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recommendations. Nonetheless, because patients with rheumatic diseases frequently undergo THA and TKA while receiving DMARDs and biologic agents, we sought to fulfill the need for guidance based on the best available evidence and agreement among stakeholders. The Patient Panel thought infection risk was much more important than flare risk, and this drove the direction of the recommendations (uniformly in favor of withholding any medications in which evidence from nonoperative populations suggested an increase in infection). Topics such as cardiac risk, deep venous thrombosis risk, risk of 90-day readmissions, and management and care of the cervical spine are related to the perioperative care of patients with rheumatic disease who are undergoing THA or TKA. The guideline was limited, however, to risks attributable to perioperative management of antirheumatic drug therapy. Antirheumatic medications and disease states were initially evaluated individually. Due to a lack of evidence, however, for each individual medication and disease state, the medications were combined by category and diseases, with the exception of SLE. With regard to patients with SLE, the Panel recognized that recommendations for perioperative medication management in a complex disease such as SLE would be challenging, as SLE is frequently complicated by multiple organ involvement, as well as complex or unusual medication regimens. Moreover, SLE flares may be organthreatening, and SLE patients may be more averse to risk of flare than to infection; therefore, the lack of SLE patients on the Patient Panel was a limitation. Nonetheless, the orthopedic and rheumatology stakeholders felt strongly that perioperative medication management guidance was needed for SLE patients. The recommendation to restart biologic agents was based on the patient’s wound healing (generally requiring a minimum of 14 days) and clinical judgment for the absence of both surgical site and non–surgical site infection. While there are differences in practice patterns and many patients do not return to their surgeon within 2 weeks of discharge, screening mechanisms to assess the wound, including utilizing visiting nurse services, and taking photographs of the wound for review by e-mail, smartphone, or other mobile health technologies, would help to identify those who should be evaluated in person prior to restarting biologic agents. The Voting Panel thought it worthwhile to suggest a research roadmap for future studies that could be conducted as part of a collaboration between the 2 organizations. The team discussed the following topics and recommended that they be targeted for future research: 1) Perioperative glucocorticoid management. While the RCT data support continuing the current glucocorticoid dose rather than “stress dosing,” limited numbers of patients and heterogeneity of dose, diagnosis, and surgical procedure leave us with only low-quality evidence; 2) Perioperative management of biologic agents. The Voting Panel suggested investigating existing biologic agents through registries and administrative databases, as well as planning multicenter RCTs to define the optimal medication management strategy; and 3) Perioperative management of DMARDs. Currently, data from RCTs for patients undergoing surgery reflect older, lower-dose regimens for methotrexate, and studies of leflunomide include small numbers of patients. Multicenter RCTs should be performed to determine the optimal perioperative management regimens and include assessment of comorbidities and glucocorticoid use in the study design. The recommendations that form this guideline are not treatment mandates, but can be used to provide guidance and promote discussion regarding medication management prior to surgery. The authors recognize that not all potential perioperative clinical scenarios are covered by this guideline, but the most common clinical scenarios are addressed. This guideline does not replace perioperative clinical assessment and optimization, and does not 1120 Goodman et al preclude a discussion of the risks and benefits of surgery as patients and their physicians prepare for THA and TKA. In summary, this guideline provides clinicians and patients with a working document regarding how to manage antirheumatic drugs in the time leading up to elective THA and TKA. The recommendations provide important guidance that was informed by the available literature, clinical expertise and experience, and patient values and preferences. The acknowledgment of low-quality evidence in this area should lay the foundation for future research. ACKNOWLEDGMENTS The authors thank Anne Bass, MD, Elie Berbari, MD, Mark Figgie, MD, MBA, Stuart Goodman, MD, PhD, Marc Hochberg, MD, MPH, Eric Matteson, MD, and William Benjamin Nowell, PhD, MSW for serving on the Expert Panel. The authors also thank the Arthritis Foundation and the Global Healthy Living Foundation for their assistance with patient involvement in this guideline project, as well as the patients who participated on the Patient Panel (Katie Acompora, Deserae Constantineau, Marshall Davis, Laureen Fable, Nancy Franklin-Hicks, Jennifer Kangal, Marna McDermott, Tiffany Ann Ohlin, Jodi Pound, Kirsten Smith, and Kelly Voight). We
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