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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). Methods. A panel of rheumatologists, orthopedic surgeons specializing in hip and knee arthroplasty, and methodologists was convened to construct the key clinical questions to be answered in the guideline. A multi-step systematic literature review was then conducted, from which evidence was synthesized for continuing versus withholding antirheumatic drug therapy and for optimal glucocorticoid management in the perioperative period. A Patient Panel was convened to determine patient values and preferences, and the Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of evidence and the strength of recommendations, using a group consensus process through a convened Voting Panel of rheumatologists and orthopedic surgeons. The strength of the recommendation reflects the degree of certainty that benefits outweigh harms of the intervention, or vice versa, considering the quality of available evidence and the variability in patient values and preferences. Results. The guideline addresses the perioperative use of antirheumatic drug therapy including traditional diseasemodifying antirheumatic drugs, biologic agents, tofacitinib, and glucocorticoids in adults with RA, SpA, JIA, or SLE who are undergoing elective THA or TKA. It provides recommendations regarding when to continue, when to withhold, and when to restart these medications, and the optimal perioperative dosing of glucocorticoids. The guideline includes 7 recommendations, all of which are conditional and based on low- or moderate-quality evidence. Conclusion. This guideline should help decision-making by clinicians and patients regarding perioperative antirheumatic medication management at the time of elective THA or TKA. These conditional recommendations reflect the paucity of high-quality direct randomized controlled trial data. INTRODUCTION Although the wide utilization of disease-modifying antirheumatic drugs (DMARDs) and biologic agents has improved the quality of life for patients with rheumatoid arthritis (RA), spondyloarthritis (SpA), juvenile idiopathic arthritis (JIA), or systemic lupus erythematosus (SLE), rates of total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain high (1–6). Patients with rheumatic conditions report significant improvement in pain and function after THA or TKA, yet critical outcomes such as infection, dislocation, and readmission are reported to be higher for patients with RA, SpA, or SLE (7–10) compared to patients with osteoarthritis. At the time of arthroplasty in a high-volume orthopedic hospital, 46% of RA patients were receiving biologic agents, 67% were receiving nonbiologic DMARDs, and 25% were receiving glucocorticosteroids, while 75% of patients with SLE were receiving immunosuppressive medications, and 15% were receiving glucocorticosteroids. The optimal strategy to manage these medications is not known (11–14). Inherent risk factors for infection, such as overall disability and disease activity/severity, may not be modifiable, but the optimal perioperative management of immunosuppressant therapy around the time of arthroplasty may present an opportunity to mitigate risk (15–19). In this setting, clinicians require guidance regarding perioperative management of antirheumatic drug therapy. Direct evidence, however, which addresses perioperative management is sparse (20,21). To our knowledge, there are no randomized controlled trials (RCTs) evaluating the cessation and reintroduction of biologic agents at the time of THA or TKA. The relevant outcomes considered for these guidelines are the potential increase in infection risk added by the medications versus the risk of disease Brigham and Women’s Hospital, Boston, Massachusetts; 20Kaleb Michaud, PhD: National Data Bank for Rheumatic Diseases, Wichita, Kansas and University of Nebraska Medical Center, Omaha; 21Ted Mikuls, MD, MSPH: University of Nebraska Medical Center, Omaha; 22Alexander Sah, MD: Dearborn-Sah Institute for Joint Restoration, Fremont, California; 23Jasvinder A. Singh, MBBS, MPH: University of Alabama at Birmingham. Drs. Goodman and Springer contributed equally to this work. Drs. Singh and Yates contributed equally to this work. Dr. Springer has received honoraria from Ceramtec (less than $10,000) and consulting fees from Stryker Orthopaedics and Convatec (more than $10,000 each). Dr. Abdel owns stock in Imagen Technologies. Dr. Giles has received consulting fees from Genentech (less than $10,000). Dr. Johnson has received consulting fees from TREG (less than $10,000). Dr. Lee has received consulting fees from EMD Serono (less than $10,000). Dr. Mandl has received consulting fees from UpToDate (less than $10,000). Dr. Sporer has received consulting fees from DJO Surgical Products (more than $10,000), and from OsteoRemedies and PixarBio (less than $10,000 each). Dr. Losina has received honoraria as Deputy Editor of Journal of Bone and Joint Surgery (more than $10,000). Dr. MacKenzie has received consulting fees from ArmadaHealth (less than
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