Rheumatologists must ‘balance’ flare, infection risks in hip, knee replacement
Click Here to Manage Email Alerts
SAN DIEGO — Mitigating infection risks while preventing flares is often a balancing act for rheumatologists managing patients undergoing hip or knee replacement, according to a presenter at the 2023 Congress of Clinical Rheumatology West.
“More patients with rheumatic diseases are utilizing and benefiting from total hip arthroplasty and total knee arthroplasty,” Susan Goodman, MD, of the Hospital for Special Surgery and Weill Cornell Medicine, in New York, told attendees.
However, with any surgery comes risks, including infections and readmissions. In patients with rheumatic and autoimmune diseases, these risks are often higher than in the general population and underscored by the threat of disease flare, according to Goodman.
“How do we balance of the risk for flare vs. the risk for infection and other complications?” she said.
According to Goodman, it is first important to understand how non-clinical factors like smoking and BMI can compound disease- and surgery-related risks.
“All of these risk factors are additive,” she said.
Another challenge for rheumatology providers working in partnership with surgery and anesthesiology is to minimize complications as much as possible. A key component of this strategy is managing the medications that keep rheumatic and autoimmune diseases under control, Goodman said.
“Stopping biologics increases the risk for flare, while taking biologics often increases the risk for infection,” she added.
In this context, the American College of Rheumatology and the American Association of Hip and Knee Surgeons in 2022 published a document to help guide perioperative surgical protocols and offer strategies for medication use.
According to these guidelines, conventional disease-modifying antirheumatic drugs should be continued through surgery.
“There is no relationship between these drugs and infections,” Goodman said. “Although disease flares were frequent and infections increased in patients who stopped these medications, the flares were significantly less important to the patients.”
Another consideration is that surgical procedures should be scheduled at the end of the dosing interval for medications that may increase infection or complication risk. For example, a patient receiving rituximab (Rituxan, Genentech) — which is dosed every 6 months — should schedule their surgery on month 7. For those receiving adalimumab (Humira, AbbVie) — which is dosed every 2 weeks — surgery should occur on week 3.
“We applied that to all the biologics used for rheumatoid arthritis, lupus and psoriatic arthritis,” Goodman said.
High-dose glucocorticoids to treat RA, ankylosing spondylitis, PsA or systemic lupus erythematosus have also been associated with infection risk.
“Any amount of glucocorticoid increases the risk for either infection or readmission,” she said. “For each 10 mg increase in glucocorticoid dosing, the odds of complications increase by 7%.”
However, Goodman acknowledged that some patients may require low steroid doses, which may not carry a significant infection risk.
“We recommend avoiding stress dosing of glucocorticoids,” she added.
Goodman described Janus kinase inhibitors, meanwhile, as “pretty significant immunosuppressants.” However, the ACR/AAHKS guideline team recommended a “short time off” JAK inhibitors to reduce the likelihood of disease flares, she said.
“We withhold the drugs that are clearly immune suppressant, then start them up if there is evidence of disease activity,” Goodman said. “The difference between short medication interruptions and long medication interruptions was insignificant, so we recommend a shorter interruption.”
After the surgery, medications should be reinitiated when wound healing begins, according to Goodman.
“If the wound looks good, the staples are out, there is no evidence of erythema, we recommend restarting medications,” she said.
Although all of these efforts may reduce infections and other complications, Goodman reminded attendees that risk cannot be eliminated entirely.
“There is a lot that is not within our control,” she said. “Many things can contribute to infection risk.”
Goodman encouraged rheumatologists to view the surgical procedure holistically, from preparation through healing and re-initiation of medications.
“It is important that the patient’s health be optimized, and that medicine, anesthesia and surgery coordinate a perioperative plan,” she said.
Collapse
Goodman S. Pre and Perioperative Management of Patients with Rheumatic Disease. Presented at The Congress of Clinical Rheumatology West; Sept. 7-10, 2023 (hybrid meeting).
Click Here to Manage Email Alerts