New York, NY—June 16, 2017
In the first such collaboration of its kind, an expert panel of rheumatologists and orthopedic surgeons has developed guidelines for the perioperative management of anti-rheumatic medication in patients undergoing total hip or knee replacement.
"Patients with rheumatic diseases who have joint replacement surgery are at increased risk for joint infection, a potentially devastating complication," said Susan Goodman, MD, co-principal investigator and a rheumatologist at Hospital for Special Surgery in New York City. "As infection risk is linked to the use of anti-rheumatic medication, our goal was to develop recommendations on when to stop medication prior to joint replacement and the optimal time for patients to restart treatment after surgery. Appropriate medication management in the perioperative period may provide an important opportunity to lower the risk of an infection or other adverse outcome."
The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons sponsored the project, and the guidelines were published in Arthritis Care & Research, a peer-reviewed medical journal of the ACR and the Association of Rheumatology Health Professionals. The recommendations are based on an extensive review of the available literature on the subject, clinical expertise and experience, and input from patients.
The expert panel consisted of 31 specialists from more than 20 hospitals and professional organizations. The medication guidelines concern adults with rheumatoid arthritis; spondyloarthritis, including ankylosing spondylitis and psoriatic arthritis; juvenile idiopathic arthritis; and lupus undergoing hip or knee replacement.
"Prior to our study, there was little to no consensus among orthopedic surgeons or rheumatologists on the optimal way to manage anti-rheumatic medication in patients having joint replacement surgery, and this often led to uncertainty in decision-making for physicians and patients alike," Dr. Goodman noted. "Our project brought together hip and knee replacement surgeons, rheumatologists and methodologists to determine optimal medical management through a group consensus process. In addition, a panel of 11 patients provided input on their preferences."
Investigators conducted a multi-step systematic literature review, screening thousands of articles. Evidence was compiled for continuing anti-rheumatic treatment versus withholding medication in the perioperative period. Researchers also sought to develop recommendations for optimal steroid management during this time.
The study included traditional disease-modifying anti-rheumatic drugs (DMARDs), biologic agents, tofacitinib, and glucocorticoids. The panel developed guidelines on when to continue, when to withhold, and when to restart these medications, as well as the optimal perioperative dosing of corticosteroids.
Among the main recommendations:
• Non-biologic DMARDs may be continued throughout the perioperative period in patients with rheumatoid arthritis, spondyloarthritis, juvenile idiopathic arthritis and lupus undergoing elective hip or knee replacement.
• Biologic medications should be withheld as close to one dosing cycle as scheduling permits prior to elective hip or knee replacement and restarted after evidence of wound healing, typically 14 days, for all patients with rheumatic diseases.
The patient panel, which had significant input, attached far greater importance to preventing infection at the time of surgery than to the possibility of a disease flare from stopping medication.
"The recommendations are intended for use by clinicians, including orthopedists, rheumatologists, and other physicians performing risk assessment and evaluation, as well as by patients," Dr. Goodman noted. "Communication is key. It is imperative that open and informed communication between the patient, orthopedic surgeon and rheumatologist take place."
The panel noted that the guidelines address common clinical situations, but may not apply in exceptional or unusual situations. While cost is a relevant factor in healthcare decisions, it was not considered in this project.
To view the guidelines, authors and institutions involved, visit https://www.rheumatology.org/Portals/0/Files/ACR-AAHKS-Perioperative-Management-Guideline.pdf
About HSS | Hospital for Special Surgery
HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the ninth consecutive year) and No. 3 in rheumatology by U.S.News & World Report (2018-2019). Founded in 1863, the Hospital has one of the lowest infection rates in the country and was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center four consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State. In 2017 HSS provided care to 135,000 patients and performed more than 32,000 surgical procedures. People from all 50 U.S. states and 80 countries travelled to receive care at HSS. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The culture of innovation is accelerating at HSS as 130 new idea submissions were made to the Global Innovation Institute in 2017 (almost 3x the submissions in 2015). The HSS Education Institute is the world’s leading provider of education on the topic on musculoskeletal health, with its online learning platform offering more than 600 courses to more than 21,000 medical professional members worldwide. Through HSS Global Ventures, the institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally.