Do immunomodulatory disease-modifying medications (e.g., methotrexate or antitumor necrosis factor (anti-TNF) agents) need to be withheld preoperatively to reduce the risk for subsequent surgical site infection/periprosthetic joint infection (SSI/PJI)?

Authors: Susan Goodman, Bryan D. Springer, Jasvinder Singh, Adolph J. Yates

RECOMMENDATION:

For adults with inflammatory arthritis (rheumatoid arthritis (RA), psoriatic arthritis (PsA), adults with juvenile idiopathic arthritis (JA), ankylosing spondylitis (AS) or systemic lupus erythematosus (SLE)), all biologic anti-rheumatic medications including TNF inhibitors and IL-6 blockers (see Table 1 for complete list) should be withheld for a full dosing cycle prior to total hip (THA) and total knee arthroplasty (TKA), and the surgery should be timed to the week following the withheld dose. These medications can be restarted no less than two weeks after surgery if the wound is healing well, all sutures are out and there are no non-surgical site infections.

For adults with inflammatory arthritis or SLE, synthetic disease-modifying anti-rheumatic drugs (DMARDs; see Table 1), including methotrexate, can be continued through the perioperative period.

For adults with severe SLE, immunomodulatory medications (see Table 1) can be continued through the perioperative period.

For adults with mild SLE, immunomodulating medications (with the exception of tacrolimus) should be withheld prior to surgery and restarted at a minimum of 14 days after surgery if the wound is healing well and all sutures are out and there is no surgical site or non-surgical site infection.

For adults with RA, SLE, AS, PsA and JIA receiving glucocorticoids (GCs) for treatment of their rheumatic disease, who did not receive GCs during development and are not receiving replacement therapy, we recommend that the usual daily GC dose be given on the day of surgery rather than supra-physiologic (“stress dose”) GCs.

LEVEL OF EVIDENCE: Limited, based on moderate to low-quality indirect evidence

DELEGATE VOTE: Agree: 87%, Disagree: 3%, Abstain: 10% (Super Majority, Strong Consensus)

RATIONALE:

G16