What is the recommended duration to discontinue prednisone (corticosteroid) before undergoing arthroplasty (joint replacement surgery)?

From the Guidelines

Patients on chronic corticosteroid therapy, such as prednisone, should maintain their regular dosage through the perioperative period rather than stopping it, as abrupt discontinuation can lead to adrenal insufficiency, which poses greater surgical risks than continuing the medication. This approach is supported by the most recent guideline from the American College of Rheumatology and the American Association of Hip and Knee Surgeons, which conditionally recommends continuing the current daily dose of glucocorticoids in patients undergoing total hip or total knee arthroplasty [ 1 ]. For patients taking higher doses (typically >20 mg prednisone daily), some surgeons may consider tapering to a lower maintenance dose before surgery when feasible, but this should be done gradually over weeks to months under medical supervision [ 1 ].

Key Considerations

• The decision regarding prednisone management should be made collaboratively between the orthopedic surgeon, anesthesiologist, and the physician managing the underlying condition requiring steroid therapy.
• During surgery, stress-dose steroids (typically 100 mg hydrocortisone) may be administered to prevent adrenal crisis.
• The risks of adrenal insufficiency should be balanced against potential concerns about wound healing and infection, with current evidence suggesting that continuing steroids at maintenance doses is safer than discontinuation for most patients [ 1 ].
• Optimization for total hip or total knee arthroplasty should include carefully tapering the glucocorticoid dose prior to surgery to <20 mg/day, when possible, as supported by the Centers for Disease Control and Prevention and observational studies demonstrating an increase in arthroplasty infection risk with long-term steroid use >15 mg/day [ 1 ].

Recommendations

• Continue prednisone through the perioperative period for patients on chronic corticosteroid therapy.
• Taper prednisone to a lower maintenance dose before surgery for patients taking higher doses, under medical supervision.
• Administer stress-dose steroids during surgery to prevent adrenal crisis.
• Collaborate between healthcare providers to make decisions regarding prednisone management.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Recommended Duration to Discontinue Prednisone Before Arthroplasty

The recommended duration to discontinue prednisone before undergoing arthroplasty is not explicitly stated in the provided studies. However, the following points can be considered:

• A study published in 2021 2 suggests that corticosteroid injections administered within 2 weeks before total knee arthroplasty (TKA) increase the risk of postoperative infection.
• The same study found that injections within 2 to 4 weeks trended toward increased infection in univariate regression, but no significant differences were observed in any other injection time frames.
• Another study published in 2021 3 found that intra-articular corticosteroid injections are associated with an increased time to total joint arthroplasty, but the clinical significance of this delay is debatable.
• The study also found that injections are safe if administered at least three months preoperatively.

Key Findings

• The use of prednisone is associated with a higher risk of postoperative infection and other complications after total joint arthroplasty 4, 5.
• The risk of infection is increased when corticosteroid injections are administered within a short period before surgery 2.
• The optimal duration to discontinue prednisone before arthroplasty is not clearly defined, but a period of at least 2-4 weeks may be recommended to minimize the risk of postoperative infection.

Considerations

• The decision to discontinue prednisone before arthroplasty should be made on a case-by-case basis, taking into account the individual patient's medical history and risk factors for infection.
• Patients with a history of rheumatoid arthritis or osteoarthritis may require special consideration due to their increased risk of postoperative infection 5.
• Further studies are needed to determine the optimal timing of arthroplasty after corticosteroid injections and to clarify the relationship between prednisone use and postoperative complications.