ACR, AAHKS Updates Guidelines for Patients with Rheumatic Disease Undergoing Knee, Hip Surgery

The American College of Rheumatology (ACR)/American Association of Hip and Knee Surgeons (AAHKS) has published guidance regarding the management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty, with emphasis placed on perioperative use of disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids (GCs). The last guideline update was published in 2017.

“Advances in antirheumatic therapy have led to remarkable improvements in treatment and quality of life for people with rheumatic musculoskeletal diseases (RMDs); however, total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain a mainstay of treatment among RMD patients with advanced symptomatic joint damage, most frequently those with inflammatory arthritis (IA), including spondylarthritis (SpA), rheumatoid arthritis (RA), or psoriatic arthritis (PsA), and those with systemic lupus erythematosus (SLE),” investigators stated.

Top Insights:

• Patients with RA, PsA, SLE, juvenile idiopathic arthritis (JIA), and ankylosing spondyloarthritis (AS) who are undergoing elective THA or TKA: continuing the usual DMARDs through surgery is conditionally recommended for methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, and/or apremilast.
• Patients with RA, PsA, JIA, and AS who are undergoing elective THA or TKA: withholding all biologics prior to surgery and planning surgery after the next dose is conditionally recommended.
• Patients with RA, PsA, JIA, and AS who are undergoing THA or TKA: withholding tofacitinib, upadacitinib, and baricitinib for 3 or more days prior to surgery is conditionally recommended.
• Patients with SLE who are interested in THA or TKA: continuing the usual dose of mycophenolate mofetil, cyclosporine, mizoribine, azathioprine, mycophenolic acid, or tacrolimus, anifrolumab, and voclosporin is conditionally recommended.
• Patients with severe SLE undergoing THA or TKA: planning surgery in the last month of the dosing cycle of rituximab and continuing belimumab treatment is conditionally recommended.
• Patients with SLE (not severe) undergoing THA or TKA: withholding the current dose of mizoribine, cyclosporine, azathioprine, mycophenolic acid, mycophenolate mofetil, or tacrolimus 1 week before surgery is conditionally recommended.
• Patients with SLE (not severe) undergoing THA or TKA: withholding the usual dose of rituximab and belimumab prior to surgery is conditionally recommended.
• Patients with severe SLE undergoing THA or TKA: continuing belimumab and planning surgery in the last month of the dosing cycle of rituximab is conditionally recommended.
• Patients with RA, PsA, AS, and SLE who had antirheumatic therapy withheld prior to undergoing THA or TKA: therapy should be restarted once wound begins to heal, there is no significant swelling, erythema, or drainage, sutures and/or staples are out, and there is no nonsurgical site infection. This occurs roughly 2 weeks after surgery and is conditionally recommended.
• Patients with RA, AS, PsA, and SLE undergoing THA or TKA receiving GCs: continuing current dose of GCs instead of administering supraphysiologic doses of GCs on the day of surgery is conditionally recommended.