Table 1

Medications included in the 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*

DMARDs: CONTINUE these medications through surgeryDosing intervalContinue/Withhold
MethotrexateWeeklyContinue
SulfasalazineOne or two times per dayContinue
HydroxychloroquineOne or two times per dayContinue
Leflunomide (Arava)DailyContinue
DoxycyclineDailyContinue
BIOLOGICS: STOP these medications prior to surgery and schedule surgery at the end of the dosing cycle. RESUME medications at minimum 14 days after surgery in the absence of wound healing problems, surgical site infection or systemic infection.Dosing intervalSchedule Surgery (relative to last biologic dose administered)
Adalimumab (Humira) 40 mgEvery 2 weeksWeek 3
Etanercept (Enbrel) 50 mg or 25 mgWeekly or two times per weekWeek 2
Golimumab (Simponi) 50 mgEvery 4 weeks (SQ) or
Every 8 weeks (intravenous)
Week 5
Week 9
Infliximab (Remicade) 3 mg/kgEvery 4, 6 or 8 weeksWeek 5, 7 or 9
Abatacept (Orencia) weight-based 500 mg; intravenous 1000 mg; SQ 125 mgMonthly (intravenous) or
Weekly (SQ)
Week 5
Week 2
Rituximab (Rituxan) 1000 mg2 Doses 2 weeks apart every 4–6 monthsMonth 7
Tocilizumab (Actemra) intravenous 4 mg/kg;
SQ 162 mg
Every week (SQ) or every 4 weeks (intravenous)Week 3
Week 5
Anakinra (Kineret) SQ 100 mgDailyDay 2
Secukinumab (Cosentyx) 150 mgEvery 4 weeksWeek 5
Ustekinumab (Stelara) 45 mgEvery 12 weeksWeek 13
Belimumab (Benlysta) 10 mg/kgEvery 4 weeksWeek 5
Tofacitinib (Xeljanz) 5 mg: STOP this medication 7 days prior to surgery.Daily or two times per day7 days after last dose
SEVERE SLE-SPECIFIC MEDICATIONS: CONTINUE these medications in the perioperative period.Dosing intervalContinue/Withhold
MycophenolateTwo times per dayContinue
AzathioprineDaily or two times per dayContinue
CyclosporineTwo times per dayContinue
TacrolimusTwo times per day (intravenous and PO)Continue
NOT-SEVERE SLE: DISCONTINUE these medications in the perioperative periodDosing intervalContinue/Withhold
MycophenolateTwo times per dayWithhold
AzathioprineDaily or two times per dayWithhold
CyclosporineTwo times per dayWithhold
TacrolimusTwo times per day (intravenous and PO)Continue
  • Dosing intervals obtained from prescribing information provided online by pharmaceutical companies.

  • *Reprinted with permission from Goodman SM, Springer B, Guyatt G, et al. American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Anti-rheumatic Medication in Patients with Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Arthritis Rheumatol. 2017 Aug 69(8);1538–51.

  • DMARDs, disease-modifying anti-rheumatic drugs; PO, per os; SLE, systemic lupus erythematosus; SQ, subcutaneous.