For their patients with inflammatory arthritis, rheumatologists and orthopedic surgeons must weigh the possibility of increasing the risks of postoperative infection, one of the top causes of joint implant failure for patients who continue anti-rheumatic drugs through the perioperative period, against an increased risk of flare if anti-rheumatic drugs are stopped prior to the procedure.
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Explore This IssueJanuary 2017
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To address this dilemma, the ACR and the American Association of Hip and Knee Surgeons (AAHKS) have collaborated to draft a new guideline, Perioperative Management of Anti-Rheumatic Medications in Patients with Rheumatic Diseases Undergoing Elective Total Hip or Knee Arthroplasty. The recommendations, which are now being reviewed for approval by the two associations, were discussed at a session held Mon., Nov. 14, at the 2016 ACR/ARHP Annual Meeting in Washington, D.C.
“Periprosthetic joint infection is a major problem after hip and knee replacement,” said Bryan D. Springer, MD, an orthopedic surgeon in Charlotte, N.C., and the co-principal investigator for the guideline project. “If you look at the five-year survival rate for a patient who develops a periprosthetic joint infection, their risk of death five years after that infection is actually higher than that of the five most common cancers in the United States. So it has a significant impact on our patients.”
Updating the Literature
Current literature offers little to guide rheumatologists and surgeons on how to manage medications in the perioperative period for patients undergoing elective arthroplasty, said Dr. Springer.
The new recommendations, which are the first collaboration between the ACR and AAHKS, are designed to guide treatment of adult patients with rheumatoid arthritis (RA), spondyloarthritis, psoriatic arthritis, juvenile idiopathic arthritis (JIA) and systemic lupus erythematosus (SLE) who are undergoing elective total hip or knee arthroplasty.
When developing the recommendations, project leaders first developed the following four PICO (Population Intervention Comparison Outcome) questions, said Jasvinder Singh, MD, MPH, professor of medicine at the University of Alabama at Birmingham, and the rheumatologist co-literature review leader for this project:
- Should anti-rheumatic drugs be held or not in the perioperative period?
- If so, when should the drugs be stopped?
- When should the drugs be restarted?
- In patients using glucocorticoids, should the usual dose or a stress dose be given at the time of surgery?
Panelists reviewed, synthesized and ranked existing literature using the GRADE methodology, said Dr. Singh. Most of the data were indirect, including no study that compared stopping or continuing biologics in the surgical setting. The key outcomes they explored in the literature were infection, flare, deep and superficial surgical site infections and death, he said. Due to the lack of direct evidence, the recommendations are conditional, rather than strong.