Managing antirheumatic medication in patients undergoing elective arthroplasty

A need for a new guideline

For the patient undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA), the advice given as to whether or not to continue with antirheumatic therapy during the perioperative period can be quite varied. On the one hand, rheumatologists frequently advise their patients to continue with their treatment, especially with non‑biologic therapies, during the perioperative period. On the other hand, orthopedic surgeons, aspiring to reduce any possible risk or adverse outcome, may advise their patient to do quite the opposite, and to discontinue all antirheumatic therapy for a considerable period. In the latter setting it is not uncommon for the patient’s underlying rheumatic disease to flare, often quite badly, which in turn may interfere with a patient’s rehabilitation or return to normal function. Up until now, in trying to find the narrow path between what evidence was available and the concerns of my orthopedic colleagues, I frequently would advise my patients to hold their synthetic or biologic disease-modifying antirheumatic drug (DMARD) for one dose preoperatively, and to restart their medication once the stitches are out and the wound has healed.

Development of the guideline

The 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons' guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective THA or TKA [1] is a most welcome development, providing physicians, surgeons and patients alike with advice as to best practice based on the currently available evidence. Having identified the key clinical questions to be answered in the guideline, the panel of rheumatologists, orthopedic surgeons and methodologists undertook a systematic literature review seeking evidence for continuing versus withholding antirheumatic drug therapy and for optimal glucocorticoid management in the perioperative period. An additional patient panel determined patient values and preferences and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to rate the quality of the evidence and the strength of the recommendations.

Guideline summary

The guideline is focused on adults with rheumatoid arthritis, spondyloarthritis including ankylosing spondylitis and psoriatic arthritis, juvenile idiopathic arthritis or systemic lupus erythematosus (SLE) undergoing THA or TKA. The guideline includes seven conditional recommendations, and is based on the low or moderate quality evidence that was found. Table 2 in the guideline highlights the seven recommendations, together with key pieces of evidence and the level of evidence for each recommendation. In brief the conditional recommendations are as follows: 

1. Current dose of methotrexate, leflunomide, hydroxychloroquine and/or sulfasalazine can be continued for patients undergoing elective THA or TKA.
2. All current biologic agents should be withheld prior to surgery in patients undergoing elective THA or TKA. The surgery should be planned at the end of the dosing cycle for that specific medication. Thus for example, for infliximab given every 8 weeks, the elective surgery should be planned for the 9th week following the last infliximab infusion.
3. For patients being treated with tofacitinib, the medication should be withheld at least 7 days prior to undergoing THA or TKA.
4. In patients with severe SLE, the current dose of mycophenolate mofetil, azathioprine, cyclosporine or tacrolimus can be continued during the surgical period in all patients undergoing THA or TKA.
5. For patients with non‑severe SLE, current dose of mycophenolate mofetil, azathioprine, cyclosporine or tacrolimus should be withheld 1 week prior to surgery in all patients undergoing THA or TKA.
6. Biologic therapy, in patients for whom biologic therapy was withheld prior to undergoing THA or TKA, should be restarted once the wound shows evidence of healing (typically approximately 14 days), all sutures/staples are out, there is no significant swelling, erythema or drainage and there is no evidence of non‑surgical site infections.
7. The current daily dose of glucocorticoids, in adult patients who are receiving glucocorticoids for their rheumatic condition and undergoing THA or TKA, should be continued rather than administering perioperative supraphysiologic glucocorticoid doses.

Conclusion

In relation to all of these recommendations, readers are encouraged to refer to the published guideline for more details. It is important to emphasize that the recommendations that form this guideline are not treatment mandates, and also that not all potential perioperative clinical scenarios are covered by the guideline. The recommendations provide important guidance that was informed by the available literature, clinical expertise and experience. Furthermore the guideline reflects patient values and preferences. Given the low‑quality evidence in this area for a number of the clinical questions, it is clear that more detailed research with larger cohorts is required. With advancing knowledge, it is likely that the guideline will require refinements and modification in the years ahead. But for now, the guideline provides clinicians with some support for their clinical decisions together with the available evidence. This guideline provides clear advice while acknowledging the limitations of our current knowledge base. Each clinician should apply the guideline with the knowledge of the individual patient being considered and the specific risks that may be pertinent.