THU0146 POOR COMPLIANCE BY RHEUMATOLOGISTS AND ORTHOPAEDISTS WITH GUIDELINES FOR THE PERIOPERATIVE MANAGEMENT OF RHEUMATOID ARTHRITIS PATIENTS UNDERGOING ARTHROPLASTY
Authors: Kieran Murray, Tristan Cassidy, Abuelmagd Abdalla, Timothy Murray, Anna O’rourke, Douglas Veale
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background:</h3> Appropriate management can reduce the increased perioperative infection risk in RA patients(1). In 2017, American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons released <i>Guidelines for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty</i>(1). Atlanto-axial subluxation at induction of general anaesthetic (GA) is another concern. Preoperative C-spine X-rays with flexion-extension views are recommended(2). <h3>Objectives:</h3> Assess compliance with medication guidelines and C-spine imaging practices for RA patients undergoing arthroplasty under GA. <h3>Methods:</h3> An anonymous 24 question paper-based survey was distributed at Irish Society of Rheumatology Meeting (September 2017) and Irish Institute of Trauma and Orthopaedic Surgery Curriculum Day (January 2018) examining clinician demographics, imaging and prescribing practices. <h3>Results:</h3> 33 orthopaedists and 23 rheumatologists responded. The majority (n=46) were trainees and &lt;40 years old (n=43). Most rheumatologists were female and orthopaedists male. The guideline advocates cDMARD continuation perioperatively(1). Rheumatologists are more likely than orthopaedists to continue cDMARDs (Pearson Chi squared, 0.001). 8 (36%) rheumatologists continue cDMARDs, 6 (27%) stop one week preoperatively and 8 (36%) at two weeks. 1 orthopaedist never stops cDMARDs. 8 (24%) stop at one week preoperatively, 13 (39%) at 2 weeks, 5 (15%) at 4 weeks. 6 (18%) were unsure. The guideline advocates stopping bDMARDs 1 dosing cycle preoperatively and restarting after wound healing. Depending on the agent, 2 to 4 rheumatologists never stop bDMARDs preoperatively. Responses varied by medication half-life. 18 hold etanercept for &lt;4 weeks and 11 hold rituximab for &gt;8 weeks. 2 orthopaedists never stop bDMARDs preoperatively. Depending on the agent, 14-15 would stop &lt;4 weeks prior, 10-12 were unsure, 4-8 weeks was chosen 4-5 times and &gt;8 weeks 0-1 times. Regarding patients on glucocorticoids for RA, the guideline advocates continuing current dosing perioperatively. 6 orthopaedists always increase steroids (13 sometimes, 9 never, 5 unsure). 7 never stop (13 sometimes, 6 always, 5 unsure). 12 rheumatologists sometimes increased steroids (8 always, 1 never, 1 not sure, 1 no answer). 14 never stop steroids (8 sometimes, one not sure). In RA patients undergoing GA, 22 orthopaedists always perform C spine imaging prior (10 sometimes, 1 never). 11 rheumatologists always do C spine imaging prior (11 sometimes, 1 never). Orthopaedists are more likely than rheumatologists to always perform spinal imaging preoperatively (P value=0.002, Fisher's exact test). <h3>Conclusion:</h3> There is poor compliance with guidelines and variability and uncertainty in prescribing. Orthopaedists often discontinue sDMARDs preoperatively despite guidelines to the contrary. Orthopaedists are more likely than rheumatologists to perform preoperative C spine imaging as per recommendations. <h3>References:</h3> [1] Goodman SM, Springer B, Guyatt G, Abdel MP, Dasa V, George M, et al. 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Arthritis care &amp; research. 2017;69(8):1111-24. [2] Wasserman BR, Moskovicich R, Razi AE. Rheumatoid arthritis of the cervical spine. Bull NYU Hosp Joint Dis.2011;69:136-48. <h3>Disclosure of Interests:</h3> Kieran Murray Grant/research support from: Newman Research Fellowship (Abbvie), Tristan Cassidy: None declared, Abuelmagd Abdalla: None declared, Timothy Murray: None declared, Anna O'Rourke: None declared, Douglas Veale: None declared