Why aren't rejection medications, such as immunosuppressants (e.g. cyclosporine or tacrolimus), typically used after joint replacement surgery?

From the Guidelines

Joint replacement surgery does not require rejection medications like immunosuppressants because it involves artificial implants, not living tissue transplants, and the use of such medications would increase the risk of infection. The primary concern after joint replacement surgery is preventing infection and promoting healing, rather than preventing rejection of the implant. According to the 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline 1, the focus is on managing antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty, rather than using immunosuppressants.

Key points to consider:

• The guideline recommends continuing nonbiologic DMARDs, such as methotrexate, leflunomide, hydroxychloroquine, and/or sulfasalazine, for patients undergoing elective THA or TKA, as the risk of infections was not increased, but in fact decreased, when DMARDs were continued 1.
• Biologic agents should be withheld prior to surgery, and the surgery should be planned at the end of the dosing cycle for that specific medication, due to the increased risk of infection associated with their use 1.
• For patients with severe SLE, the current dose of mycophenolate mofetil, azathioprine, cyclosporine, or tacrolimus should be continued through the surgical period, while for non-severe SLE, these medications can be withheld 1 week prior to surgery and restarted after surgery in the absence of complications 1.
• The use of immunosuppressants, such as cyclosporine or tacrolimus, is not recommended after joint replacement surgery, as they would increase the risk of infection and are not necessary for preventing rejection of the artificial implant.

Overall, the management of joint replacement surgery focuses on preventing infection, managing pain, and promoting healing, rather than preventing rejection of the implant, and the use of immunosuppressants is not necessary or recommended.

From the Research

Joint Replacement and Rejection Medications

• Joint replacement surgery, such as total hip arthroplasty (THA) and total knee arthroplasty (TKA), does not typically require the use of rejection medications, also known as immunosuppressants, like cyclosporine or tacrolimus 2, 3, 4, 5, 6.
• The primary reason for this is that joint replacement involves the use of inert materials, such as metal and plastic, which do not trigger an immune response in the same way that organ transplants do.
• Instead of rejection medications, patients undergoing joint replacement surgery typically receive antibiotic prophylaxis to prevent surgical site infections (SSIs) and prosthetic joint infections (PJIs) 2, 3, 4, 5, 6.

Antibiotic Prophylaxis in Joint Replacement

• Cefazolin is a commonly used antibiotic for prophylaxis in joint replacement surgery, and studies have shown that it is effective in reducing the risk of SSIs and PJIs 2, 3, 4, 5.
• Other antibiotics, such as vancomycin and clindamycin, may also be used in certain situations, but cefazolin is generally considered the first-line agent for prophylaxis in joint replacement surgery 3, 4, 5.
• The use of extended antibiotic prophylaxis may be beneficial in high-risk patients, but more research is needed to determine the safety and efficacy of this approach 6.

Immune Response and Joint Replacement

• The immune response to joint replacement surgery is different from that of organ transplantation, and rejection medications are not typically necessary 2, 3, 4, 5, 6.
• The use of immunosuppressants, such as cyclosporine or tacrolimus, is not typically required in joint replacement surgery, and their use may even increase the risk of infection and other complications 2, 3, 4, 5, 6.