A collaboration between the American College of Rheumatology and the American Association of Hip and Knee Surgeons developed an evidence-based guideline for the perioperative management of antirheumatic drug therapy for adults with rheumatoid arthritis (RA); spondyloarthritis (SpA), including ankylosing spondylitis and psoriatic arthritis; juvenile idiopathic arthritis (JIA); or systemic lupus erythematosus (SLE) undergoing elective total hip (THA) or total knee arthroplasty (TKA). Guidelines are as follows:

1. RA, SpA including AS and PsA, JIA, and SLE receiving nonbiologic DMARDs: Continue current dose of methotrexate, leflunomide, hydroxychloroquine, and/or sulfasalazine for patients undergoing elective THA or TKA.
2. RA, SpA including AS and PsA, JIA, or SLE: Withhold all current biologic agents prior to surgery and plan surgery at end of dosing cycle for that specific medication.
3. RA, SpA including AS and PsA, or JIA: Withhold tofacitinib for at least 7 days prior to surgery in patients with RA, SpA including AS and PsA, or JIA.
4. Severe SLE: Continue current dose of methotrexate, mycophenolate mofetil, azathioprine, cyclosporine, or tacrolimus through surgical period.
5. Not-severe SLE: Withhold current dose of mycophenolate mofetil, azathioprine, cyclosporine, or tacrolimus 1 week prior to surgery.
6. RA, SpA including AS and PsA, JIA, or SLE: Restart biologic therapy in patients for whom biologic therapy was withheld prior to undergoing surgery once wound shows evidence of healing, all sutures/staples are out, there is no significant swelling, erythema, or drainage, and there is no clinical evidence of non–surgical site infections.
7. RA, SpA including AS and PsA, or SLE: Continue current daily dose of glucocorticoids in adult patients with RA, SpA including AS and PsA, or SLE who are receiving glucocorticoids for their rheumatic condition and undergoing surgery, rather than administering perioperative supra-physiologic glucocorticoid doses.