Infection Greater Worry Than Flare: Collaborative Guideline Offers Guidance to Prevent Joint Replacement Complications & Failure

“We felt that guidance was needed for the common clinical situations even where the data were sparse,” said Susan M. Goodman, MD, a rheumatologist at the Hospital for Special Surgery in New York City, and the project’s co-principal investigator. “We didn’t want to configure treatment mandates—that’s not what this is about. This doesn’t replace any of the perioperative management or optimization of the patient.” The panelists did not take medication cost into account for these recommendations, she noted.

Susan M. Goodman, MD, a rheumatologist at the Hospital for Special Surgery in New York City, and the project’s co-principal investigator.

Patient Panelists Weigh In
The day before the guideline panel voted on the recommendations, Drs. Goodman and Singh and ACR staff met with 11 adult patients who have either RA or JIA, to hear their input on the questions the panel would discuss the next day. These patients strongly prioritized infection prevention over flare risk, said Dr. Goodman.

“We wanted to try to understand why. I see patients every day, and they hate flares. Yet the patient panelists felt the perioperative flare was a much more controlled risk than an infection,” said Dr. Goodman. “They thought flares were difficult, but that infections could considerably postpone their recovery and introduce other problems. Their overwhelming priority was lowering the risk of infection.”

The patient panelists also noted that people with lupus might view flare as a greater risk than infection, because it could be either organ or life threatening. Carefully consider your patient’s values and preferences when implementing these recommendations, she said.

Draft Recommendations
Here are the draft recommendations produced by the group, which are being reviewed for ACR, AAHKS and journal approval now:

• Continue the current dose of methotrexate, leflunomide, hydroxychloroquine and sulfasalazine for patients undergoing hip or knee replacement surgery;
• Withhold all current biologic therapies prior to surgery in patients with inflammatory arthritis, and plan surgery at the end of the drug dosing cycle;
• Withhold tofacitinib for at least seven days before surgery in patients with RA, spondyloarthritis and JIA;
• Withhold rituximab and belimumab prior to surgery in all SLE patients undergoing arthroplasty, and plan the surgery at the end of the dosing cycle;
• For patients with severe lupus, continue the current dose of methotrexate, mycophenolic acid, azathioprine, mizoribine, cyclosporine or tacrolimus through surgery;
• For patients whose lupus is not considered severe, withhold these medications for seven days prior to surgery and for three to five days after surgery, in the absence of complications;
• Restart biologic therapy in patients with inflammatory arthritis once the wound shows evidence of healing, which is usually after about 14 days; and
• Continue the current, usual daily dose of glucocorticoids in adults with RA, spondyloarthritis or SLE, rather than stress dosing after surgery.

Project Limitations & Strengths
Limitations for the guideline project included “the paucity of high-quality, direct evidence for medications and perioperative risk,” said Dr. Goodman. “For the most part, we used indirect evidence from randomized controlled trials performed on patients not undergoing surgery, and then we applied that evidence to the surgical setting for these recommendations.”