TKA and THA were originally selected as a focus for the perioperative guideline because they are performed so frequently, Dr. Goodman explains, adding, “They can provide the most data for us to work with in defining our recommendations.” Although the guideline is intended to apply to patients undergoing these specific orthopedic surgery types, Dr. Singh notes that as a matter of practicality, some clinicians may extrapolate from them to use in other surgical settings (e.g., shoulder replacement) for which guidelines do not currently exist.
Post-surgery infections occur more often in patients with rheumatoid arthritis, spondyloarthritis & SLE than in patients with osteoarthritis.
Guideline Development
The rheumatologists, orthopedic surgeons and infectious disease specialists who updated this current guideline performed additional systematic literature review and wrote population, intervention, comparator and outcome (PICO) questions to reflect current medications. Like other recent ACR guidelines, they also used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of the evidence and the strength of the recommendations using group consensus. Dr. Singh notes that this was a highly collaborative process, with each group contributing their expertise; consensus for the recommendations was quite high, with none achieving less than 80% agreement.
No new randomized, controlled trials informed the evidence base for this update. Dr. Goodman points out that the literature used to make these recommendations contained very little data directly comparing outcomes in patients taking or withholding anti-rheumatic medications at the time of surgery. “Therefore, we applied studies that determined the risk of infection with the medications in patients who were not undergoing surgery and used that to assess risk,” she explains. Some data were also extrapolated from patients without rheumatic diseases. Clinicians can make their own assessment of the data used to compile the guidelines via information freely available on the ACR website.
Recommendations
A brief discussion of some of the recommendations from the guideline follows. For the full set of recommendations and their context, please see the complete guideline. The recommendations apply to patients with inflammatory arthritis (i.e., rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis or juvenile idiopathic arthritis) and patients with SLE who are undergoing elective THA or TKA. All these recommendations are conditional, indicating the level of evidence on which they are based is low or that the decision may be subject to patient preference.
Recommendation: For patients with inflammatory arthritis or SLE, the following DMARDs should be continued through surgery without interruption: methotrexate, leflunomide, hydroxychloroquine, sulfasalazine and apremilast.
