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AAHKS, ACR Release Guidelines for Management of Antirheumatic Drugs for Patients Who Undergo TKA, THA
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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.”
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“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
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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.
Perspective
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S. David Stulberg, MD
This group of experts in the care of patients with rheumatic diseases and in the provision of hip and knee arthroplasty has provided valuable, up-to-date information on the perioperative use of the medications used in the treatment of inflammatory arthropathies, including SLE, in patients undergoing total hip and knee replacement surgery. The summary of the findings presented in Table 2 are clear and easy to implement. This summary should be accessible to and readily used by surgeons performing these procedures. The recommendation to continue the daily dose of glucocorticoids rather than administering perioperative supra-physiologic glucocorticoids doses (so-called “stress dosing” — a practice often carried out in patients on these medications) is worth noting and following. The authors acknowledge that the guidelines are not intended to dictate the care of a particular patient and that they are conditional (ie, the desirable effects of following the recommendations probably outweigh the undesirable effects). Therefore, these important recommendations should be used by physicians regarding each patient’s individual circumstances.
Perspective
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Denis Nam, MD, MSc
As a TJA surgeon, I frequently encounter patients who receive DMARDs and biologic agents for treatment of their inflammatory arthropathy. However, once indicated for THA or TKA, optimal management of these medications in the perioperative period has always been a question. The guidelines set forth by the ACR and AAHKS are tremendously useful and finally provide some direction in how to manage the growing number of DMARDs, biologics and glucocorticosteroids prescribed. The collaboration in developing these guidelines should be commended as it blended the perspectives and expertise of surgeons and rheumatologists.
However, despite the use of a well-defined and validated method for guideline development, the inability to provide a “strong” grade to any of their recommendations points to the paucity of high-quality data surrounding this topic. The committee members have emphasized the limitations of the data available and point toward future research and the need for multi-center collaboration to further determine the optimal management of newer regimens of DMARDs and biologics. As a surgeon, I am also interested in research that focuses on perioperative interventions (ie, antibiotics, surgical techniques, dressings) that may mitigate the risk of infection in this high-risk population. As the panel notes, more work is necessary, but these guidelines are an excellent initiative as they provide clear, needed suggestions as to how to manage these complex patients.
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