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severe than a flare in SLE that is not severe. Low These medications can be withheld 1 week prior to surgery, permitting return of some immune function, and restarted at 3–5 days after surgery in the absence of wound healing complications or infection at the surgical site or elsewhere. There are multiple mechanisms postulated for immunosuppression with these medications, including leukopenia, interference with T cell costimulatory signaling, and blocking the de novo pathway of purine synthesis, with different time courses for onset and reversal (101,102). Suggest a conservative withhold of 7 days prior to surgery until additional research increases understanding of these medications. RA, SpA including AS and PsA, JIA, or SLE: Restart biologic therapy in patients for whom biologic therapy was withheld prior to undergoing THA and TKA once the wound shows evidence of healing (typically ~14 days), all sutures/staples are out, there is no significant swelling, erythema, or drainage, and there is no clinical evidence of non–surgical site infections, rather than shorter or longer periods of withholding. The decision to restart antirheumatic therapy should be based on careful assessment of the patient’s wound status and clinical judgment for absence of surgical and non–surgical site infections. Normal wound closure typically requires ;14 days. Low RA, SpA including AS and PsA, or SLE: Continue the current daily dose of glucocorticoids in patients who are receiving glucocorticoids for their rheumatic condition and undergoing THA or TKA, rather than administering perioperative supra-physiologic glucocorticoid doses (so-called “stress dosing”). This recommendation specifically refers to adults with RA, AS, PsA or SLE who are receiving glucocorticoids for their rheumatic condition, and does not refer to JIA patients receiving glucocorticoids who may have received glucocorticoids during childhood developmental stages, or to patients receiving glucocorticoids to treat primary adrenal insufficiency or primary hypothalamic disease. The literature review found information on hemodynamic instability in a systematic literature review on patients with rheumatic diseases whose mean prednisone (or equivalent) dose was #16 mg/day. The CDC considers the cut-off for immunosuppression at 20 mg of prednisone/day for at least 2 weeks, and observational studies demonstrate an increase in arthroplasty infection risk with long-term steroid use .15 mg/day. Optimization for THA and TKA should include carefully tapering the glucocorticoid dose prior to surgery to ,20 mg/day, when possible (102,103). Low * THA 5 total hip arthroplasty; TKA 5 total knee arthroplasty; RA 5 rheumatoid arthritis; SpA 5 spondyloarthritis; AS 5 ankylosing spondylitis; PsA 5 psoriatic arthritis; JIA 5 juvenile idiopathic arthritis; SLE 5 systemic lupus erythematosus; DMARDs 5 disease-modifying antirheumatic drugs; RCTs 5 randomized controlled trials; RR 5 relative risk; 95% CI 5 95% confidence interval; CDC 5 Centers for Disease Control and Prevention. ACR/AAHKS Guideline for Perioperative Management 1119 associated with the administration of live vaccines. In addition, observational studies demonstrate an increase in infection risk following TJA for long-term users of glucocorticoids at doses of .15 mg/day. A patient in optimal condition for elective THA or TKA would be receiving a dose of prednisone or equivalent that was ,20 mg/day, when possible, and receive their usual daily dose rather than the “stress dose” in light of the effect on infection risk (102,103). DISCUSSION The 2017 ACR/AAHKS guideline for the perioperative management of antirheumatic drug therapy for adults undergoing elective THA and TKA was designed for use by clinicians and patients during the perioperative period. Included recommendations address the use of treatment with antirheumatic drugs (including DMARDs, tofacitinib, biologic agents, and glucocorticoids) for the adult patient with RA, SpA including AS and PsA, JIA, or SLE, recognizing that antirheumatic medication is frequently used at the time of THA or TKA, and that rates of infection and adverse events, including readmission, are increased in this population. The optimal management of antirheumatic medications to treat these diseases may mitigate risks. We have used GRADE methodology to synthesize the best available evidence and have been transparent regarding both the strength of the recommendation and the limited quality of the evidence for each recommendation. This project brought together major stakeholders (orthopedic arthroplasty surgeons, rheumatologists, methodologists, and patients) to create a patient-centric, expert-led group to determine optimal management of these high-risk patients through a group consensus process. To date, there has been little to no consensus among orthopedic surgeons or rheumatologists on the optimal way to manage antirheumatic medications during the TJA perioperative period, which often leads to uncertainty in decision-making for physicians and patients alike. A major limitation of this guideline is the paucity of high-quality, direct evidence regarding medications and perioperative risk of infection and flare. The indirect nature of the evidence was the primary reason the quality of evidence was considered low, which led to a conditional designation for all the
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