goodman-newA new guideline presented at the 2016 ACR/ARHP Annual Meeting in Washington, D.C., which the American College of Rheumatology and the American Association of Hip and Knee Surgeons jointly developed, is being touted as historic.

“This guideline is the first collaboration of rheumatologists and orthopedists to formulate recommendations for the perioperative management of anti-rheumatic therapy,” said Susan Goodman, associate professor of clinical medicine at Weill Cornell Medical School and ACR co-principal guideline investigator.

The guidelines, which Dr. Goodman presented at the conference with Jasvinder Singh, professor of medicine and epidemiology at the University of Alabama in Birmingham, draw upon feedback from an 11-person panel of patients with rheumatoid arthritis or juvenile idiopathic arthritis.

The collaboration creates a “terrific precedent” of doctors in the two disciplines working together to improve patient outcomes, according to Dr. Goodman.

“We have not only covered blind spots and facilitated implementation of the optimal medication regimens, but the guideline has established a relationship to move forward with a research agenda, so that the outcomes can be improved further for rheumatic disease patients,” she said.

Among the main takeaways for patients undergoing total hip or knee arthroplasty, according to Dr. Goodman, were:

  1. The utilization of total hip and total knee arthroplasty remain high for rheumatic disease patients, but there is an increased risk of complications, including infections.
  2. Managing anti-rheumatic medication in the perioperative period — the time leading up to, during and immediately following surgery — may allow for mitigating infection risks.
  3. Patients with rheumatic disease who are undergoing hip or knee arthroplasty may continue to take non-biologic disease-modifying antirheumatic drugs (DMARDs) during the preoperative period.
  4. One dosing cycle prior to hip or knee arthroplasty, patients should not take biologic medications. They can restart biologics when there is evidence of the surgical wound healing.

Although Dr. Goodman said in her remarks that she sees patients everyday who hate flares of their disease, the patients in the 11-person panel worried more about the risk of infection, which they saw as less controlled than flares.

“They didn’t think an average infection existed,” she said, noting that the patients regarded the perioperative period as a job, which had its challenges, such as flares.

Even as the new guidelines were being presented, they’ve already generated some controversy. As Medscape reports, some doctors are calling the guidelines “overcautious.”

“The patient concern about a higher infection risk is actually completely irrelevant if there is no higher infection risk,” one doctor told Medscape. “I acknowledge that patients think it is very important, but if there’s no extra risk, then they don’t have to be afraid.”

Responding to the criticism, Dr. Goodman said: “We had very clear direction from our patient panel, which felt that infection was much, much more significant a risk than a disease flare. They influenced the strength and direction of all of our recommendations.” 

She added, “In particular, for any question where there was a risk of infection linked to a certain activity, our recommendation was against that. I think we were conservative in that regard and gave considerable weight to the values and preferences expressed by the patients. We felt that given the quality of the evidence, the input of the patient panel was incredibly valuable and necessary.”