Summary of Recommendations (all are conditional)

Document Overview

Design and created by Guideline Central in participation with the American Association of Hip and Knee Surgeons and American College of Rheumatology.

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

American Association of Hip and Knee Surgeons

American College of Rheumatology

Publication Date: Jun 20, 2022

Page Last Updated: May 5, 2026

Recommendation Grading

Grade Definitions on Strength of Recommendation and Guide to Interpretation
Strength	Wording in the guideline	For the patient	For the clinician
Strong	"should use" or "should be used"	Most individuals in this situation would want the recommended course and only a small proportion would not.	Most individuals should receive the recommended course of action. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences.
Conditional	"may be used" or "may consider" or "Y (less preferred drug) may be used instead of X (preferred drug)" or "may consider Y instead of X (preferred drug)"	The majority of individuals in this situation would want the suggested course, but many would not.	Different choices would be appropriate for different patients. Decision aids may be useful in helping individuals in making decisions consistent with their values and preferences. Clinicians should expect to spend more time with patients when working towards a decision.

Grade Definitions of Quality and Certainty of the Evidence
Quality Grade	Definition
High	Very confident that the true effect lies close to that of the estimate of the effect.
Moderate	Moderately confident in the effect estimate. The true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different.
Low	Confidence in the estimate is limited. The true effect may be substantially different from the estimate of effect.
Very low	Very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.

Document Overview

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

Authoring Societies

American Association of Hip and Knee Surgeons

American College of Rheumatology

Document Publication Date: Jun 20, 2022

Page Last Reviewed/Updated: May 5, 2026

Document Type: Guideline

Country of Publication: United States

Full Text Freely Available: Yes

Full Text Guideline: onlinelibrary.wiley.com/doi/full/10.1002/art.42140

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 Implementation Resources

Document Scope, Criteria, and Use Cases

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)

Scope: Management, Prevention

Diseases/Conditions (MeSH)

D019645 - Arthroplasty, Replacement, Knee

D019990 - Perioperative Care

D001178 - Arthroplasty

D012216 - Rheumatic Diseases

D019645 - Arthroplasty, Replacement, Knee

D019990 - Perioperative Care

D001178 - Arthroplasty

D012216 - Rheumatic Diseases

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

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

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

Recommendation Development Processes & Methodology

PICO Questions

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?
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?
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?
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?
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?
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?

Supplemental Methodology Resource: Data Supplement

Number of Source Documents: 103

Literature Search End Date: Sunday, March 6, 2016

Includes peer/external review process?: Yes

Includes public comment process?: Yes

Methodologist involvement?: Yes

Patient involvement?: Yes

Includes multi-disciplinary group?: Yes

Includes systematic review?: Yes

Grades quality of strength of evidence?: Yes

Grades quality of strength of recommendation?: Yes

Discloses funding source?: Yes

Discloses conflicts of interest?: Yes

Includes benefits/harms analysis with recommendations?: Yes

Identifies study selection process?: Yes

Identifies study selection criteria?: Yes

Identifies methods used to evaluate and analyze the evidence?: Yes

Identifies key questions addressed by the systematic review?: Yes

Identifies search strategy?: Yes

		SLE
RA, SpA including AS and PsA	JIA	Nonbiologic DMARDs	SLE	Severe SLE
✓	✓	✓

		SLE
RA, SpA including AS and PsA	JIA	Nonbiologic DMARDs	SLE	Severe SLE
✓	✓		✓

		SLE
RA, SpA including AS and PsA	JIA	Nonbiologic DMARDs	SLE	Severe SLE
✓	✓

		SLE
RA, SpA including AS and PsA	JIA	Nonbiologic DMARDs	SLE	Severe SLE
				✓

		SLE
RA, SpA including AS and PsA	JIA	Nonbiologic DMARDs	SLE	Severe SLE
			✓