In patients with rheumatic disease, the risk of joint infection resulting from total hip arthroplasty (THA) and from total knee arthroplasty (TKA) may be reduced with careful management of antirheumatic medications during the perioperative process, according to new guidelines.
The evidence-based guidelines address perioperative management of antirheumatic drug therapy for adults who have rheumatoid arthritis (RA); spondyloarthritis (SpA), including ankylosing spondylitis and psoriatic arthritis; juvenile idiopathic arthritis (JIA); or systemic lupus erythematosus (SLE).
The guidelines, from the from the American College of Rheumatology and the American Association of Hip and Knee Surgeons, include seven recommendations regarding when to continue, withhold, and restart medications commonly used to treat inflammatory rheumatic diseases (e.g., rheumatoid arthritis, spondyloarthritis, and systemic lupus erythematosus), as well as the optimal perioperative dosing of glucocorticoids. All of the guidelines are conditional and based on low to moderate quality evidence due to the lack of direct evidence and the lack of randomized controlled trials that evaluate the safety and efficacy of discontinuing and resuming biologic therapy during this time.
In addition to rheumatology and orthopedic experts, a patient panel was incorporated to ensure the guidelines adequately represented patients’ concerns and preferences.
“There was a very clear message from the patient panel that they were willing to deal with flares if it meant reducing their likelihood for infections and other complications,” said Susan M. Goodman, M.D., a rheumatologist at the Hospital for Special Surgery in New York, who also served as a co-principal investigator. “The panel also noted that this preference could differ in lupus patients where a flare could mean inflammation of the organs, which poses a greater risk to their health than getting an infection from continuing their medications.”
Total hip arthroplasty and total knee arthroplasty can result in improvements in pain and function for patients, but RA, SpA, or SLE patients are more susceptible to infection and dislocation and they have high rates of readmission as compared with osteoarthritis patients.
“The optimal strategy to manage these medications is not known. Inherent risk factors for infection, such as overall disability and disease activity/severity, may not be modifiable, but the optimal perioperative management of immunosuppressant therapy around the time of arthroplasty may present an opportunity to mitigate risk,” the authors wrote.
One analysis showed that at the time of surgery, 46% of RA patients were taking biologics, 67% were receiving nonbiologic DMARDs, and 25% were receiving glucocorticosteroids; 75% of patients with SLE were receiving immunosuppressive medications, and 15% were receiving glucocorticosteroids.
ACR guidelines are developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, which sets forth rigorous standards for judging the quality of the available literature and assigns strengths to the recommendations. Due to limited data in some areas, many of the recommendations were low to moderate in strength.
Both the guidelines and a separate paper detailing patient insights on perioperative management have been published in Arthritis Care & Research, a peer-reviewed medical journal by the ACR and the Association of Rheumatology Health Professionals (a division of the ACR). The guidelines and patient panel paper are also available on the ACR website.
The guidelines are intended for orthopedists, rheumatologists, and other physicians who conduct perioperative risk assessment and evaluation.
Susan M. Goodman, Bryan Springer, Gordon Guyatt, et al. "2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty," Arthritis Care & Research. Epublish ahead of print. June 16, 2017. DOI 10.1002/acr.23274