Surgical interventions are known to induce widespread immune suppression and interfere with cell-mediated immunity, and the immunosuppressive effects of therapies used to treat inflammatory arthritides can compound the risk for surgical infection and impede wound healing. At the same time, there are well-founded concerns that taking patients with inflammatory arthritis off certain immunomodulatory therapies could lead to disease flares.1
Patients with rheumatoid arthritis (RA), spondyloarthritis (SpA), juvenile idiopathic arthritis (JIA), or systemic lupus erythematosus (SLE) are frequent recipients of total hip arthroplasty (THA) or total knee arthroplasty (TKA). Often, such surgeries are a result of rheumatoid disease-induced joint erosion and destruction, but improvements in the management of inflammatory arthritis over recent decades has also resulted in an increase of patients living long enough, and being healthy enough, to undergo surgeries for age-related osteoarthritis.2
On the basis of a systematic review of the medical literature, recommendations from the American College of Rheumatology and the American Association of Hip and Knee Surgeons (ACR/AAHKS) for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective THA or TKA include:3
- Continuation of nonbiologic disease-modifying antirheumatic drugs (DMARDs).
- Discontinuing biologic therapy before surgery in patients with inflammatory arthritis and planning the surgery at the end of the dosing cycle.
- Withholding tofacitinib for at least 7 days before surgery in patients with RA, SpA, and JIA.
- Withholding rituximab and belimumab before surgery in all patients with SLE undergoing arthroplasty.
- No administration of preoperative corticosteroid stress doses.
For an interdisciplinary perspective on the perioperative management of antirheumatic medications, Rheumatology Advisor interviewed Alireza Meysami, MD, RhMUSUS, senior staff rheumatologist at Henry Ford Hospital and assistant professor of medicine at Wayne State University, Detroit, Michigan, and Vinod Dasa, MD, associate professor of clinical orthopedics at Louisiana State University School of Medicine, New Orleans, and coauthor of the ACR/AAHKS guidelines.
Rheumatology Advisor: What are the main concerns orthopedic surgeons have when providing perioperative management for patients with rheumatic diseases undergoing hip or knee arthroplasty? Do their concerns typically differ from those of rheumatologists?
Dr Meysami: Concerns include the risk for infection, flare-up due to holding medication for surgery, healing, surgery complications such as atlantoaxial subluxation in patients with RA, or developing antibodies against some of the biologic treatments when medication is stopped for surgery. There is a risk for deep vein thrombosis after surgery due to immobility and the fact that most of the patients with rheumatic disease have some hypercoagulable tendency. These are mainly the same concerns for both rheumatologists and orthopedic surgeons.
Dr Dasa: One of the major concerns is risk for infection and failure of surgery due to the powerful immunosuppressive actions of many of the current breakthrough medications. I don’t think orthopedic concerns differ from those of rheumatologists, in that we all want the most optimal outcomes for our mutual patients.
Rheumatology Advisor: How can rheumatologists and orthopedic surgeons best collaborate to enhance the perioperative care of these patients?
Dr Meysami: By following the same guideline approved by both colleges and encouraging robust communication among the rheumatologist, orthopedic surgeon, and patient.
Dr Dasa: Most importantly, we should have effective communication. Traditionally, orthopedic surgeons do not manage these powerful medications, so collaborate to optimize the patient’s risk factors, including timing of withdrawal, timing of surgery, and when best to restart various medications.
Rheumatology Advisor: What changes have been made at your institution or in your own clinical practice as a result of the 2017 ACR/AAHKS guidelines?
Dr Meysami: We were following very similar guidelines at our hospital, but the possible changes for any rheumatologist would be careful evaluation of the patient for possible infection after surgery, holding all biologic treatments before surgery, not starting biologic treatment until the healing process is completed or okayed by the surgeon, continuing DMARDs treatment during surgery, and not giving patients stress doses of steroids.
Dr Dasa: We now plan our surgeries in coordination with the patient based on the timing of administration of some of the medications. We also now continue certain medications, whereas in the past they would be discontinued. It’s difficult to manage and keep track of the ever-changing landscape of data and advancements, and this is 1 area where technology and innovation can help us manage the tremendous amount of data needed to make the best possible patient-centered decisions.
Rheumatology Advisor: What improvements are expected as a result of implementing the recent guidelines?
Dr Meysami: Less infection after surgery by withholding biologics before and surgery, less flare up, better outcome of surgery, and less disability due to surgical complications.
Dr Dasa: Optimizing outcomes by reducing complications such as infections and improving pain and function by understanding what medications to start, what medications to stop, and when to restart. I have a number of patients who have significant discomfort when they come off certain medications, so knowing when we can safely restart those medications will help their postoperative recovery.
Rheumatology Advisor: What are the outstanding research questions regarding the perioperative management of these patients?
Dr Meysami: Outstanding questions include: Can the dose of biologic treatments be adjusted by lowering the doses around the time of surgery before surgery instead of stopping them? What is the risk for infection during or after surgery if DMARDs and high-dose glucocorticoids more than 40 to 60 mg are being used at the same time? What are the effects of other comorbidities on rheumatic disease and the outcome of surgery?
Dr Dasa: The research used for these guidelines was very limited, and many findings were based on less-than-optimal data. We need more robust studies to better understand the effect of current and future medications on our surgical outcomes.
Interview was lightly edited for style and clarity.
- Moghadam MG, Vonkeman HE, Klooster PM ten, et al. Stopping tumor necrosis factor inhibitor treatment in patients with established rheumatoid arthritis in remission or with stable low disease activity: a pragmatic multicenter, open-label randomized controlled trial. Arthritis Rheumatol. 2018;68:1810-1817.
- Gualtierotti R, Parisi M, Ingegnoli F. Perioperative management of patients with inflammatory rheumatic diseases undergoing major orthopaedic surgery: a practical overview.Adv Ther. 2018;35:439-456.
- Goodman SM, Springer B, Guyatt G, et al. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Arthritis Rheumatol. 2017;69:1538-1551.