This 2017 ACR/AAHKS collaborative guideline addresses perioperative management of antirheumatic medications in adults with RA, SpA, JIA, or SLE undergoing elective THA or TKA. Using GRADE methodology and systematic literature review, it answers when to continue, withhold, and restart each medication class. All 7 recommendations are conditional, reflecting the absence of high-quality direct RCT data in the surgical context.
When you see an RA or SpA patient on a biologic heading to the OR for THA or TKA, the instinct to just "hold it for a few half-lives" is not what this guideline recommends — and it gets the timing wrong.
The correct framework: schedule surgery at the END of the dosing cycle (when drug effect is at its nadir), then restart only after the wound is healed. Typically 14 days, with no swelling, erythema, drainage, or infection. For nonbiologic DMARDs, do the opposite: keep them going through surgery, because the data show they reduce infection risk, not increase it.
For glucocorticoids, stress dosing is not indicated for RA/SpA/SLE patients on their usual dose. Continue the current daily amount, and if the patient is on more than 20 mg/day prednisone equivalent, optimize downward before elective surgery.
The critical SLE nuance: severe versus not-severe SLE determines whether immunosuppressants like mycophenolate and tacrolimus are continued (severe) or withheld for one week (not-severe). This distinction requires direct input from rheumatology before scheduling these patients.
This 2017 ACR/AAHKS collaborative guideline addresses perioperative management of antirheumatic medications in adults with RA, SpA, JIA, or SLE undergoing elective THA or TKA. Using GRADE methodology and systematic literature review, it answers when to continue, withhold, and restart each medication class. All 7 recommendations are conditional, reflecting the absence of high-quality direct RCT data in the surgical context.
When you see an RA or SpA patient on a biologic heading to the OR for THA or TKA, the instinct to just "hold it for a few half-lives" is not what this guideline recommends — and it gets the timing wrong.
The correct framework: schedule surgery at the END of the dosing cycle (when drug effect is at its nadir), then restart only after the wound is healed. Typically 14 days, with no swelling, erythema, drainage, or infection. For nonbiologic DMARDs, do the opposite: keep them going through surgery, because the data show they reduce infection risk, not increase it.
For glucocorticoids, stress dosing is not indicated for RA/SpA/SLE patients on their usual dose. Continue the current daily amount, and if the patient is on more than 20 mg/day prednisone equivalent, optimize downward before elective surgery.
The critical SLE nuance: severe versus not-severe SLE determines whether immunosuppressants like mycophenolate and tacrolimus are continued (severe) or withheld for one week (not-severe). This distinction requires direct input from rheumatology before scheduling these patients.