Due to immunosuppressive medications and other disease factors, patients with inflammatory arthritis or systemic lupus erythematosus (SLE) are at increased risk of infection following total hip arthroplasty (THA) or total knee arthroplasty (TKA). However, withholding such medications around the time of surgery increases the risk of disease flares. A new guideline update recently released by the ACR and the American Association of Hip and Knee Surgeons (AAHKS) provides clinicians with specific information to help with perioperative management.1
DMARD Guidance
In 2017, the ACR and the AAHKS collaboratively produced the first guideline on perioperative management of these patients, specifically with respect to the use of disease-modifying anti-rheumatic drugs (DMARDs).2 The recently released guideline update reflects changes in the medical literature since that time. It also provides specific recommendations on therapies newly approved by the U.S. Food & Drug Administration (FDA) for these conditions (e.g., ixekizumab).
Post-surgery infections occur more often in patients with rheumatoid arthritis, spondyloarthritis and SLE than in patients with osteoarthritis, which is the most common reason for these replacements in the general population.2 For example, one study found that patients with rheumatoid arthritis had twice the risk of developing an infection in the region surrounding their new prosthetic joint compared with patients with osteoarthritis.3 The guideline recommendations are designed to balance the risks of post-surgical infection with the risks of disease flare, which can be quite serious in such conditions as severe SLE.
Dr. Singh
One of the guideline panel participants, Jasvinder A. Singh, MD, MPH, professor of medicine and epidemiology at the University of Alabama at Birmingham and a staff rheumatologist at the Birmingham Veterans Affairs Medical Center, notes these infections can range in severity from mild suture infections to deep infections that spread into the joint and prosthesis. “Although rare, the latter are disastrous—a huge deal for both the patient and the surgeon,” he says.
Dr. Singh explains that recovery from such infections can require multiple surgeries over a one- to two-year period, causing major issues with patient disability and immobility, as well as a high risk of reinfection when a new prosthesis is eventually surgically implanted.
Dr. Goodman
Lead guideline author Susan M. Goodman, MD, professor of clinical medicine at Weill Cornell Medicine and an attending rheumatologist at the Hospital for Special Surgery, New York City, notes that the patients who participated in the patient panel on the 2017 guideline were more concerned about infection risk than the risk of flare, even though disease flares after surgery may occur in more than half of patients.1,2 “They were remarkably unified in their concern about infection,” Dr. Goodman says. “They felt that while flares were very difficult, infections could become severe, and their unpredictable nature was even more difficult.”
