Wednesday, 20 Nov 2019

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ACR/AAHKS Guidelines on Perioperative Management

The American College of Rheumatology has partnered with the American Association of Hip and Knee Surgeons to develop consensus-based guidelines for perioperative management of antirheumatic therapies for patients with rheumatic diseases who plan to undergo total joint replacement.

A multidisciplinary panel of orthopedists, rheumatologists and patients reviewed the available evidence regarding the safety of steroid, DMARD or biologic perioperatively, with the primary goal being the reduction in infectious risk and perioperative infections. The recommendations are primarily expert opinion with some guidance from prior studies.

The ACR published these new ACR/AAHKS guidelines on its website (Citation source: http://buff.ly/2rSoja8 ).

These are intened to aid the managment of patients with inflammatory rheumatic diseasea undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA).

The guidelines discuss perioperative management of patients with rheumatoid arthritis (RA), spondyloarthritis (SpA), juvenile idiopathic arthritis (JIA) and systemic lupus erythematosus (SLE).

These guidelines specifically address the use of corticosteroids, DMARDs, biologic agents, and tofacitinib.

7 Primary Recommendations Governing Anti-Rheumatic Drug Use in Rheumatic disease Patients Undergoing Elective THA or TKA:

  1. Nonbiologic-DMARDs should be continued in the during and throughout the perioperative period for patients TKA or THA.
  2. Biologic therapies should be withheld for surgery and prior to surgery, biologics should be held for one-dosing cycle or surgery should be planned for the end of the dosing cycle. of that medication.
  3. Tofacitinib be withheld 7 days before surgery in patients with RA, SpA and JIA.
  4. Severe SLE patients: continue methotrexate, mycophenolate mofetil, azathioprine, cyclosporine or tacrolimus in cases with severe SLE through the surgical period.
  5. However, non-severe SLE: mycophenolate mofetil, azathioprine, cyclosporine or tacrolimus should be withheld 1 week before patients undergo total joint replacement.
  6. Biologic therapy that was withheld prior to surgery should be re-started with evidence of wound healing and no sign of infection or drainage (~14 days).
  7. There is no need/utility to "stress dose steroids" for those on chronic steroids; the panel recommended the continued use of daily dose of glucocorticoids for patients throughout surgery.

The evidence for each of these was low as there are few if any well designed trials to answer these questions conclusively.

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

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