For a patient with rheumatoid arthritis undergoing elective total knee arthroplasty, when should abatacept (Orencia) be held before surgery and when can it be restarted post‑operatively?

Perioperative Management of Abatacept (Orencia) for Total Knee Arthroplasty

For patients with rheumatoid arthritis undergoing elective total knee arthroplasty, withhold abatacept infusions and schedule surgery at the end of the dosing cycle (approximately 4 weeks after the last infusion), then restart therapy once the wound shows evidence of healing at approximately 14 days postoperatively. 1

Preoperative Timing

Withhold abatacept before surgery and plan the procedure after the next dose is due:

• For intravenous abatacept (dosed every 4 weeks), schedule surgery during week 5 after the last infusion 1
• This timing allows active drug levels to be at their lowest while minimizing the risk of disease flare 1
• The rationale is that planning surgery after the end of the dosing interval ensures minimal circulating drug levels 1

Evidence Supporting This Approach

The 2022 ACR/AAHKS guidelines base this recommendation on administrative claims data showing no difference in postoperative outcomes when comparing short medication interruptions of approximately one dosing interval to longer interruptions 1. Importantly, patients receiving intravenous abatacept within 2 weeks of surgery (one-half of a dosing interval) had a numerically higher rate of adverse events, though this was not statistically significant 1.

Research directly evaluating abatacept timing found that withholding the drug for ≥4 weeks (one dosing interval) before surgery was not associated with lower risk of hospitalized infection, prosthetic joint infection, or 30-day readmission compared to shorter intervals 2. However, the guideline recommendation favors the conservative approach of scheduling surgery after the full dosing cycle 1.

Exceptions to Standard Timing

Patients may elect to proceed with surgery within the dosing cycle under specific circumstances:

• Severe symptoms from the operative joint where anticipated pain relief outweighs possible infection risk (e.g., advanced osteonecrosis) 1
• Disease that has been challenging to control, where withholding medication risks loss of disease control 1
• History of severe or recurrent infections or prior prosthetic joint infection may warrant longer withholding periods 1

Postoperative Restart Timing

Restart abatacept once ALL of the following criteria are met (typically ~14 days):

• The wound shows evidence of healing 1
• All sutures or staples are removed 1, 3
• No significant swelling, erythema, or drainage is present 1, 3
• No clinical evidence of surgical site or non-surgical site infections 1

The decision to restart therapy should be based on careful wound assessment and clinical judgment for absence of infection 1. Normal wound closure typically requires approximately 14 days 1.

Critical Caveats

Glucocorticoid management is equally important:

• Continue the current daily dose of glucocorticoids through surgery rather than administering stress-dose steroids 1
• Glucocorticoid use >7.5 mg/day is associated with significantly greater risk of hospitalized infection (OR 2.19) and non-urinary hospitalized infection (OR 2.38) 2
• Glucocorticoid doses >10 mg/day confer a predicted risk for hospitalized infection of 13.25% versus 6.78% with no glucocorticoid use 4
• Optimize glucocorticoid dosing to <20 mg/day prednisone equivalent prior to surgery when possible 1

Additional risk factors for prosthetic joint infection include:

• Alcohol abuse 5
• Diabetes mellitus 5
• Obesity 5
• Tobacco use 5

Comparative Risk Among Biologics

Research comparing different biologic agents found similar risks for hospitalized infection and prosthetic joint infection across abatacept, adalimumab, etanercept, infliximab, rituximab, and tocilizumab 4. The predicted risk for hospitalized infection with abatacept was 8.16%, with other biologics ranging from 6.87% to 8.90% 4. This suggests that the specific choice of biologic is less important than proper timing and glucocorticoid management 4, 5.