Atlanta—Cautious management of antirheumatic medications during the perioperative period can help reduce joint infections related to total hip and knee replacement.

That’s according to a new guideline released by the American College of Rheumatology (ACR) and American Association of Hip and Knee Surgeons (AAHKS). The recommendations, published in Arthritis Care & Research, are the first to be cooperatively developed by rheumatologists and orthopedic surgeons, according to authors of the report.

“Periprosthetic joint infection remains one of the most common reasons for failure of hip and knee replacement,” explained coprincipal investigator Bryan D. Springer, MD, an orthopedic surgeon at the OrthoCarolina Hip and Knee Center in Charlotte, North Carolina, and AAHKS Education Council Chair. “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.”

The panels creating the guidelines offer advice on when to continue, withhold and re-initiate medications commonly used to treat inflammatory rheumatic diseases such as rheumatoid arthritis, spondyloarthritis, and systemic lupus erythematosus. They also offer recommendations on perioperative dosing of glucocorticoids.

The document suggests discontinuing biologic therapy prior to surgery in patients with inflammatory arthritis, as well as withholding tofacitinib for at least 7 days prior to surgery in rheumatoid arthritis, spondyloarthritis, and juvenile idiopathic arthritis patients. Specifically, for systemic lupus erythematosus patients undergoing arthroplasty, the guidelines advise withholding rituximab and belimumab prior to surgery.

At least some of the recommendations were in response to concerns expressed by a patient panel that was convened to advise the expert group.

“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,” pointed out co-principal investigator Susan M. Goodman, MD, a rheumatologist at the Hospital for Special Surgery in New York. “The panel also noted that this preference could differ in lupus patients, in whom a flare could mean inflammation of the organs, which poses a greater risk to their health than getting an infection from continuing their medications.”

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