ACR Updates Guideline for Medication Management in Hip or Knee Arthroplasty

The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) published an updated version of their guideline for perioperative managment of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or knee anthroplasty.

The previous guideline addressing this topic was released by the organizations in 2017. Since then, new data have been attained that led investigators to recommend withholding biologic medications in patients with inflammatory arthritis (IA) for a dosing cycle prior to surgery. These patients should schedule the surgery for after the time of the abstained dose.

In addition to inflammatory arthritis, the guideline states recommendations for people with system lupus erythematosus (SLE), spondyloarthritis (SpA), juvenile idopathic arthritis (JIA), rheumatoid arhtritis among other inflammatory arthritis conditions.

“Patients with rheumatic diseases such as rheumatoid arthritis or psoriatic arthritis are at a much higher risk for adverse events, particularly infections, after total hip and total knee replacement,” Susan M Goodman, MD, Rheumatologist at the Hospital for Special Surgery and co-principal investigator of the guideline said in a statement.

“Some risk factors for infection, such as disease severity or overall disability, are not modifiable," she continued, "but immunosuppressing medications used to treat rheumatic musculoskeletal diseases are an accessible target where perioperative management may decrease risk."

If it's possible to withhold biologics in patients with less severe cases of SLE and low risk of organ damage, rheumatologists should do so according to a new recommendation. However, it's crucial to continue treating patients who have severe cases of SLE with biologics.

Some new medications were introduced in the guideline that don't yet have any data in relation to joint replacement surgery. The immunosuppressant medications, anifrolumab and voclosporin are implemented in SLE treatment and increase the risk of infection, and therefore warrant a review by the rheumatologist for patietns with severe SLE cases considering surgery.

“While these new medications do not have any data as of yet related to joint replacement surgery, the guideline development team felt it was important to include them to allow for a discussion of the risks, benefits and shared decision making between doctor and patient,” Bryan D Springer, MD, first vice president of AAHKS and co-principal investigator of the guideline said in a statement.