Full ACR Guideline on Medication Management for Hip, Knee Anthroplasty Released

The latest recommendations referencing the medical management of patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty was just published by the American College of Rheumatology (ACR)/American Association of Hip and Knee Surgeons (AAHKS) with a focus on perioperative use of disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids (GCs).

While the last full guideline update was published in 2017, a summary of the updated recommendations was released earlier this year because new data were discovered that led investigators to recommend withholding biologic medications in patients with inflammatory arthritis (IA) for a dosing cycle prior to surgery.

According to professionals, these patients should schedule the surgery for after the time of the abstained dose.

Now, the full manuscript is available to elaborate on the earlier summary of antirheumatic medication for patients recovering from a total hip or total knee anthroplasty.

Perioperative Guideline Recomendations for THA, TKA

Patients who are undergoing elective THA or TKA with rheumatoid arhtritis (RA), psoriatic arhtritis (PsA), systemic lupus erythematosus (SLE), juvenile idiopathic arthritis (JIA), and ankylosing spondyloarthritis (AS) should continue their routine DMARDs through surgery based on their individual case if they're on methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, and/or apremilast.

Withholding all biologics prior to surgery and planning surgery after the next dose is conditionally recommended for patients with RA, PsA, JIA, and AS. Additonally, these patients who are taking tofacitinib, upadacitinib, and baricitinib should generally withold for 3 or more days prior to surgery.

For these patients, 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.

For these populations of patient receiving GCs it's recommended to continuethe current dose of GCs instead of administering supraphysiologic doses of GCs on the day of surgery.

Systemic Lupus Erythematosus

If individuals with SLE pursue a procedure, it's recommended that they continue the usual dose of mycophenolate mofetil, cyclosporine, mizoribine, azathioprine, mycophenolic acid, or tacrolimus, anifrolumab, and voclosporin.

However, those with severe SLE undergoing THA or TKA should plan surgery in the last month of the dosing cycle of rituximab and continue belimumab treatment.

Those with SLE (not severe) should abstain from the current dose of mizoribine, cyclosporine, azathioprine, mycophenolic acid, mycophenolate mofetil, or tacrolimus 1 week before surgery. Another recommendation for these patients is to withhold the usual dose of rituximab and belimumab prior to surgery.

Of course, all recommendations are to be individually assessed and conditonally based on patient and disease presentation.

“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 wrote.