2017 Advances in Rheumatology

Introduction

There were numerous important advances in clinical rheumatology and related fields in 2017. Here I review the items I believe are at the top of list, as well as several other odds and ends that may affect rheumatologic care.

Rheumatic Disease and Joint Replacement: New Guidelines

Earlier this year, the American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons jointly developed and published guidelines for the perioperative management of antirheumatic medications in patients undergoing elective total hip or knee arthroplasty.^[1]

I, of course, recommend that readers review the guidelines themselves. However, in brief, they recommend that for patients with most rheumatic diseases, most nonbiologic disease-modifying antirheumatic drugs (DMARDs) can be continued through the operative period. Special consideration was given to tofacitinib, which should be held at least 7 days prior to surgery.

In addition, in systemic lupus erythematosus (SLE) that is deemed "non-severe," mycophenolate, azathioprine, cyclosporine, and tacrolimus should be held 1 week prior to surgery and restarted 3-5 days postoperatively, assuming no surgical complications occur. For severe SLE, these medications can be continued throughout the perioperative period. In addition, biologic DMARDs should be held and surgery performed at the end of the dosing cycle for the particular medication. Biologic therapy—as well as other therapies that may have been stopped—can typically be restarted after 14 days, again assuming there are no complications and that the surgical wound is healing well. Finally, the guidelines recommend that the daily dose of corticosteroids (CSs) be continued rather than administering "stress-dosing," although there are some exceptions.

These guidelines represent a considerable effort on the parts of both rheumatologists and surgeons and help to balance the risks of disease flaring against surgical complications of infection and poor wound healing. However, there are several caveats to the guidelines, including that the level of evidence supporting the recommendations is overall low and that there may be individual variability among patients. Also, some perioperative topics are not addressed in the new document—including anticoagulation and cardiovascular disease (CVD) risk assessment—nor are joints or regions of the body beyond the hip and knee.

New Guidance for Preventing and Treating Glucocorticoid-Induced Osteoporosis

The ACR also published new guidelines for the prevention and treatment of glucocorticoid (GC)-induced osteoporosis.^[2] Again, I suggest that you review the full guidelines yourselves; however, here I will summarize their gist.

The new guidance includes an initial risk assessment that entails careful appraisal of clinical factors such as GC dose and duration, fall risk, prior fractures, comorbidities (eg, malnutrition, thyroid disease, smoking, alcohol use). They also include bone mineral density (BMD) testing and disease-adjusted FRAX scores. BMD testing is recommended within 6 months of the start of GC therapy for adults over the age of 40 years or younger individuals who have a history of fracture or risk factors for osteoporosis. Repeat BMD assessments are recommended every 12 months for most individuals with ongoing GC use.

Treatment recommendations are also provided that include a general goal to reduce the amount and duration of GC use. Also, it is generally recommended to optimize calcium and vitamin D intake in adults taking a prednisone equivalent of ≥2.5 mg per day for ≥3 months, as well as to optimize lifestyle modifications such as healthy diet and weight, smoking cessation, and weight-bearing exercise.

Specific recommendations regarding additional therapy, such as bisphosphonates (oral or intravenous), teriparatide, denosumab, or raloxifene, are based on escalating risk for fracture. Treatments for special populations such as children, women with childbearing potential, and those on high doses of GCs are also discussed.

A caveat to these guidelines is that there are limited amounts of strong evidence to support many of the recommendations, and individual variability can affect therapy. However, the guidelines are an important advance and should be reviewed by clinicians.

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