Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty
(Part 3)
Let us continue with our discussion on the guideline regarding the use of antirheumatic drugs in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA).
All recommendations in this guideline are conditional. A conditional recommendation means that the good effects of the recommendation might outweigh the bad effects, so the recommendation may be beneficial to most but not all patients.
As the recommendation is conditional, it means that any treatment should involve the patient aside from the doctor in the decision making regarding the treatment regimen.
For patients with rheumatic arthritis (RA), spondyloarthritis (SpA) including psoriatic arthritis (PsA), juvenile idiopathic arthritis (JIA), and systematic lupus erymatosus (SLE) who are using nonbiologic disease modifying anti rheumatic drugs (DMARDs), the guideline states that it is best to continue with the use of methotrexate, leflunomide, hydroxychloroquine, and/or sulfasalazine especially for patients undergoing elective THA or TKA.
This recommendation was based on low- to moderate-quality evidence.
A systematic review of literature, which included randomized control trials (RCT) of continuing versus discontinuing DMARDs at the time of surgery, show that the risk of infections decreased, with the use DMARDs.
The evidence base is rated down from high to moderate for reduction in infection risk after orthopedic surgery when these drugs are used continuously.
There is evidence showing the use of DMARDs in events other than THA and TKA providing lower infection risk.
This recommendation was based only on infection risk, however flares are also less frequent after surgery in those who continue.
Patients with RA, SpA including PsA, JIA, or SLE among others should withhold all current biologic agents prior to surgery for elective THA and TKA.
The doctor and patient should plan the surgery at the end of the dosing cycle for that specific medication.
This recommendation was based on evidence that was rated down in quality for indirectness, as no RCTs were performed in patients undergoing THA or TKA.
It is important to know that avoiding infection was significantly more important to patients than flares after the surgery for THA or TKA.