (systemic lupus erythematosus) SLE. There is guidance for initiation and cessation of medications. There are also recommendations for rescue medications for flares that occur in the postoperative setting.

“Infection is a major issue after replacement surgery,” Springer said. “It is the number one cause of failure after knee replacement and the number three cause of failure after hip replacement.”

He said the morbidity and mortality associated with these procedures is not to be underestimated.

“The risk of being alive 5 years after infection in one of these joint replacement procedures is lower than it is for four of the five most common cancers,” he said. “Patients with inflammatory diseases are particularly at risk.”

There has been little in the peer-reviewed literature to guide medication use in these patients, according to Springer. “This collaboration between the [American College of Rheumatology] ACR and [American Association of Hip and Knee Surgeons] AAHKS is one of the first collaborations between our societies to critically take a look at the evidence that is available in these patients,” he said.

Overview of methods

Singh said the guidelines were developed by a core leadership team, a literature review team, an expert panel, a voting panel and a patient panel.

“The scope of the document included patients with RA, [spondyloarthritis] SpA, AS, PsA, JIA and SLE who were undergoing elective procedures,” he said.

There were four core questions that the groups aimed to address, which Singh referred to as the “PICO” questions: patient, intervention, comparator and outcome. The first question was whether to continue or withhold anti-rheumatic medications. The second pertained to when to withhold those medications. The third dealt with when to re-start the medications. The fourth dealt with whether to use stress-doses of glucocorticoids.

The group also reviewed abstracts with information regarding adverse events and infections associated with these medications outside of the hip and knee replacement setting. The final series of abstracts offered insight on systemic autoimmune inflammatory disease states.

“The literature review included 3,000 abstracts initially,” Singh said. He noted, however, that for most of the questions, there was no direct evidence available. “The data for the PICO questions were largely based on observational studies and meta-analyses. We used the GRADE methodology to guide this process.”

Because of the nature of the evidence, Goodman noted all the recommendations are conditional. “Randomized controlled trials are the gold standard,” she said. “There were none.”

Summary of guidelines

Goodman said the document is undergoing review.

Regarding the first PICO question, Goodman said disease-modifying antirheumatic drugs should be continued in patients with RA, AS, PsA, JIA and SLE undergoing hip or knee replacement. However, tofacitinib should be withheld. In SLE, non-biologic therapies may be continued when the disease is severe, but biologics may be held in cases of severe SLE.

For the second PICO question, Goodman said the panel recommended withholding all biologics prior to surgery in patients with RA, PsA, SpA or JIA undergoing replacement.

“Plan the surgery at the end of [the] dosing cycle,” she said.

Rituximab and belimumab should be withheld for patients with SLE, she said.

“We did feel that the evidence demonstrated an increase in infection risk associated with biologic use,” she said. “We found that infection risk for biologics was strongly associated with high-dose, or higher doses than standard therapy.”

The main recommendation for the third PICO question is that biologic therapies should be re-started when the wound from the surgery is healed.

“This is usually at about 14 days,” Goodman said.

For the fourth PICO question, Goodman said the current daily dose of glucocorticoids may continue to be used in adult patients with RA, AS, PsA, SpA or SLE. “The rationale is that meta-analyses showed no hemodynamic difference between the daily dose and the stress dose,” she said. “I should note that this recommendation is for adults, and not children with JIA.”

Goodman said the main limitation of the document was the paucity of direct evidence on medications and perioperative risk.

“There was not sufficient literature to review medications individually, so we reviewed mediations and diseases together,” she said.

A strength of the document is the clinicians had clear guidance in terms of preferences of the patient panel, according to Goodman.

“They were helpful in guiding us,” she said. “They felt infection was much more of a risk than flare. We created a patient-centric, expert-led group.” — by Rob Volansky

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Presented at: The American College of Rheumatology Annual Meeting; Nov. 11-16, 2016; Washington.

Disclosures: Goodman reports no relevant financial disclosures. Singh reports associations with TAP, Savient, Takeda, Regeneron, Merz, Iroko, Bioiberica, Crealta, Allergan pharmaceuticals, WebMD and UBM LLC.