This article is more than 5 years old. Information may no longer be current.
ACR/AAHKS present guidelines for perioperative management of antirheumatic drugs in hip, knee replacement
Click Here to Manage Email Alerts
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.
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 [rheumatoid arthritis] RA, [spondyloarthritis] SpA, [ankylosing spondylitis] AS, [psoriatic arthritis] PsA, [juvenile idiopathic arthritis] JIA and [systemic lupus erythematosus] SLE who were undergoing elective procedures,” he said.
There were four core questions 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 antirheumatic 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 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.”
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.
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.
“We did feel that the evidence demonstrated an increase in infection risk associated with biologic use,” she said.
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.
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.
Reference:
Singh SA and Goodman SM. Perioperative management of anti-rheumatic medication in patients with rheumatic diseases undergoing elective total hip or knee arthroplasty: A New ACR/AAHKS clinical guideline. 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.