Last updated June 21, 2022

Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

Summary of Recommendations (all are conditional)

Continue the current dose of methotrexate, leflunomide, hydroxychloroquine, and/or sulfasalazine (nonbiologic DMARDs) for patients undergoing elective THA or TKA. (Level of Evidence: Low - Moderate) ( Conditional , Moderate )
SLEa
RA, SpA including
AS and PsA
JIA Nonbiologic
DMARDs
SLE Severe SLE
607

Withhold all current biologic agents prior to surgery in patients undergoing elective THA or TKA, and plan the surgery at the end of the dosing cycle for that specific medication. ( Conditional , Low )
SLEa
RA, SpA including
AS and PsA
JIA Nonbiologic
DMARDs
SLE Severe SLE
607

Withhold tofacitinib for at least 3 days prior to surgery in patients undergoing THA or TKA. ( Conditional , Low )
SLEa
RA, SpA including
AS and PsA
JIA Nonbiologic
DMARDs
SLE Severe SLE
607

Continue the current dose of mycophenolate mofetil, azathioprine, cyclosporine, or tacrolimus through the surgical period in all patients undergoing THA or TKA. ( Conditional , Low )
SLEa
RA, SpA including
AS and PsA
JIA Nonbiologic
DMARDs
SLE Severe SLE
607

Withhold the current dose of mycophenolate mofetil, azathioprine, cyclosporine, or tacrolimus 1 week prior to surgery in all patients undergoing THA or TKA. ( Conditional , Low )
SLEa
RA, SpA including
AS and PsA
JIA Nonbiologic
DMARDs
SLE Severe SLE
607

Restart biologic therapy in patients for whom biologic therapy was withheld prior to undergoing THA or TKA once the wound shows evidence of healing (typically ~14 days), all sutures/staples are out, there is no significant swelling, erythema, or drainage, and there is no clinical evidence of non–surgical site infections, rather than shorter or longer periods of withholding. ( Conditional , Low )
SLEa
RA, SpA including
AS and PsA
JIA Nonbiologic
DMARDs
SLE Severe SLE
607

Continue the current daily dose of glucocorticoids in adult patients who are receiving glucocorticoids for their rheumatic condition and undergoing THA or TKA, rather than administering perioperative supra-physiologic glucocorticoid doses (so-called “stress dosing”). ( Conditional , Low )
SLEa
RA, SpA including
AS and PsA
JIA Nonbiologic
DMARDs
SLE Severe SLE
607

Recommendation Grading

Overview

Title

Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

Authoring Organizations

Publication Month/Year

June 20, 2022

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Develop a 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)

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physical therapist, physician, physician assistant

Scope

Management, Prevention

Diseases/Conditions (MeSH)

D019645 - Arthroplasty, Replacement, Knee, D019990 - Perioperative Care, D001178 - Arthroplasty, D012216 - Rheumatic Diseases

Keywords

total knee arthroplasty, perioperative care, elective total hip, TKA, rheumatic diseases, Antirheumatic Medication

Source Citation

Goodman SM, Springer BD, Chen AF, Davis M, Fernandez DR, Figgie M, Finlayson H, George MD, Giles JT, Gilliland J, Klatt B, MacKenzie R, Michaud K, Miller A, Russell L, Sah A, Abdel MP, Johnson B, Mandl LA, Sculco P, Turgunbaev M, Turner AS, Yates A Jr, Singh JA. 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. Arthritis Care Res (Hoboken). 2022 Jun 19. doi: 10.1002/acr.24893. Epub ahead of print. PMID: 35718887.

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
103
Literature Search Start Date
January 1, 1966
Literature Search End Date
March 6, 2016
Description of External Review Process
Principal Investigators (PIs) are asked to share a draft of the near-final guideline paper with the ACR Guideline Subcommittee chair and staff liaison to the guideline project development group before submission for journal or ACR approval. The subcommittee chair / staff liaison will examine the paper with organizational policies and high-level project goals in mind and provide any relevant feedback to the PI. The authors are required to respond to this feedback with related manuscript revisions; if PIs disagree with the feedback and do not wish to make requested revisions, they should discuss this with the subcommittee chair/staff liaison until consensus can be reached.
Description of Public Comment Process
The ACRh Clinical Methodology Manual describes the process for posting Clinical Guidelines for public comment on the society’s website. Feedback is evaluated prior to systematic review begins. Responses are included in the document. Public comments will be collected after publication.
Specialties Involved
Geriatric Medicine, Orthopaedic Surgery, Pediatrics, Rheumatology, Surgery General, Pediatric Rheumatology, Pediatrics
Description of Systematic Review
Use of GRADE to Evaluate the Evidence and Develop Recommendations Beginning in late 2011, the ACR will use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology for all new guideline development projects, including systematic reviews of evidence and guideline recommendations. Information about GRADE may be found online at http://www.gradeworkinggroup.org/ , including a 20-part guide on GRADE from the Journal of Clinical Epidemiology.
List of Questions
PICO 1 In patients with RA, AS, PsA, JIA, severe or not severe SLE undergoing THA or TKA and who are receiving one or more of the candidate drugs, what is the effect of stopping the drug prior to surgery versus continuing? PICO 2 In patients with RA, AS, PsA, JIA, severe or not severe SLE undergoing THA or TKA who are receiving one or more of the candidate drugs in whom one has decided to stop the drug, what is the effect of stopping the drug early prior to surgery versus stopping late? PICO 3 In patients with RA, AS, PsA, JIA, severe or not severe SLE undergoing THA or TKA who are receiving one or more of the candidate drugs in whom one has decided to stop the drug, what is the effect of restarting the drug early after surgery versus restarting late? PICO 4 In patients with RA, AS, PsA, JIA, severe or not severe SLE undergoing THA or TKA who are receiving chronic glucocorticoids, what is the effect of administering supra-physiologic doses of glucocorticoids perioperatively (stress-dose corticosteroids) vs. continuing the usual glucocorticoid dose? QUESTION 5: Indirect evidence of drug-related adverse effects from non-surgical studies What is the risk for serious adverse events, infections, or hospitalizations, associated with use of each of the candidate drugs outside of the surgical setting, limiting the search to systematic literature reviews and meta-analyses for RA, SpA, and JIA, and including observational studies in SLE, as indicated? QUESTION 6: Baseline risk of adverse events in patients with inflammatory arthritis undergoing THA or TKA who were not receiving the drugs of interest What is the background risk for adverse events associated with THA or TKA in patients with RA, SpA, JIA, or SLE independent of the use of anti-rheumatic medications of interest?
Description of Study Criteria
A systematic literature review is used as the basis for development of the recommendations within all ACR guidelines. The systematic review is based on a project protocol (i.e., project plan) that is developed by the project PI, systematic review team leader, and the rest of the Core Team, as well as selected project participants (including the systematic review team and the leader of the guideline panel, if the project PI is not also serving in this role), in conjunction with the ACR. In addition to serving as the basis for the literature review, the protocol guides project leaders and participants as they work to accomplish the goals and objectives of the project. The protocol is essential to minimize bias[15] and to ensure that the end product(s) delivered meet the needs of the ACR membership and the original intent of the project. The protocol will address broad specifications for the project, as well as the detailed information related to the systematic review. (See below for more details of what will be included in the project protocol and Appendix 8 for the ACR protocol template.) Specific clinical questions need to be answered in the systematic review, and the literature search strategy is based on these questions. The “PICO” format informs the key questions/clinical questions being asked. The acronym PICO stands for Population (condition(s), patient, or problem being addressed); Interventions (e.g., treatment), Comparator (alternative intervention for comparison), and Outcomes (clinical outcomes of interest). Important and critical outcomes should be the focus, i.e., as defined by patient or clinician, rather than those driven by available evidence. In addition to PICO, pre-specified types of studies are included as part of the criteria for the systematic review development. Sometimes the setting is also an important aspect of the question. The systematic review leader and team, with input from the project PI and the guideline panel leader, develop PICO questions for each guideline project using a consensus process involving the Guideline Subcommittee, an adequately representative sample of clinicians, and the patient/consumer representative(s). Once the clinical questions have been developed, they are included in the project protocol for ACR approval and subsequent public comment via the online feedback mechanism described below.
Description of Search Strategy
The protocol will also include how studies will be identified (and include an electronic strategy for Medline/PubMed search with a notation that the search will be modified for other named databases, and how and if gray literature will be identified), inclusion and exclusion criteria for studies, information about quality assessment, and a priori specification, for example, about how to deal with such methodological issues as heterogeneity.
Description of Study Selection
A literature review leader is determined (unless done by third party). A literature review team of approximately 4-5 people will conduct the review of available evidence that will serve as the basis of the recommendations made in the guideline. At least 51% of the literature team must have no COI. Disagreements were resolved through consensus. Evidence tables are provided in the manuscript and/or in Data Supplement.
Description of Evidence Analysis Methods
ACRh describes the overall methodology in the 2015 Clinical Methodology Manual. The details of the process used for this guideline are published in the supplements. The systematic review team compiles output from the systematic review to help inform the drafting of recommendations. This information takes the form of Evidence Profiles that provide simple, transparent summaries of the quality of evaluated studies and their findings relevant to the outcomes being examined in the guideline. The Summary of Findings information includes a qualification of the quality of evidence as very low, low, moderate or high, based on several factors explicitly outlined in the GRADE methodology.
Description of Evidence Grading
High: High confidence that the available evidence reflects the true magnitude and direction of the net effect (i.e., balance of benefits v harms) and that further research is very unlikely to change either the magnitude or direction of this net effect. Intermediate: Moderate confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research is unlikely to alter the direction of the net effect; however, it might alter the magnitude of the net effect. Low: Low confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research may change either the magnitude and/or direction this net effect.
Description of Recommendation Grading
Once this work has been completed by the systematic review team, each guideline panel member is asked to consider the quality of available evidence, judge the balance between desirable and undesirable effects, consider patient / clinician values and preferences as well as resource allocation (i.e., cost), and determine what type and strength of recommendations should be made. The strength of the recommendations is categorized as either “strong” or “conditional.” Typically, if panel members are very certain that benefits do, or do not, outweigh risks and burdens, they will make a strong recommendation. If panel members decide that benefits and risks/burdens are balanced, and/or considerable uncertainty exists about the magnitude of benefits and risks, they may make a conditional recommendation. In addition, when panel members believe that fully informed patients are likely to make different choices based on their own values and preferences despite strong evidence, they will likely offer a conditional recommendation. The Voting Panel made strong recommendations when it inferred compelling evidence of efficacy and that benefits clearly outweighed harms and burdens. Thus, a strong recommendation means that the Voting Panel was confident that the desirable effects of following the recommendation outweigh potential undesirable effects (or vice versa), so the course of action would apply to all or almost all patients, and only a small proportion of patients would not want to follow the recommendation. The Voting Panel made conditional recommendations when the quality of the evidence proved low or very low and/or the balance of benefits versus harms and burdens was sufficiently close that shared decision-making between the patient and the clinician would be particularly important. Conditional recommendations are those for which the majority of informed patients would choose to follow the recommended course of action, but some would not. Thus, conditional recommendations are particularly value- and preference-sensitive and always warrant a full shared decision-making approach involving a complete and clear explication of benefits, harms, and burdens in language and in a context that patients understand.
Description of Funding Source
ACRh provides funding for Guideline Development.
Company/Author Disclosures
ACRh’s Conflict of Interest Policy is provided in the ACRh Clinical Guideline Methodology Manual. Disclosures of relationships are obtained from anyone contributing intellectually to an ACR guideline development project, using either the ACR or the journals’ disclosure forms, depending on the stage of the project/review. This disclosure happens at various points in the application, development and approval process, both in writing and verbally.
Percentage of Authors Reporting COI
100