Table 1.

Summary of American College of Rheumatology (ACR)/American Association of Hip and Knee Surgeons (AAHKS) recommendations for the perioperative management of immunosuppression in patients undergoing total hip and knee arthroplasty, with comments on current evidence

	ACR/AAHKS recommendations	Current evidence
Conventional DMARDs
Hydroxychloroquine, sulfasalazine, methotrexate, leflunomide	Continue without interruption	No or low serious infection risk in non-surgical studies; continuing not associated with increased risk in small randomized trials
Other conventional immunosuppressive drugs
Azathioprine, cyclosporine mycophenolate mofetil, tacrolimus	Stop for 7 days before surgery in non-severe SLE	Limited direct evidence
	Continue without interruption in severe SLE
Biologic/targeted therapies
TNF inhibitors, abatacept, rituximab, tocilizumab, secukinumab, ustekinumab, belimumab, anakinra	Stop for 1 dosing interval before surgery	Risk of serious infection from non-surgical studies; holding therapy not associated with large benefits in observational studies of infliximab and abatacept
Tofacitinib	Stop for 7 days before surgery	No direct studies of timing; similar serious infection risk to biologic therapies
Glucocorticoids
Prednisone, prednisolone, methylprednisolone, dexamethasone, etc.	Taper to < 20 mg/day (prednisone equivalent) if possible	Increased risk at doses ≥ 10 mg/day in observational studies with possible risk even at lower doses

ACR/AAHKS guidelines recommend waiting ≥ 14 days after surgery to restart therapy in cases in which treatment is interrupted before surgery, making sure the wound is healing well and there are no signs of local or systemic infection before restarting

DMARDs disease-modifying antirheumatic drugs