ACR/AAHKS guideline for antirheumatics use in patients undergoing total knee or hip arthroplasty
USA: A recent study has reported a summary of the 2022 American College of Rheumatology (ACR)/American Association of Hip and Knee Surgeons (AAHKS) guideline for the use of antirheumatics in patients undergoing total knee arthroplasty (TKA). It addresses the perioperative management of disease-modifying medications for adults with rheumatic diseases, specifically inflammatory arthritis (IA)...
USA: A recent study has reported a summary of the 2022 American College of Rheumatology (ACR)/American Association of Hip and Knee Surgeons (AAHKS) guideline for the use of antirheumatics in patients undergoing total knee arthroplasty (TKA). It addresses the perioperative management of disease-modifying medications for adults with rheumatic diseases, specifically inflammatory arthritis (IA) and systemic lupus erythematosus (SLE) undergoing elective total hip arthroplasty (THA) and total knee arthroplasty.
The guideline, an update to the 2017 recommendations, was updated by a panel of rheumatologists, orthopedic surgeons, and infectious disease specialists and included currently available medications for the clinically relevant population, intervention, comparator, and outcomes (PICO) questions.
The updated guideline includes changes in the recommendations regarding rituximab and belimumab for patients with severe SLE and now includes anifrolumab and voclosporin. For spondyloarthritis patients, there has been the addition of the management of ixekizumab and guselkumab. Also, there has been a change of recommendations for the management of JAK inhibitors and suggest withholding for 3 days before surgery; tofacitinib, upadicitinib, and baricitinib are now included.
Given below are the key points of the updated guideline:
- It is recommended to continue biologics used to treat SLE ― rituximab, and belimumab ― in patients with severe SLE but continues to recommend withholding them in less severe cases where there is little risk of organ damage.
- In severe SLE cases, the guidelines recommend timing total joint replacement surgery for 4–6 months after the latest IV dose of rituximab (Rituxan), which is given every 4–6 months.
- For patients taking belimumab (Benlysta), time surgery anytime when weekly subcutaneous doses are administered or at week 4 when monthly IV doses are given.
- The guidelines also make recommendations regarding two new drugs for the treatment of severe SLE: Anifrolumab (Saphnelo): Time surgery at week 4 when IV treatment is given every 4 weeks, and Voclosporin (Lupkynis): Continue doses when they're given twice daily.
- It is recommended that certain drugs be withheld for patients with rheumatoid arthritis, ankylosing spondylitis, or any type of SLE and then "restarting the anti-rheumatic therapy once the wound shows evidence of healing, any sutures/staples are out, there is no significant swelling, erythema or drainage, and there is no ongoing non-surgical site infection, which is typically about 14 days.
- It is recommended to continue withholding biologic medications in patients with inflammatory arthritis, withholding the medication for a dosing cycle prior to surgery, and scheduling the surgery after that dose would be due.
- The new recommendations for biologics suggest scheduling surgery at week 5 when the interleukin (IL)-17 inhibitor ixekizumab (Taltz) is given once every 4 weeks and at week 9 when the IL-23 inhibitor guselkumab (Tremfya) is given every 8 weeks.
- The guidelines also revise the previous recommendation about tofacitinib (Xeljanz): Surgery should be scheduled on day 4 when the drug is given once or twice daily. New recommendations for fellow JAK inhibitors baricitinib (Olumiant, daily) and upadacitinib (Rinvoq, daily) are the same: Withhold for 3 days prior to surgery and perform surgery on the fourth day.
- It is suggested to shorten the time between the last dose of JAK inhibitors and surgery to 3 days from 7 based on trial data demonstrating early flares when the drug was withheld, suggesting the immunosuppressant effect wears off sooner than we previously thought.
- The guideline caution that the recommendations for JAK inhibitors are for infection risk but do not consider the risk of cardiac events or venous thromboembolism.
- In patients with nonsevere SLE, the guidelines revise the recommendations for mycophenolate mofetil (twice daily), cyclosporine (twice daily), and tacrolimus (twice daily, IV and oral). The new advice is to withhold the drugs for 1 week after the last dose prior to surgery. New recommendations offer the same advice for belimumab, both IV and subcutaneous: Withhold for 1 week after the last dose prior to surgery.
The guideline summary was approved by the board of the ACR; the full manuscript has been submitted for peer review with an eye toward later publication in the journals Arthritis and Rheumatology and Arthritis Care and Research.
2022 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
Medha, MSc. Biotechnology
Medha Baranwal joined Medical Dialogues as an Editor in 2018 for Speciality Medical Dialogues. She covers several medical specialties including Cardiac Sciences, Dentistry, Diabetes and Endo, Diagnostics, ENT, Gastroenterology, Neurosciences, and Radiology. She has completed her Bachelors in Biomedical Sciences from DU and then pursued Masters in Biotechnology from Amity University. She has a working experience of 5 years in the field of medical research writing, scientific writing, content writing, and content management. She can be contacted at email@example.com. Contact no. 011-43720751