Embedded Files
Text words were used in PubMed and Embase, and keyword/title/abstract words in the Cochrane Library. Searches resulted in 2,230 total references (see Supplementary Appendix 5, http://onlinelibrary.wiley.com/doi/ 10.1002/acr.23274/abstract). A final search update was performed for the time period of January 1 to September 8, 2016, using the inclusive search terms of the disease states, coupled separately with “arthroplasty”; no randomized trials were identified that were relevant to the guideline. DistillerSR software (http://systematic-review.net/) was used to screen the literature search results grouped by their match with the pertinent PICO questions. The Literature Review Team analyzed and synthesized data from eligible studies. Due to the lack of RCTs, we were unable to prepare GRADE Summary of Findings tables for most PICO questions. Microsoft Excel was used for abstracting data from observational studies. When available, the evidence summaries included the benefits and harms for outcomes of interest across studies, the relative effect (with 95% confidence interval [95% CI]), the number of participants, and the absolute effects. We rated the quality of evidence for each critical and important outcome as high, moderate, low, or very low quality, taking into account limitations of study design (including the risk of bias), inconsistency, indirectness, imprecision, and other considerations (including publication bias). Moving from evidence to recommendations. The Patient Panel attached far greater importance to infection at the time of surgery than to flares. They were unable to precisely quantify the difference in value, noting that it was greater than 10:1. The Voting Panel met to decide the final recommendations. The Panel discussed the evidence in the context of both their clinical experience and the input from the Patient Panel. The Panel voted anonymously, and 80% agreement defined the threshold for a recommendation; if 80% agreement was not achieved during an initial vote, ACR/AAHKS Guideline for Perioperative Management 1115 the Panel members held additional discussions before revoting. Considerations that led to rating down of quality of evidence included indirectness (much of the evidence came from RCTs outside of the surgical context, or from foot or spine procedures in which infection risks may vary markedly from THA or TKA); heterogeneity in baseline medication dose and duration, particularly relevant in studies addressing glucocorticoid “stress-dose” therapy; and imprecision associated with small sample size. All recommendations were supported by more than 80% of the Panel, and all but 1 were supported unanimously. In some instances, the Panel combined PICO questions into 1 final recommendation. For recommendations to withhold a medication, a recommendation for the suggested timing of surgery in relation to the last drug-dose was included. RESULTS/RECOMMENDATIONS How to interpret the recommendations 1. All recommendations in this guideline are conditional due to the quality of the evidence (see bolded statements in Table 2). A conditional recommendation means that the desirable effects of following the recommendation probably outweigh the undesirable effects, so the course of action would apply to the majority of the patients, but may not apply to all patients. Because of this, conditional recommendations are preference sensitive and always warrant a shared decision-making approach. No strong recommendations are made in this guideline. 2. For each recommendation, a summary of the supporting evidence or conditions is provided. 3. Therapies that were approved after the original systematic literature review are not included in these recommendations. 4. PICO questions were combined in the final recommendations for clarity. Recommendations 1. RA, SpA including AS and PsA, JIA, and SLE receiving nonbiologic DMARDs Continue the current dose of methotrexate, leflunomide, hydroxychloroquine, and/or sulfasalazine for patients undergoing elective THA or TKA (Table 2). This conditional recommendation was based on low- to moderate-quality evidence. A systematic review of literature, which included RCTs of continuing versus discontinuing DMARDs at the time of surgery, revealed that the risk of infections was in fact decreased, with continuing DMARDs having a relative risk (RR) of 0.39 (95% CI 0.17–0.91) (37,38). The evidence base is rated down from high to moderate for reduction in infection risk after orthopedic surgery when these drugs are continued, because of risk of bias. There is indirect evidence describing a low infection risk with these specific DMARDs in settings other than THA and TKA (39). This recommendation was based on infection risk, although flares are also less frequent after surgery in those who continue DMARDs, and the RRs of flares when DMARDs are continued versus stopped (RR 0.06 [95% CI 0.0–1.10]) were derived from low-quality evidence (37,40). 2. RA, SpA including AS and PsA, JIA, or SLE 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 (Table 2). This recommendation was based on evidence that was rated down in quality for indirectness, as no RCTs were
Google Sites
Report abuse