Background/Purpose:

In response to the lack of clear data to dictate recommendations for use of DMARDs and biologic therapy in the perioperative period, The American College of Rheumatology and American Association of Hip and Knee Surgeons developed guidelines for management of these medications in patients undergoing elective hip or knee arthroplasty. Based on literature review, it is recommended to continue DMARDs through elective hip or knee arthroscopy and to hold biologic therapy during the perioperative period. This QI study examines compliance of a community hospital system with these preoperative guidelines and assesses patient outcomes, specifically infectious complications and rheumatologic disease flare.

Methods:

Retrospective data was obtained using the community hospital’s electronic medical record based on completion of an elective surgical procedure, use of maintenance DMARDs, biologic agents, and steroids, and ongoing care under the LVHN Rheumatology department for inflammatory arthritis, connective tissue disease, or giant cell arteritis between the dates of 1/1/2016 and 1/1/2018. Post-procedure disease flare was characterized as addition/increase of systemic steroids based on reported symptoms. Post-operative surgical site infection (SSI) was defined as the addition of antibiotic therapy due to concern for surgical site infection.

Results:

A total of 54 patient charts met parameters, however 20 of these charts (37%) did not provide adequate data regarding perioperative medication use. From the remaining 34 patient charts, most patients had rheumatoid arthritis (76.5%), were female (76.5%), and had a median age of 58 years old. Orthopedic elective surgeries made up the majority of elective surgical procedures (47.1%). Sixteen out of 34 patients (47%) received correct instruction regarding perioperative medication use, and of these 44% were rheumatology-directed. When direction was identifiable, the patient’s rheumatologist or surgeon was responsible for directing medication changes (29.4% and 26.5%, respectively), although 29.4% did not have clear provider ownership of given instructions. There were 2 post-operative SSI’s which occurred in patients with inadequate pre-operative medication holding times. There were 4 post-operative flares, 50% associated with inappropriate hold of patient medication.

Conclusion:

Although this project is ongoing, results thus far show that clear preoperative patient instruction regarding immunosuppressive medications is lacking. Multiple studies support the correlation between medication error and lack of clear patient instruction regarding medication use. Deviation from typical perioperative medication recommendations was seen in half of patients with unclear contributing factors. Medications dosed less frequently than monthly such as Rituximab and Infliximab tended to correlate with shorter than preferred pre-operative hold times while biologic agents given more frequently were held for a longer duration than recommended. Implementation of formatted written patient instructions as well as provider-directed education sessions with reassessment of guideline compliance are planned next steps for improved patient outcomes.

ACR Meeting Abstracts - https://acrabstracts.org/abstract/guideline-adherence-for-perioperative-use-of-immunosuppressive-medications-in-patients-with-rheumatologic-disease/