Principles
- Balance infection risk against disease flare
- Based on the ACR and AAHKS guideline for elective hip and knee arthroplasty (2022)
- Plan with the treating rheumatologist
- Infection after arthroplasty is more common in inflammatory arthritis than in osteoarthritis
- Applies to elective surgery, while urgent fracture surgery proceeds without delay
Recommendations
| Medication | Plan |
|---|---|
| Methotrexate, leflunomide, hydroxychloroquine, sulfasalazine | Continue through surgery |
| Biologics, such as TNF inhibitors | Withhold and operate at the end of the dosing interval |
| JAK inhibitors | Withhold for 3 days before surgery |
| Glucocorticoids | Continue the usual daily dose. Routine stress dosing is not needed |
- Restart biologics about 14 days after surgery once the wound has healed and there is no infection
- Severe SLE, continue usual medication
- Schedule surgery in the week after the missed biologic dose, for example week 3 for adalimumab given every 2 weeks
- Rituximab given every 6 months, schedule surgery in month 7
- Abatacept given monthly intravenously, schedule surgery in week 5
- In severe disease such as lupus nephritis most agents are continued after discussion with rheumatology
Postoperative Care
- Watch for disease flare, which can mimic infection
- Restart conventional DMARDs promptly if they were held
- Low threshold to review the wound and investigate fever
- Consider adrenal insufficiency in patients on long term steroids with unexplained hypotension
Related Pages
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.