New Guideline Aims to Reduce Infections in TJA Patients with Rheumatic Disease

    In the first collaboration of its kind, an expert panel of orthopaedic surgeons and rheumatologists has developed guidelines on the management of anti-rheumatic medications during the perioperative period to reduce the risk of periprosthetic joint infection in patients with rheumatic disease who are undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA).

    “Periprosthetic joint infection remains one of the most common reasons for failure of hip and knee replacement,” said Bryan D. Springer, MD, an orthopedic surgeon at the OrthoCarolina Hip and Knee Center in Charlotte, North Carolina, who served as a co-principal investigator for the guideline project.

    “Because periprosthetic joint infections are associated with such high morbidity and mortality, we felt there was a dire need for perioperative management recommendations that could be subscribed to by both disciplines in order to provide arthritis patients with better outcomes.”

    Susan Goodman, MD, a rheumatologist at Hospital for Special Surgery in New York City, was co-principal investigator. She noted that “as infection risk is linked to the use of anti-rheumatic medication, our goal was to develop recommendations on when to stop medication prior to joint replacement and the optimal time for patients to restart treatment after surgery.”

    “Appropriate medication management in the perioperative period may provide an important opportunity to lower the risk of an infection or other adverse outcome.”

    8 Recommendations in the Guideline

    The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons sponsored the project, and the guidelines were published in Arthritis Care & Research, a peer-reviewed medical journal of the ACR and the Association of Rheumatology Health Professionals.

    The recommendations are based on a multi-step systematic literature view of thousands of published articles, clinical expertise and experience, and input from patients. The expert panel consisted of 31 specialists from more than 20 hospitals and professional organizations.

    The guideline they developed includes 8 recommendations for when to continue, withhold, and re-start medications commonly used to treat inflammatory rheumatic diseases, such as disease-modifying anti-rheumatic drugs (DMARDs), biologic agents, tofacitinib, and glucocorticoids, in patients undergoing THA or TKA who have any of the following:

    • Rheumatoid arthritis
    • Spondyloarthritis, including ankylosing spondylitis and psoriatic arthritis
    • Juvenile idiopathic arthritis
    • Systemic lupus erythematosus

    Among the main recommendations:

    • Discontinue biologic therapy prior to surgery in patients with inflammatory arthritis.
    • Withhold tofacitinib for at least 7 days prior to surgery in patients with rheumatoid arthritis, spondyloarthritis, or juvenile idiopathic arthritis.
    • Withhold rituximab and belimumab prior to surgery in all patients with systemic lupus erythematosus patients undergoing arthroplasty.
    • Withhold biologic medications as close to 1 dosing cycle as scheduling permits prior to elective THA or TKA and then restart them after evidence of wound healing, typically 14 days, for all patients with rheumatic diseases.

    Input from Patients

    The patient panel, which had significant input, attached far greater importance to preventing infection at the time of surgery than to the possibility of a disease flare from stopping medication.

    “There was a very clear message from the patient panel that they were willing to deal with flares if it meant reducing their likelihood for infections and other complications,” Dr. Goodman said.

    “The panel noted that this preference could differ in lupus patients where a flare could mean inflammation of the organs, which poses a greater risk to their health than getting an infection from continuing their medications.”

    The panel said that the guidelines address common clinical situations, but may not apply in exceptional or unusual situations. Although cost is a relevant factor in healthcare decisions, it was not considered in this project.

    The new guideline can be found here.