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    ACR proposes changes to guidelines for hip and knee replacements for people with arthritis



    Considering joint replacement? This could increase your chances of avoiding infection and flare-ups.

    American College of Rheumatology and American Association of Hip and Knee Surgeons have published information about their updated guidelines for adults who use disease-modifying medication before elective total and partial knee replacements. These recommendations are for people with inflammatory arthritis (IA), systemic lupus-erymatosus(SLE). They include new medication recommendations, minor changes based upon new treatment recommendations for Lupus, and a shorter time frame in which patients should stop taking certain medications before they undergo surgery.

    Joint replacement is more common in people with Inflammatory Arthritis

    People suffering from progressive diseases like rheumatoid or ankylosing spondylitis (AS), are more likely than others to need total hip or knee replacement. Some people may need total joint replacement despite taking medication. Sometimes, the pain is so severe that it doesn’t respond well to other treatments. A total joint replacement can improve mobility and decrease pain.

    What’s new in the ACR/AAHKS 2022 Guidelines

    An overactive immune system can cause inflammation. Immune suppressant medication are usually prescribed to people with RA, psoriatic (PsA), and other forms of IA. Because of their medication and their basic disease process, these people are more susceptible to infection during a planned hip/knee replacement. To reduce the risk of infection, many patients with juvenile Idiopathic arthritis (JIA), and other forms IA or SLE stop taking their medications before undergoing surgery. These are the updates:

    • In 2017, the last guideline recommended that JAK inhibitors be stopped a week prior to surgery. The latest update has reduced that window to just three days.
    • After the surface wound is closed, but not draining, restart medication. This typically takes 2 weeks.
    • Patients with severe SLE should not be denied biologics.

    Experts want to reduce infection risk

    “The ACR regularly revisits recommendations about every five years because there are always more data that could be applied and new medications that have been added. Susan M. Goodman MD, an attending rheumatologist at Hospital for Special Surgery, is co-principal investigator for the guideline. We know that patients suffering from inflammatory arthritis are at greater risk of infection after orthopaedic surgery. This is consistent around 40-60 percent. The easiest thing to spot is medication. We know that immunosuppressing medication lowers your immune response and increases your risk of infection. This is the low-hanging tree when trying to reduce the risks associated with surgery.

    These changes may help people avoid flares without increasing the risk of infection

    2017 saw the introduction of recommendations, initially because there wasn’t a standard guideline for orthopedic colleagues on when patients should stop taking their medication or keep it. The main determinant of how long drugs remained in the body was what prompted the recommendations. The ACR and AAHKS revised the guidelines to reduce the time the drug is off the body. This means that patients are less likely to get rheumatism flare-ups. New data shows that they reduced the time to which biologics can be stopped to ensure safety, but it does not increase the risk of infection. It all depends on how long these drugs remain in the body,” Jonathan Greer MD, a rheumatologist at Arthritis & Rheumatology Associates, Palm Beach, and a medical advisor to CreakyJoints, explains. The guidelines were not developed by Dr. Greer.

    Guidelines are just guidelines

    Dr. Goodman says that these guidelines aren’t set in stone. “Our fundamental goal” is to balance the theoretical risk for flare-ups of disease and the risk of infection. These recommendations are not absolute. Sometimes, patients or their doctors might not agree with these recommendations.

    Greer agrees. “Patients have the potential for flares. The new guidelines reduce the time patients are off the drug and don’t increase the risk of infection. This might not be the best option for everyone. To determine the best treatment for their individual needs, patients should talk to their surgeons and rheumatologists about the current guidelines. Patients must also understand the benefits and risks of stopping taking the drug. Patients who require emergency surgery should seek it immediately, regardless of their current drug status.

    Goodman stated that the ACR has approved these guidelines. The manuscript is currently being reviewed and will be published in the respective professional journals.



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