Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

Publication Date: June 20, 2022
Last Updated: June 21, 2022

Summary of Recommendations (all are conditional)

Continue the current dose of methotrexate, leflunomide, hydroxychloroquine, and/or sulfasalazine (nonbiologic DMARDs) for patients undergoing elective THA or TKA. (Level of Evidence: Low - Moderate) ( Conditional , Moderate )
SLEa
RA, SpA including
AS and PsA		 JIA Nonbiologic
DMARDs		 SLE Severe SLE
✓ ✓ ✓
607
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. ( Conditional , Low )
SLEa
RA, SpA including
AS and PsA		 JIA Nonbiologic
DMARDs		 SLE Severe SLE
✓ ✓ ✓
607
Withhold tofacitinib for at least 3 days prior to surgery in patients undergoing THA or TKA. ( Conditional , Low )
SLEa
RA, SpA including
AS and PsA		 JIA Nonbiologic
DMARDs		 SLE Severe SLE
✓ ✓
607
Continue the current dose of mycophenolate mofetil, azathioprine, cyclosporine, or tacrolimus through the surgical period in all patients undergoing THA or TKA. ( Conditional , Low )
SLEa
RA, SpA including
AS and PsA		 JIA Nonbiologic
DMARDs		 SLE Severe SLE
✓
607
Withhold the current dose of mycophenolate mofetil, azathioprine, cyclosporine, or tacrolimus 1 week prior to surgery in all patients undergoing THA or TKA. ( Conditional , Low )
SLEa
RA, SpA including
AS and PsA		 JIA Nonbiologic
DMARDs		 SLE Severe SLE
✓
607
Restart biologic therapy in patients for whom biologic therapy was withheld prior to undergoing THA or TKA once the wound shows evidence of healing (typically ~14 days), all sutures/staples are out, there is no significant swelling, erythema, or drainage, and there is no clinical evidence of non–surgical site infections, rather than shorter or longer periods of withholding. ( Conditional , Low )
SLEa
RA, SpA including
AS and PsA		 JIA Nonbiologic
DMARDs		 SLE Severe SLE
✓ ✓ ✓
607
Continue the current daily dose of glucocorticoids in adult patients who are receiving glucocorticoids for their rheumatic condition and undergoing THA or TKA, rather than administering perioperative supra-physiologic glucocorticoid doses (so-called “stress dosing”). ( Conditional , Low )
SLEa
RA, SpA including
AS and PsA		 JIA Nonbiologic
DMARDs		 SLE Severe SLE
✓ ✓
607

Recommendation Grading

Overview

Title

Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

Authoring Organizations

American Association of Hip and Knee Surgeons

American College of Rheumatology

Publication Month/Year

June 20, 2022

Last Updated Month/Year

November 7, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Develop a guideline for the perioperative management of antirheumatic drug therapy for adults with rheumatoid arthritis (RA), spondyloarthritis (SpA) including ankylosing spondylitis and psoriatic arthritis, juvenile idiopathic arthritis (JIA), or systemic lupus erythematosus (SLE) undergoing elective total hip (THA) or total knee arthroplasty (TKA)

Target Patient Population

Adults age ≥18 years with RA, SpA, including AS and PsA, JIA, or SLE, undergoing elective THA or TKA, and who are on an antirheumatic drug at the time of surgery

Target Provider Population

Rheumatologists, orthopedic surgeons, and infectious disease specialists

PICO Questions

  1. In patients with RA, AS, PsA, JIA, severe or not severe SLE undergoing THA or TKA and who are receiving one or more of the candidate drugs, what is the effect of stopping the drug prior to surgery versus continuing?

  2. In patients with RA, AS, PsA, JIA, severe or not severe SLE undergoing THA or TKA who are receiving one or more of the candidate drugs in whom one has decided to stop the drug, what is the effect of stopping the drug early prior to surgery versus stopping late?

  3. In patients with RA, AS, PsA, JIA, severe or not severe SLE undergoing THA or TKA who are receiving one or more of the candidate drugs in whom one has decided to stop the drug, what is the effect of restarting the drug early after surgery versus restarting late?

  4. In patients with RA, AS, PsA, JIA, severe or not severe SLE undergoing THA or TKA who are receiving chronic glucocorticoids, what is the effect of administering supra-physiologic doses of glucocorticoids perioperatively (stress-dose corticosteroids) vs. continuing the usual glucocorticoid dose?

  5. What is the risk for serious adverse events, infections, or hospitalizations, associated with use of each of the candidate drugs outside of the surgical setting, limiting the search to systematic literature reviews and meta-analyses for RA, SpA, and JIA, and including observational studies in SLE, as indicated?

  6. What is the background risk for adverse events associated with THA or TKA in patients with RA, SpA, JIA, or SLE independent of the use of anti-rheumatic medications of interest?

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physical therapist, physician, physician assistant

Scope

Management, Prevention

Diseases/Conditions (MeSH)

D019645 - Arthroplasty, Replacement, Knee, D019990 - Perioperative Care, D001178 - Arthroplasty, D012216 - Rheumatic Diseases

Keywords

total knee arthroplasty, perioperative care, elective total hip, TKA, rheumatic diseases, Antirheumatic Medication

Source Citation

Goodman SM, Springer BD, Chen AF, Davis M, Fernandez DR, Figgie M, Finlayson H, George MD, Giles JT, Gilliland J, Klatt B, MacKenzie R, Michaud K, Miller A, Russell L, Sah A, Abdel MP, Johnson B, Mandl LA, Sculco P, Turgunbaev M, Turner AS, Yates A Jr, Singh JA. 2022 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 Res (Hoboken). 2022 Jun 19. doi: 10.1002/acr.24893. Epub ahead of print. PMID: 35718887.

Supplemental Methodology Resources

Data Supplement