Continue these medications through surgery.  These include

Methotrexate

Sulfasalazine

Hydroxychloroquine

Leflunomide

Doxycycline

The ACR-AAHKS guideline cites evidence that continued use of non-biologic DMARDs is actually associated with lower rates of post-operative infection, not higher.

When to Stop

Biologics are significantly immunosuppressive and are associated with increased infection risk.  They must be stopped prior to surgery.  With one exception (tofacitinib/Xeljanz), the general approach is skip a dose in the dosing cycle and perform surgery in the week when the next dose would have occurred.  For example, an agent given q4 weeks would be skipped and surgery performed in week 5.  An agent given q12 weeks would be skipped and surgery performed in the 13th week.  This guidance generally applies to agents cited in the guideline including

Adalimumab (Humira)

Etanercept (Enbrel)

Golimumab (Simponi)

Infliximab (Remicade)

Abatacept (Orencia)

Certolizumab (Cimzia)

Rituximab (Rituxan)

Tocilizumab (Actemra)

Anakinra (Kineret)

Secukinumab (Cosentyx)

Ustekinumab (Stelara)

Belimumab (Benlysta)

Tofacitinib (Xeljanz): is the exception.  Even though this agent is given qDay or BID, it should be held 7 days prior to surgery.

When to Resume

Resume medications at least 14 days after surgery in the absence of wound healing problems, surgical site infection, or systemic infection.

With end-organ damage at risk in severe SLE, the stakes are higher when considering stopping medication treatment.  Evidence on this question is sparse and extrapolated from anti-rejection studies.  The ACR-AAHKS guidline leans towards continuing medications perioperatively, while giving much latitude to individualized guidance from the patient’s rheumatologist.  This guidance applies to medications including

Mycophenolate mofetil

Azathioprine

Cyclosporine

Tacrolimus

Withhold medications for systemic lupus erythematosus for 1 week prior to surgery to permit some return of normal immune function and reduce the risk of infection.  This guidance applies to medications including

Mycophenolate mofetil

Azathioprine

Cyclosporine

Tacrolimus

Resume medications 3-5 days after surgery in the absence of wound healing compilcations or evidence of infection at the wound or elsewhere.

Continue glucocorticoid dose as-is.

For patients taking ≤ 16 mg Prednisone daily or equivalent, the ACR-AAHKS guideline notes that evidence shows no benefit to supra-physiologic “stress dosing” of corticosteroids.  The guideline does not comment on higher daily doses.

The guideline also notes that infection risk is higher for those taking > 15 mg Prednisone daily.

This guidance only applies to adult patients treated with corticosteroids for their rheumatologic condition, not for those with adrenal or hypothalamic failure or those with JIA treated during childhood.

Severe SLE

For purposes of guidance in the ACR-AAHKS guideline, severe SLE is defined as 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-losing enteropathy, malabsorption, orbital inflammation/myositis, severe keratitis, posterior severe uveitis/ retinal vasculitis, severe scleritis, optic neuritis, anterior ischemic optic neuropathy

Not severe SLE

Not currently treated for manifestations listed under Severe SLE above.

Populations for whom ACR-AAHKS guideline applies

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.