Medication Management Guidelines Released for Rheumatic Disease Patients Undergoing Joint Replacement

New guidelines have been released regarding the perioperative management of anti-rheumatic medication in patients undergoing total hip or knee replacement.

The guidelines, published in Arthritis Care & Research, aim to reduce the risk of joint infection post-surgery, according to the authors.

“Patients with rheumatic diseases who have joint replacement surgery are at increased risk for joint infection, a potentially devastating complication,” said co-principal investigator Susan Goodman. “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 outcomes.”

The guidelines are based on an extensive review of available literature, clinical expertise and experience, and patient input. The expert panel consisted of 31 specialists from more than 20 hospitals and professional organizations.

“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 said. “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.”

The new medication guidelines pertain to adults with rheumatoid arthritis (RA), spondyloarthritis—–including ankylosing spondylitis and psoriatic arthritis––juvenile idiopathic arthritis, and lupus, who are undergoing hip or knee replacement surgery.

In a multi-step systematic literature review, investigators screened thousands of articles and compiled evidence for continuing anti-rheumatic treatment versus withholding medication in the perioperative period. Additionally, the investigators sought to develop optimal steroid management recommendations during this period.

Included in the study were traditional disease-modifying anti-rheumatic drugs (DMARDs), biologic agents, tofacitinib, and glucocorticoids.

The primary recommendations included: non-biologic DMARDs can be continued throughout the perioperative period in patients with RA, spondyloarthritis, juvenile idiopathic arthritis, and lupus who are undergoing elective hip or knee replacement surgery; and biologic medications should be withheld as close to 1 dosing cycle as scheduling permits prior to elective hip or knee replacement and restarted after evidence of wound healing—–usually 14 days––among all patients with rheumatic diseases.

“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 said. “Communication is key. It is imperative that open and informed communication between the patient, orthopedic surgeon, and rheumatologists take place.”

Although the guidelines address common clinical situations, they may not apply in exceptional or usual situations, the panel noted.