Two sets of guidelines—one on managing anti-rheumatic drugs perioperatively for patients undergoing total hip and knee replacements, and another that updates glucocorticoid-induced osteoporosis prevention and treatment strategies—will be featured in sessions at the 2016 ACR/ARHP Annual Meeting this month.
The Sessions
Sunday, Nov. 13, 2:30–3:30 p.m.: Glucocorticoid-Induced Osteoporosis Prevention and Treatment: A New ACR Clinical Guideline
- Monday, Nov. 14, 9:00–10:00 a.m.: Perioperative Management of Anti-Rheumatic Medication in Patients with Rheumatic Diseases Undergoing Elective Total Hip or Knee Arthroplasty: A New ACR/AAHKS Clinical Guideline
Perioperative Management Guideline
Key Points & Current Status
Some of the points to be covered in the perioperative anti-rheumatic medication management guideline—developed by the ACR in partnership with the American Association of Hip and Knee Surgeons—include recommendations for:
- High-risk patients, including systemic autoimmune inflammatory diseases with inflammatory arthritis and systemic lupus erythematosus;
- The stopping and restarting of medications; and
- The use of “rescue” medications for post-op flares.
The manuscript is now under review, says Susan Goodman, MD, the ACR co-principal investigator for the guideline and associate professor of medicine at Weill Cornell Medical College.
Infection/Biologic Concerns
She says the time is right for the introduction of these recommendations, because the increased use of disease-modifying drugs and biologics means that most patients coming in for these surgeries will be taking these medications.
“The biggest concern with knee and hip replacement surgery is the risk of infection,” Dr. Goodman says. “The [guideline] gives our recommendations on what medications to stop before surgery and what should be continued and, if stopped, when they should be restarted.”
One of the recommendations concerns biologics.
“All of the biologic medications were found to be associated with an increased risk of infection,” she says. “Because of this and the level of importance patients place on minimizing infection risk, we’ve recommended that biologics be withheld prior to surgery.”
Glucocorticoid-Induced Osteoporosis Guideline
What’s Involved?
Lenore Buckley, MD, MPH, the principal investigator and professor of rheumatology and pediatrics at Yale University, says updating the ACR’s 2010 guidelines on glucocorticoid-induced osteoporosis prevention and management involved reexamining the benefits and harms of fracture-reduction therapies. It also involved focusing on subpopulations and the use of more finely tailored fracture-risk assessment tools that combine other osteoporosis risk factors with glucocorticoid use to generate an absolute fracture risk that aids clinicians and patients in decision making.
“The estimate is that about one in 100 adults may be on chronic glucocorticoids in the U.S. and internationally,” she says. “And they’re not just prescribed by rheumatologists; they’re prescribed by primary care physicians and many specialties for various inflammatory diseases, from severe asthma to inflammatory bowel disease to inflammatory neurologic diseases. So we think the recommendations will have a wide impact.”
Not many new therapies have been introduced since the last set of guidelines, but the committee has expanded its area of focus to include specific populations, such as children and those who’ve had organ transplants.
Key Recommendations
The drafted recommendations, which are still under journal and ACR review, include the reinforcement that oral bisphosphonates are still the safest and most appropriate treatment for many patients with glucocorticoid-induced osteoporosis and for the general osteoporosis population. The guideline also underscores the value of fracture-risk tools, such as the online tool FRAX, which now incorporates glucocorticoid dosing rather than just “yes” or “no” input, Dr. Buckley says.
“We’re really encouraging rheumatologists and other care providers to use tools that help us give absolute fracture risk.”
No Reason to Miss These Important Sessions
If scheduling prevents you from attending these sessions during the 2016 ACR/ARHP Annual Meeting, you can catch them later on SessionSelect.
Tom Collins is a freelance writer living in South Florida.
