Kate Johnson

November 15, 2016

WASHINGTON, DC — Patients with inflammatory arthritis who undergo total hip or knee arthroplasty often fear postsurgical infection more than a flare of their condition, according to an 11-member panel of patients with rheumatoid arthritis or juvenile idiopathic arthritis.

This unexpected finding forms the basis of new guidelines drafted jointly by the American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons. They address the perioperative management of antirheumatic medication in patients undergoing elective total hip or knee arthroplasty.

"In routine practice, patients really hate having flares, so I was surprised," said Susan Goodman, MD, codirector of the Inflammatory Arthritis Center and associate professor of clinical medicine at the Weill Cornell Medical School in New York City.

Dr Goodman presented the guidelines here at the ACR 2016 Annual Meeting, along with Bryan Springer, MD, an orthopedic surgeon at OrthoCarolina Hip and Knee Center in Charlotte, North Carolina.

It is expected that the guidelines — which recommend the preoperative continuation of conventional disease-modifying antirheumatic drugs (DMARDs) but the discontinuation of biologics (with specific recommendations for systemic lupus erythematosus) — will have a significant effect on patient management, Dr Goodman and Dr Springer told the audience.

"Orthopedic surgeons are always concerned about infection — that's number one on our list. From a rheumatologist's standpoint, they're obviously concerned about flares. But this was never a case of them fighting flares and us fighting infections," Dr Springer explained.

"What broke that barrier were patient values and preferences. I don't think patients had a swing vote — we were all on the same page — but the patient panel solidified our thinking," he told Medscape Medical News.

Patients on the panel had a mean disease duration of 26 years and had undergone hip or knee replacement. One of the panel members experienced a prosthetic joint infection.

"Their overwhelming priority was decreasing the risk of infection," Dr Goodman reported.

The patients "felt they knew how to deal with flares — their lives were set up to manage flares — but they felt the burden of infection was significantly greater than the burden of flare. So they voted that surgery be timed to the drug-dosing cycles," she explained.

On the basis of patient input and a search of published evidence, which is sparse, the guidelines team proposed eight conditional recommendations for patients undergoing elective total hip or knee arthroplasty who have a diagnosis of rheumatoid arthritis, juvenile idiopathic arthritis, spondyloarthritis (including ankylosing spondylitis), psoriatic arthritis, or systemic lupus erythematosus.

The team recommends continuing current doses of synthetic DMARDs but withholding current biologics prior to surgery; withholding tofacitinib for at least 7 days before surgery; restarting biologic therapy as soon as the surgical wound shows evidence of healing (normally about 14 days); and continuing the current daily dose of glucocorticoids rather than a perioperative supraphysiologic glucocorticoid dose (so-called stress dosing).

For patients with systemic lupus erythematosus, the team recommends withholding current treatment with rituximab and belimumab prior to surgery and planning surgery for the end of a dosing cycle. The also recommend continuing current doses of methotrexate, mycophenolic acid, azathioprine, mizoribine, cyclosporine, and tacrolimus in patients with severe disease, but withholding them for patients whose condition is not severe for 7 days before surgery until 3 to 5 days after surgery, unless wound-healing complications or infections arise.

Because of the poor quality of the evidence — there are no randomized controlled trials of the perioperative use of biologics — "we have to consider these recommendations conditional," Dr Goodman cautioned.

Guidelines "Overcautious"

Initial reaction to the guidelines suggest that there might be some pushback from rheumatologists.

"Newer evidence being presented at this meeting suggest these guidelines are overcautious," said Jeffrey Curtis, MD, a rheumatologist from the University of Alabama at Birmingham.

That evidence comes from a study Dr Curtis was involved in, which was presented by Michael George, MD, from the University of Pennsylvania in Philadelphia.

The retrospective cohort study of Medicare data involved 4288 elective total knee or hip arthroplasties. Patients with rheumatoid arthritis, inflammatory bowel disease, psoriasis, psoriatic arthritis, or ankylosing spondylitis received infliximab in the 6 months before surgery.

The researchers compared patients who stopped infliximab less than 4 weeks before surgery with those who stopped 4 to 8 weeks, 8 to 12 weeks, and 12 to 16 weeks before surgery. They found no increased risk for 30-day postoperative infection or 1-year prosthetic joint infection in patients who stayed on infliximab longer.

In fact, one of the most significant risk factors for infection was glucocorticoid administration.

"If people are stopping therapy but increasing glucocorticoids, that could be a major problem," Dr George pointed out.

If a flare leads to "glucocorticoids, which then leads to an infection, patients end up with both," he told Medscape Medical News.

"The patient concern about a higher infection risk is actually completely irrelevant if there is no higher infection risk," Dr Curtis explained. "I acknowledge that patients think it is very important, but if there's no extra risk, then they don't have to be afraid."

Dr Goodman and Dr Springer have disclosed no relevant financial relationships. Dr Curtis reports financial relationships with Roche/Genentech, UCB, Janssen, Corrona, Amgen, Pfizer, BMS, Crescendo, AbbVie

American College of Rheumatology (ACR) 2016 Annual Meeting: Abstract 2052. Presented November 14, 2016.


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