ACR/AAHKS guideline for antirheumatics use in patients undergoing total knee or hip arthroplasty

Given below are the key points of the updated guideline:

• It is recommended to continue biologics used to treat SLE ― rituximab, and belimumab ― in patients with severe SLE but continues to recommend withholding them in less severe cases where there is little risk of organ damage.
• In severe SLE cases, the guidelines recommend timing total joint replacement surgery for 4–6 months after the latest IV dose of rituximab (Rituxan), which is given every 4–6 months.
• For patients taking belimumab (Benlysta), time surgery anytime when weekly subcutaneous doses are administered or at week 4 when monthly IV doses are given.
• The guidelines also make recommendations regarding two new drugs for the treatment of severe SLE: Anifrolumab (Saphnelo): Time surgery at week 4 when IV treatment is given every 4 weeks, and Voclosporin (Lupkynis): Continue doses when they're given twice daily.
• It is recommended that certain drugs be withheld for patients with rheumatoid arthritis, ankylosing spondylitis, or any type of SLE and then "restarting the anti-rheumatic therapy once the wound shows evidence of healing, any sutures/staples are out, there is no significant swelling, erythema or drainage, and there is no ongoing non-surgical site infection, which is typically about 14 days.
• It is recommended to continue withholding biologic medications in patients with inflammatory arthritis, withholding the medication for a dosing cycle prior to surgery, and scheduling the surgery after that dose would be due.
• The new recommendations for biologics suggest scheduling surgery at week 5 when the interleukin (IL)-17 inhibitor ixekizumab (Taltz) is given once every 4 weeks and at week 9 when the IL-23 inhibitor guselkumab (Tremfya) is given every 8 weeks.
• The guidelines also revise the previous recommendation about tofacitinib (Xeljanz): Surgery should be scheduled on day 4 when the drug is given once or twice daily. New recommendations for fellow JAK inhibitors baricitinib (Olumiant, daily) and upadacitinib (Rinvoq, daily) are the same: Withhold for 3 days prior to surgery and perform surgery on the fourth day.
• It is suggested to shorten the time between the last dose of JAK inhibitors and surgery to 3 days from 7 based on trial data demonstrating early flares when the drug was withheld, suggesting the immunosuppressant effect wears off sooner than we previously thought.
• The guideline caution that the recommendations for JAK inhibitors are for infection risk but do not consider the risk of cardiac events or venous thromboembolism.
• In patients with nonsevere SLE, the guidelines revise the recommendations for mycophenolate mofetil (twice daily), cyclosporine (twice daily), and tacrolimus (twice daily, IV and oral). The new advice is to withhold the drugs for 1 week after the last dose prior to surgery. New recommendations offer the same advice for belimumab, both IV and subcutaneous: Withhold for 1 week after the last dose prior to surgery.

The guideline summary was approved by the board of the ACR; the full manuscript has been submitted for peer review with an eye toward later publication in the journals Arthritis and Rheumatology and Arthritis Care and Research.