Hip and Knee Replacement for People With Arthritis: ACR Proposes Changes to Guidelines

Considering joint replacement? You may be able to improve your chances of avoiding infections and disease flares-ups.

The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) have released information on their proposed updated guidelines for adults who take disease-modifying medications ahead of elective total hip and knee replacements. Recommendations are specific to individuals who have inflammatory arthritis (IA) and systemic lupus erythematosus (SLE); they include medications that were introduced after the last update, minor changes based on new treatment recommendations for lupus, and a shortening of the time period in which patients should go off certain medications before surgery.

Joint Replacement Is More Common in People With Inflammatory Arthritis

People with progressive diseases such as rheumatoid arthritis (RA) or ankylosing spondylitis (AS) are more likely to undergo total hip or knee replacement. Despite medication, some may have joint damage severe enough to call for total joint replacement. In other cases, pain simply doesn’t respond to other treatments. Total joint replacement may help improve mobility and reduce pain.

What’s New in the ACR and AAHKS 2022 Guidelines

Inflammatory arthritis occurs because of an overactive immune system. People diagnosed with RA, psoriatic arthritis (PsA) and other types of IA are generally given immune suppressant medications. These people, both because of their medications, and because of their fundamental disease process, are at higher risk of infection when going in for a planned hip or knee replacement. Many patients with juvenile idiopathic arthritis (JIA) and other forms of IA or SLE go off their medications prior to surgery to reduce this risk. The updates include these recommendations:

• The last guideline, published in 2017, recommended going off JAK inhibitors a week before surgery. This latest update has shortened that window to three days before.
• Restart medication after the surface wound has closed and is not draining. This usually takes two weeks.
• Do not withhold biologics in patients with severe SLE.

Experts Want to Reduce Infection Risk

“The ACR routinely revisit recommendations, about every five years, because there is always more data that can be applicable, and there are always new medications that have been introduced. It’s important that we keep updating,” says Susan M. Goodman, MD, the attending rheumatologist at the Hospital for Special Surgery and a co-principal investigator of the guideline. “We know that patients with inflammatory arthritis have an increased risk of infection (consistently around 40 to 60 percent) after orthopedic surgery. When you look at what the modifiable risk factors are, the easiest to catch is medication. We know that immunosuppressing medications lower your immune response and increase your risk of infection. Changing that is the low-hanging fruit in trying to address the risks of surgery.”

Changes May Help People Avoid Flares Without Increasing Infection Risk

There were recommendations put in place in 2017, originally because there was no standardized guideline to advise orthopedic colleagues as to when patients should stop or hold their medication prior to hip or knee surgery. It was based primarily on how long the drugs stayed in the body. “The ACR and AAHKS have revised these guidelines to make them a shorter period of time off the drug, so the patient doesn't have as great a risk of flaring up their underlying rheumatic condition. According to new data, they shortened the time off biologics to a point where they believe it's still safe, but does not increase the overall risk of infection. It’s all based on how long these drugs stay in the body,” explains Jonathan Greer, MD, a rheumatologist with Arthritis & Rheumatology Associates of Palm Beach and a medical adviser to CreakyJoints. Dr. Greer was not involved in developing the guidelines.

Guidelines Are Just Guidelines

Dr. Goodman adds that these guidelines are not set in stone: “Our fundamental goal is to balance the theoretical risk of flares of disease with the risk of infection. None of these recommendations is absolute. In some situations, patients and their doctors may choose not to follow them.”

Greer agrees. “Patients do have risks of flares, and the new guidelines shorten the time they're off the drug while not increasing the risk for infection. But that might not work for every patient. Patients should discuss the current guidelines with their rheumatologists and surgeons based on their own disease states and the drugs they're on to decide what is best or most optimal for each individual patient. And the patients need to understand the risks and benefits of stopping the drug. If patients need emergency surgery, they should get it right away, regardless of where they are in their drug cycle.”

According to Goodman, these proposed guidelines been approved by the ACR and AAHKS. The manuscript is currently under review to be published in each organization’s professional journal.