Medication prescribing

Updated Medication Recommendations for Hip, Knee Replacement

The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) have updated their joint guidelines on medication use in individuals with rheumatic diseases who are undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA).1

The update includes changes to the group’s 2017 recommendations as well as the addition of recommendations on several new medications. Patient populations included are individuals with systemic lupus erythematosus (SLE), spondylarthritis, juvenile idiopathic arthritis, rheumatoid arthritis, and other forms of inflammatory arthritis.

Among the updates:

  • Apremilast should be continued through surgery for all patients
  • Rituximab, belimumab (subcutaneous and intravenous), anifrolumab, and voclosporin should be continued through surgery for patients with severe SLE
  • Belimumab (subcutaneous and intravenous) should be withheld 1 week prior to surgery in individuals with nonsevere SLE
  • Ixekizumab and IL-23 guselkumab should be withheld 5 and 9 weeks, respectively, prior to surgery for individuals with spondylarthritis
  • Tofacitinib, baricitinib, and upadacitinib should be withheld 3 days prior to surgery

Ixekizumab, IL-23 guselkumab, baricitinib, and upadacitinib were among the newly added medications in this update. Patients should only restart these antirheumatic medications after the wound shows evidence of healing, any staples or sutures are removed, and there is no signs of swelling, erythema or drainage, or non-surgical site infection.

“Patients with rheumatic diseases such as rheumatoid arthritis or psoriatic arthritis are at a much higher risk for adverse events, particularly infections, after total hip and total knee replacement,” concluded study author Susan Goodman, MD, in a press release.2 “Some risk factors for infection, such as disease severity or overall disability, are not modifiable, but immunosuppressing medications used to treat rheumatic musculoskeletal diseases are an accessible target where perioperative management may decrease risk. New data and medications have become available since our last guideline in 2017, so we felt it was important to update our recommendations.”


—Leigh Precopio



  1. 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty: guideline summary. News release. American College of Rheumatology & American Association of Hip and Knee Surgeons; February 24, 2022. Accessed March 1, 2022.
  2. Updated guideline introduces new recommendations for use of medications around total hip and knee replacement. American College of Rheumatology; February 28, 2022. Accessed March 1, 2022.