The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) released updated guidelines for the perioperative management of antirheumatic medications among patients with rheumatic diseases undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA). The full report was published on the ACR website.1

The current version includes updates from the original recommendations released in 20172 and reflects advances in medications that rheumatologists can consider for the treatment of inflammatory arthritis (IA) and systemic lupus erythematosus (SLE).

The guidelines also take into account the increased risk for infection in patients with IA and SLE after total joint arthroplasty (TJA), along with the risk for disease flares, which can decrease quality of life and lead to organ damage in patients with severe SLE.


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General recommendations are included for continuing disease-modifying antirheumatic drugs (DMARDs) through surgery and holding biologics and Janus kinase (JAK) inhibitors prior to surgery.

A separate set of recommendations is provided for patients with SLE, which offer specific guidance for continuing medications among patients with severe SLE and holding medications in nonsevere SLE.

With regard to holding medications prior to surgery, the authors noted, “For patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, or all SLE for whom antirheumatic therapy was held prior to undergoing [TJA], restarting the antirheumatic therapy once the wound shows evidence of healing, any sutures/staples are out, there is no significant swelling, erythema or drainage, and there is no ongoing nonsurgical site infection, which is typically about 14 days.”

General Recommendations

DMARDs: Continue These Medications Through Surgery (All Patients)
MedicationCurrent Dosing IntervalRecommended Timing of Surgery Since Last Medication Dose
MethotrexateWeeklyAnytime
SulfasalazineOnce or twice dailyAnytime
HydroxychloroquineOnce or twice dailyAnytime
LeflunomideDailyAnytime
DoxycyclineDailyAnytime
ApremilastTwice dailyAnytime
   
Biologics: Hold These Medications Prior to Surgery
InfliximabEvery 4, 6, or 8 weeksWeek 5, 7, or 9
AbataceptMonthly IV
Weekly SQ
Week 5
Week 2
CertolizumabEvery 2 or 4 weeksWeek 3 or 5
RituximabTwo doses 2 weeks apart every 4 to 6 monthsMonth 7
TocilizumabWeekly SQ
Every 4 weeks IV
Week 2
Week 5
AnakinraDailyDay 2
SecukinumabEvery 4 weeksWeek 5
UstekinumabEvery 12 weeksWeek 13
IxekizumabEvery 4 weeksWeek 5
GuselkumabEvery 8 weeksWeek 9
JAK Inhibitors: Withhold These Medications Prior to Surgery*
TofacitinibDaily or twice dailyDay 4
BaricitinibDailyDay 4
UpadacitinibDailyDay 4
*Recommendation relates to infection risk and does not account for the risk for cardiac events or venous thromboembolism.
IV=intravenous; SQ=subcutaneous

Recommendations for Patients With SLE

Patients With Severe SLE: Continue These Medications Through Surgery in Consultation With Treating Rheumatologist
MedicationCurrent Dosing IntervalRecommended Timing of Surgery Since Last Medication Dose
Mycophenolate mofetilTwice dailyAnytime
AzathioprineDaily or twice dailyAnytime
CyclosporineTwice dailyAnytime
TacrolimusTwice daily (IV and PO)Anytime
RituximabEvery 4 to 6 months IVMonth 4 to 6
BelimumabWeekly SQ
Monthly IV
Anytime
Week 4
AnifrolumabEvery 4 weeks IVWeek 4
VoclosporinTwice dailyContinue
PO=oral
Patients With Nonsevere SLE: Hold These Medications 1 Week Before Surgery
Mycophenolate mofetilTwice daily1 week after last dose
AzathioprineDaily or twice daily1 week after last dose
CyclosporineTwice daily1 week after last dose
TacrolimusTwice daily1 week after last dose
RituximabEvery 4 to 6 monthsMonth 7
Belimumab Weekly SQ
Monthly IV
Week 2
Week 5

References

  1. American College of Rheumatology & American Association of Hip and Knee Surgeons. 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: guideline summary. Updated March 17, 2022. Accessed April 4, 2022. https://www.rheumatology.org/Portals/0/Files/Perioperative-Management-Guideline-Summary.pdf
  2. Goodman SM, Springer B, Guyatt G, 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 Res. Published online June 16, 2017. doi:10.1002/acr.23274

This article originally appeared on Rheumatology Advisor