- Patients with rheumatic diseases undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) are at increased risk for periprosthetic joint infection.
- Appropriate management of antirheumatic medication in the perioperative period may provide an important opportunity to
- Nonbiologic disease-modifying antirheumatic drugs may be continued throughout the perioperative period in patients with rheumatic diseases who are undergoing elective THA and TKA.
- Biologic medications should be withheld as close to 1 dosing cycle as scheduling permits prior to elective THA and TKA and restarted after evidence of wound healing, typically 14 days, for all patients with rheumatic diseases.
Table 1. Medication in Patients with Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty
|DMARDs: CONTINUE these medications through surgery.|
|Sulfasalazine||Once or twice daily||Continue|
|Hydroxychloroquine||Once or twice daily||Continue|
|TARGETED THERAPIES/BIOLOGIC AGENTS: STOP these medications prior to surgery and schedule surgery at the end of the dosing cycle. RESUME medications at minimum 14 days after surgery in the absence of wound healing problems, surgical site infection, or systemic infection.|
|Dosing Interval||Schedule Surgery (relative to last biologic agent dose administered) during|
|Adalimumab (Humira)||Weekly or every 2 weeks||Week 2 or 3|
|Etanercept (Enbrel)||Weekly or twice weekly||Week 2|
|Golimumab (Simponi)||Every 4 weeks (SQ) or every 8 weeks (IV)||Week 5|
|Infliximab (Remicade)||Every 4, 6, or 8 weeks||Week 5, 7, or 9|
|Abatacept (Orencia)||Monthly (IV) or weekly (SQ)||Week 5|
|Rituximab (Rituxan)||2 doses 2 weeks apart every 4–6 months||Month 7|
|Tocilizumab (Actemra)||Every week (SQ) or every 4 weeks (IV)||Week 2|
|Anakinra (Kineret)||Daily||Day 2|
|Secukinumab (Cosentyx)||Every 4 weeks||Week 5|
|Ustekinumab (Stelara)||Every 12 weeks||Week 13|
|Belimumab (Benlysta)||Every 4 weeks||Week 5|
|Tofacitinib (Xeljanz) : STOP this medication 7 days prior to surgery||Daily or twice daily||7 days after last dose|
|SEVERE SLE: CONTINUE these medications in the perioperative period.|
|Mycophenolate mofetil||Twice daily||Continue|
|Azathioprine||Daily or twice daily||Continue|
|Tacrolimus||Twice daily (IV and PO)||Continue|
|NOT-SEVERE SLE: DISCONTINUE these medications 1 week prior to surgery.|
|Mycophenolate mofetil||Twice daily||Withhold|
|Azathioprine||Daily or twice daily||Withhold|
|Tacrolimus||Twice daily (IV and PO)||Withhold|
Dosing intervals were obtained from prescribing information provided online by pharmaceutical companies.
Table 2. Populations Included in the Guideline
|Adults age ≥18 years diagnosed with rheumatoid arthritis, spondyloarthritis including ankylosing spondylitis and psoriatic arthritis, juvenile idiopathic arthritis, or SLE (see below), who are deemed to be appropriate surgical candidates, undergoing elective total hip arthroplasty or total knee arthroplasty, and who are treated with antirheumatic drug therapy at the time of surgery.|
|SLE includes patients with severe or not severe SLE (defined below), and who are in optimal condition for surgery:|
|Currently treated (induction or maintenance) for severe organ manifestations: lupus nephritis, central nervous system lupus, severe hemolytic anemia (hemoglobin <9.9 g/dL), platelets <50,000/mL, vasculitis (other than mild cutaneous vasculitis), including pulmonary hemorrhage, myocarditis, lupus pneumonitis, severe myositis (with muscle weakness, not just high enzymes), lupus enteritis (vasculitis), lupus pancreatitis, cholecystitis, lupus hepatitis, protein-losing enteropathy, malabsorption, orbital inflammation/myositis, severe keratitis, posterior severe uveitis/retinal vasculitis, severe scleritis, optic neuritis, anterior ischemic optic neuropathy (derived from the SELENA–SLEDAI Flare Index and BILAG 2004).|
|Not severe SLE|
|Not currently treated for manifestations listed under Severe SLE.|
a All patients carrying the diagnoses listed, without restriction to those meeting diagnostic or classification criteria.