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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) (22–24). Not severe SLE Not currently treated for manifestations listed under Severe SLE. * SLE 5 systemic lupus erythematosus; SELENA–SLEDAI 5 Safety of Estrogens in Lupus Erythematosus National Assessment version of the Systemic Lupus Erythematosus Disease Activity Index; BILAG 5 British Isles Lupus Assessment Group. † All patients carrying the diagnoses listed, without restriction to those meeting classification criteria. ACR/AAHKS Guideline for Perioperative Management 1113 Figure 1. Medications included in the 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. Dosing intervals were obtained from prescribing information provided online by pharmaceutical companies. DMARDs 5 disease-modifying antirheumatic drugs; SQ5 subcutaneous; IV 5 intravenous; SLE 5 systemic lupus erythematosus; PO 5 oral. 1114 Goodman et al managed according to ACR policy (available at Using GRADE, a recommendation can be either in favor of or against the proposed intervention and either strong or conditional (31,32). Much of the evidence was indirect, coming from nonsurgical studies, and all evidence was low to moderate quality (33,34). A strong recommendation indicates that most or almost all informed patients would choose the recommended action. Conditional recommendations are those in which the majority of the informed patients would choose to follow the recommended course of action, but a minority might not (35,36). Teams involved. This project was a collaboration between the ACR and the American Association of Hip and Knee Surgeons (AAHKS). All participating teams contained representatives from both organizations, including a Core Leadership Team for project oversight (5 members), the Literature Review Team, who reviewed the literature and compiled the literature report, the Expert Panel, who helped frame the scope of the project, and the Voting Panel (consisting of orthopedic surgeons, rheumatologists, an infectious disease expert, an SLE expert, patient representatives, rheumatology methodologists, and a GRADE expert), who determined the final recommendations (for a complete listing of Panel and Team members see Supplementary Appendix 2 [available on the Arthritis Care & Research web site at THA or TKA, reviewed the evidence and provided input on their values and preferences. PICO (population/intervention/comparator/outcomes) question development and importance of outcomes. The Core Leadership Team initially drafted the project scope, key principles, and relevant clinical PICO questions, which were then presented to the Expert Panel, the Voting Panel, and the Literature Review Team for their review at a face-to-face meeting where the project plan was defined. The relevant topics addressed included: 1) Should antirheumatic medications be withheld prior to elective THA/ TKA? 2) If they are withheld, when should they be stopped? 3) If withheld, when should they be restarted after surgery? 4) In patients receiving glucocorticoids, what dose should be administered at the time of surgery? The full list of PICO questions is shown in Supplementary). Direct high-quality RCT data available comparing the risk of THA or TKA in those receiving versus not receiving the medications of interest, or comparing the background risk of THA and TKA in the populations of interest, were sparse. To address this gap, 2 questions were included to inform the recommendations. The first asked, “What is the background risk for serious adverse events including infections, or hospitalization, associated with use of each of the candidate drugs in patients not undergoing surgery?” The second question asked, “What is the background risk of adverse events associated with THA or TKA, independent of use of candidate medications in the populations of interest?” The group determined that both superficial and deep surgical site infection (reported within the first year after surgery), non–surgical site infection (within 90 days of surgery), and disease flare were the most critical outcomes; other outcomes such as hospital readmission, death, and long-term arthroplasty outcome were also deemed relevant. Systematic synthesis of the literature and evidence processing. Systematic literature searches were performed in Embase (searched since 1974), the Cochrane Library, and PubMed (searched since the mid-1960s) from January 1, 1980 through March 6, 2016. The search strategies were developed using the controlled vocabulary or thesauri language for each database: Medical Subject Headings (MeSH) for PubMed and Cochrane Library and Emtree terms for Embase (see Supplementary Appendix 4, available on the Arthritis Care & Research web site at .
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