Collaboration Among Providers Can Improve Rheumatoid Arthritis Outcomes

Dr Susan Goodman, the Associate Director of the Inflammatory Arthritis Center at Hospital for Special Surgery in New York, couldn’t resist the pun:

“Clearly, this was going to be a joint operation, and it really turned out to be an enormous amount of fun.”

She, alongside Dr Bryan Springer, an Orthopedic Surgeon at the OrthoCarolina Hip and Knee Center in North Carolina, spoke together at the 2016 American College of Rheumatology Annual Meeting about a collaboration between rheumatologists and orthopedists. With extensive literature review and expert input, the ACR and the American Association of Hip and Knee Surgeons (AAHKS) have come together to propose a set of guidelines for medication during the perioperative period for patients undergoing knee or hip arthroplasty.

Despite the increasingly widespread use of potent biologic or disease-modifying antirheumatic drugs (DMARDs), the prevalence of such large joint arthroplasty operations remains constant, according to Goodman. The majority of patients seeking such surgeries are also undergoing those treatments, creating a need for the surgeons and prescribing rheumatologists to jointly address any possible complications they may cause.

“The rheumatic disease patients, both those with inflammatory arthritis and lupus, are at high risk for complications related to surgery or arthroplasty,” Goodman explained in the press conference. "We know the incidence of infection is increased in these patients, and these are really devastating complications."

Because disease severity and general debility are not modifiable factors, it becomes even more necessary for clinicians to monitor the things they can control, like medication.

The group’s first recommendation was that synthetic DMARDs should continue to be taken throughout the time of surgery, citing data that showed risk of infection actually was decreased in their use. Biologics, based on previous randomized control trial data outside of the surgical setting, did however show an increased risk.

Lupus patients presented a particular set of a considerations. Observational studies had shown those with severe manifestations of the disease had high perioperative risk, they still recommended the continuation of synthetic DMARD treatment. Biologics, however, were recommended to be withheld.

For lupus that was not deemed severe, they recommended all medications be discontinued for time of surgery, as the team considered a flare of the disease to present a lower chance of morbidity than an operative infection.

They did not recommend cessation of glucocorticoids, but suggested that those on high doses be tapered down before clearing them for surgery.

Dr Springer noted the importance of an official recommendation, detailing a typical go-between that occurs between rheumatologists, arthritic patients, and surgeons in an effort to mitigate risks.

Conflicting opinions between specialists as to whether or not, and for how long, the rheumatic medications should be discontinued, and the time it takes for the 3 parties involved to communicate, can cause uncertainty and lengthy delays for patient treatment.

“In the literature, particularly in the orthopedic literature, there’s really nothing to guide us on how to manage these patients that come in that are high risk,” Springer said. “I think the importance of this guideline is that we now have a document that’s based on available evidence and expert opinion to help us manage these patients much more thoroughly around the perioperative period.”

Before the press conference, he was asked to ponder whether or not the guidelines were a “win” for orthopedic surgeons. He said if just the American Academy of Hip and Knee Surgeons or just the American College of Rheumatology came out with these guidelines unilaterally, the other organization would frown upon it.

“This was never like an 8th grade dance, where the boys were on one side and the girls were on one side and only occasionally someone came to the middle to dance," Springer said. "I think we all went into this with very open minds, and with the patient first.

“It’s really a win for the patients, and really a win for collaborative efforts and research, which we just don’t do enough of in many fields.”

The ACR and AAHKS’s collaborative Recommendations for Perioperative Management of Rheumatic Disease Medications are currently awaiting peer review, and are on track to be published later in 2016.