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$10,000). Dr. Mikuls has received consulting fees from Pfizer (less than $10,000) and research grants from Astra Zeneca and Bristol-Myers Squibb. Dr. Sah has received speaking fees and/or honoraria from Pacira, Medtronic, Zimmer Surgical Specialties, and Convatec (less than $10,000 each) and from Smith & Nephew and Mallinckrodt (more than $10,000 each). Dr. Singh has received consulting fees from Takeda (more than $10,000) and from Savient, Regeneron, Merz, Iroko, Bioiberica, Crealta/Horizon, Allergan, WebMD, and UBM LLC (less than $10,000 each), research grants from Takeda and Savient and was principal investigator for an investigatorinitiated study funded by Horizon through a grant to Dinora (more than $10,000). Address correspondence to Susan M. Goodman, MD, Hospital for Special Surgery/Weill Cornell, 535 East 70th Street, New York, NY 10021. E-mail: goodmans@hss.edu. Submitted for publication September 26, 2016; accepted in revised form April 28, 2017. 1112 Goodman et al flare when the medications are withheld. This guideline pertains only to adult patients with RA, SpA including ankylosing spondylitis (AS) and psoriatic arthritis (PsA), JIA, or SLE, who are undergoing elective THA or TKA, and incorporates patient preferences. This guideline addresses management of antirheumatic medication in those adult patients with diagnoses of RA, SpA, JIA, or SLE, but is not limited to those who meet classification criteria. This guideline is to be used for those who have elected and have been deemed appropriate candidates for THA or TKA. We would caution against extrapolation of this guideline to other orthopedic procedures until further data are available. This guideline is intended for use by clinicians, including orthopedists, rheumatologists, and other physicians performing perioperative risk assessment and evaluation, as well as patients. The guideline addresses common clinical situations, but may not apply in all exceptional or unusual situations. It is imperative that open and informed communication between the patient, orthopedic surgeon, and rheumatologist takes place. In addition, while cost is a relevant factor in health care decisions, it was not considered in this project. The populations included in this guideline are shown in Table 1 (22–24). Figure 1 contains a list of the drugs included in the evaluation, along with their dosing intervals, as the Panel determined that the dosing interval and route were more relevant for this guideline because they reflect the duration of effect. This guideline does not address indications for THA or TKA, medical decisions unrelated to antirheumatic drug therapy, choice of implant, surgical approach, or perioperative evaluation and management of concurrent disease, such as that affecting the cervical spine of patients with RA. Although patients with RA, SpA, JIA, or SLE should be assessed for risk of venous thromboembolism and major acute coronary event (8,25), this guideline does not address cardiac risk assessment or perioperative venous thromboembolism prophylaxis; both are covered in existing guidelines (26–29). METHODS Overall methodology. This guideline follows the American College of Rheumatology (ACR) guideline development process (http://www.rheumatology.org/Practice-Quality/ Clinical-Support/Clinical-Practice-Guidelines), using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to rate the quality of the available evidence and to develop the recommendations (30). Conflicts of interest and disclosures were Significance & Innovations 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 mitigate risk. 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. Populations included in the guideline* Populations† 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 SLE includes patients with severe or not severe SLE (defined below), and who are in optimal condition for surgery: Severe SLE Currently treated (induction or maintenance) for severe organ manifestations: lupus nephritis, central nervous system lupus, severe hemolytic anemia (hemoglobin ,9.9), 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-
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