American College of Rheumatology 2017 Annual Meeting Updates
- Holding methotrexate therapy for 2 weeks after vaccination led to higher antibody levels without disease flares.
- A reassuring report showed that children born to mothers receiving biologic agent therapy did not have an increase in serious infections.
- Drug holidays of more than 2 years from osteoporosis therapy with alendronate or Reclast led to a 40% increase in fractures.
Recommendations for Immunomodulatory Medications with Joint Replacement Surgery
A joint committee of Rheumatologists and Orthopedic Surgeons has issued the following recommendations for medication management around hip and knee replacement:
- Synthetic disease modifying antirheumatic drugs (DMARDs) such as methotrexate, leflunomide, hydroxychloroquine can be taken up to and through the post operative period. There is no need to hold these medications before surgery.
- Biologic agents such as Remicade, Orencia, Humira, Enbrel, Actemra should be held 1 cycle before surgery. For example, hold Enbrel the week before, or have the surgery done just before the next IV dose of Remicade, Actemra, Orencia.
- These agents can be restarted when the wound is clean and there is no drainage, approximately 14 days.
- Xeljanz should be held 7 days before surgery.
- Patients with severe lupus should continue medication up to and after surgery.
- Patients with mild lupus should hold medication 1 week before surgery.
- There is no reason to increase steroid dose with surgery, just continue usual dose.
Vaccinations are a critical part of medical care and represented a major advance in health. The recent outbreak of measles in unvaccinated people demonstrates that diseases that were once common and nearly eliminated by vaccination will reappear if vaccination is ignored. The first vaccination was to smallpox in the 1700s. This disease which killed 40% of people infected has been eliminated by way of universal vaccination. Those of us old enough to remember polio may recall that introduction of the Salk vaccine in 1956 meant that 1 year there were wards of people in iron lung machines, and the next year there were none.
It is important to maintain vaccinations, particularly for those with illnesses or on medications that suppress immunity. Yearly flu vaccine and both pneumonia vaccines for those over 60 or on immunosuppressive medication are recommended. There is a new shingles vaccine available that can be given to people on biologic agents and is recommended for patients over the age of 50. Other vaccines are not effected by medication, except for corticosteroid dosages greater than prednisone 20mg which can reduce effectiveness. Other vaccines are also important in adults- Tetanus, diphtheria, pertussis, and hepatitis B for people exposed to blood products. There are many vaccines which are important if you travel to some tropical areas which needs to be reviewed with a specialist. We urge you to keep your vaccinations up to date.