WASHINGTON, D.C.—Total joint arthroplasty is one of the most common surgical procedures performed on adults with end-stage arthritis. One recent estimate showed that 2.5 million individuals in the U.S. are living with a total hip replacement and 4.7 million are living with knee replacements.
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.
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.
“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.
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.
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.”
The recommendation to withhold biologics before surgery and plan the procedure at the end of the dosing cycle was based on various data that suggested “the infection risk for biologics was associated with high-dose therapy, higher than standard, and wasn’t as clearly related to patients receiving low-dose therapy,” said Dr. Goodman. “We were also concerned that the serum half-life probably didn’t correspond to the duration to the immunosuppressant effect, so we felt the dosing cycle would give us the more rational approach to the withholding period.”
Patient input was a notable strength of this project, Dr. Goodman said.
“We had very clear guidance in terms of the values and preferences of the patient panel. They were very helpful in directing this effort. They found that infection was much more important than flare. They were in favor of postponing medication when the risk of infection would be increased,” she said.
Missed This Important Session?
If you were unable to attend the session, Perioperative Management of Anti-Rheumatic Medications in Patients with Rheumatic Diseases Undergoing Elective Total Hip or Knee Arthroplasty, catch it now on SessionSelect.
Susan Bernstein is a freelance medical journalist based in Atlanta.