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

Abstract

Objective This collaboration between the American College of Rheumatology and the American Association of Hip and Knee Surgeons developed an evidence‐based guideline for the perioperative management of antirheumatic drug therapy for adults with rheumatoid arthritis (RA), spondyloarthritis (SpA) including ankylosing spondylitis and psoriatic arthritis, juvenile idiopathic arthritis (JIA), or systemic lupus erythematosus (SLE) undergoing elective total hip (THA) or total knee arthroplasty (TKA). Methods A panel of rheumatologists, orthopedic surgeons specializing in hip and knee arthroplasty, and methodologists was convened to construct the key clinical questions to be answered in the guideline. A multi‐step systematic literature review was then conducted, from which evidence was synthesized for continuing versus withholding antirheumatic drug therapy and for optimal glucocorticoid management in the perioperative period. A Patient Panel was convened to determine patient values and preferences, and the Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of evidence and the strength of recommendations, using a group consensus process through a convened Voting Panel of rheumatologists and orthopedic surgeons. The strength of the recommendation reflects the degree of certainty that benefits outweigh harms of the intervention, or vice versa, considering the quality of available evidence and the variability in patient values and preferences. Results The guideline addresses the perioperative use of antirheumatic drug therapy including traditional disease‐modifying antirheumatic drugs, biologic agents, tofacitinib, and glucocorticoids in adults with RA, SpA, JIA, or SLE who are undergoing elective THA or TKA. It provides recommendations regarding when to continue, when to withhold, and when to restart these medications, and the optimal perioperative dosing of glucocorticoids. The guideline includes 7 recommendations, all of which are conditional and based on low‐ or moderate‐quality evidence. Conclusion This guideline should help decision‐making by clinicians and patients regarding perioperative antirheumatic medication management at the time of elective THA or TKA. These conditional recommendations reflect the paucity of high‐quality direct randomized controlled trial data.

Turkish League Against Rheumatism Consensus Report: Recommendations For Management of Axial Spondyloarthritis

“…Of the studied articles, 14 were guidelines. [4][5][6][7][8][9][10][11][12][13][14][15][16][17] The articles were analyzed, summarized, and discussed. The draft of TLAR opinion whose roof consisted of international treatment recommendations, particularly the ASAS/EULAR Recommendations was composed.…”

“…Following the wound healing (approximately 14 days) and after sutures are removed, if the wound site is clean, treatment may be readministered on conditional basis. 16 Progressive spinal deformity that interferes with horizontal view, walking, and interaction may develop in ax-SpA patients. Corrective osteotomies may be considered in these patients.…”

“…3 In recent years, several guidelines regarding management of SpA including the Assessment of SpondyloArthritis International Society (ASAS) and European League Against Rheumatism (EULAR) Recommendations have been published parallel with the novelties in early diagnosis and treatment. [4][5][6][7][8][9][10][11][12][13][14][15][16][17] Turkish League Against Rheumatism (TLAR) published the recommendations on management of SpA in 2011 for the first time. 18 In this study, we aimed to update 2011 TLAR SpA Recommendations, and to compose a national expert opinion on management of ax-SpA under guidance of current guidelines, and implantation and dissemination of these international guidelines into our clinical practice.…”

Perioperative Medication Management in the Rheumatic Diseases

“…The methodology employed is summarized herein [4]. After convening to construct the key clinical questions to be addressed in a relevant guideline, a systematic literature review pertaining to the continuing versus withholding of anti-rheumatic therapy was conducted.…”

“…As modern day rheumatic disease therapy is a complex and rapidly evolving domain, perioperative management in this clinical context may seem challenging particularly to physicians less familiar with these therapies. This commentary presents a succinct summary of the relevant pharmacological considerations emphasizing the results of a recently published collaboration of American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) from which evidence-based guidelines for the perioperative management of antirheumatic drug therapy have been developed [4]. Owing to their anti-inflammatory and immunosuppressive nature, concerns regarding the risk of postoperative infection as well as impaired wound healing have long encircled the use of these medications in the surgical setting.…”