Updated guideline released for managing antirheumatic drugs in patients undergoing hip or knee replacement

The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) released a summary of their updated guideline for the Perioperative Management of Antirheumatic Medication in Patients with Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty.

The guideline, updated from the organizations' 2017 joint guideline on the same topic, includes recommendations for people with systemic lupus erythematosus (SLE), spondyloarthritis (SpA), juvenile idiopathic arthritis (JIA), rheumatoid arthritis and other forms of inflammatory arthritis (IA). It also includes a list of medications patients should continue to take through surgery and a list of medications to withhold prior to surgery.

Patients with rheumatic diseases such as rheumatoid arthritis or psoriatic arthritis are at a much higher risk for adverse events, particularly infections, after total hip and total knee replacement. Some risk factors for infection, such as disease severity or overall disability, are not modifiable, but immunosuppressing medications used to treat rheumatic musculoskeletal diseases are an accessible target where perioperative management may decrease risk. New data and medications have become available since our last guideline in 2017, so we felt it was important to update our recommendations."

Susan M. Goodman, MD, attending rheumatologist at the Hospital for Special Surgery and co-principal investigator of the guideline

That new data prompted guideline investigators to recommend withholding biologic medications in patients with IA, withholding medication for a dosing cycle prior to surgery and scheduling the surgery after that dose is due. For example, if a patient takes their medication every four weeks, the patient should withhold a dose of medication and schedule surgery on the fifth week after their last dose.

Another important recommendation is to continue treating patients with severe SLE with biologics, but to withhold biologics in less severe cases where there's little risk of organ damage. The guideline recommends shortening the time between the last dose of JAK inhibitors and surgery, from seven to three days, to avoid early flares.

The updated guideline also includes recently introduced immunosuppressive medications, anafrolumab and voclosporin, which are used to treat SLE. Although the medications are included in the guideline, there is no published, peer reviewed data regarding their use in the perioperative period. The medications do increase the risk of infection, and therefore their use in patients with severe SLE would merit review by the treating rheumatologist in consideration of surgery.

"While these new medications do not have any data as of yet related to joint replacement surgery, the guideline development team felt it was important to include them to allow for a discussion of the risks, benefits and shared decision making between doctor and patient," said Bryan D. Springer, MD, first vice president of AAHKS and co-principal investigator of the guideline.

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