2022 ACR/AAHKS Guidelines for Management of Antirheumatic Medications Among Patients Undergoing Total Joint Arthroplasty

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.

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)
Medication	Current Dosing Interval	Recommended Timing of Surgery Since Last Medication Dose
Methotrexate	Weekly	Anytime
Sulfasalazine	Once or twice daily	Anytime
Hydroxychloroquine	Once or twice daily	Anytime
Leflunomide	Daily	Anytime
Doxycycline	Daily	Anytime
Apremilast	Twice daily	Anytime

Biologics: Hold These Medications Prior to Surgery
Infliximab	Every 4, 6, or 8 weeks	Week 5, 7, or 9
Abatacept	Monthly IV Weekly SQ	Week 5 Week 2
Certolizumab	Every 2 or 4 weeks	Week 3 or 5
Rituximab	Two doses 2 weeks apart every 4 to 6 months	Month 7
Tocilizumab	Weekly SQ Every 4 weeks IV	Week 2 Week 5
Anakinra	Daily	Day 2
Secukinumab	Every 4 weeks	Week 5
Ustekinumab	Every 12 weeks	Week 13
Ixekizumab	Every 4 weeks	Week 5
Guselkumab	Every 8 weeks	Week 9

JAK Inhibitors: Withhold These Medications Prior to Surgery*
Tofacitinib	Daily or twice daily	Day 4
Baricitinib	Daily	Day 4
Upadacitinib	Daily	Day 4

Recommendations for Patients With SLE

Patients With Severe SLE: Continue These Medications Through Surgery in Consultation With Treating Rheumatologist
Medication	Current Dosing Interval	Recommended Timing of Surgery Since Last Medication Dose
Mycophenolate mofetil	Twice daily	Anytime
Azathioprine	Daily or twice daily	Anytime
Cyclosporine	Twice daily	Anytime
Tacrolimus	Twice daily (IV and PO)	Anytime
Rituximab	Every 4 to 6 months IV	Month 4 to 6
Belimumab	Weekly SQ Monthly IV	Anytime Week 4
Anifrolumab	Every 4 weeks IV	Week 4
Voclosporin	Twice daily	Continue

Patients With Nonsevere SLE: Hold These Medications 1 Week Before Surgery
Mycophenolate mofetil	Twice daily	1 week after last dose
Azathioprine	Daily or twice daily	1 week after last dose
Cyclosporine	Twice daily	1 week after last dose
Tacrolimus	Twice daily	1 week after last dose
Rituximab	Every 4 to 6 months	Month 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