Perioperative Medication Management for Knee Replacement Surgery
Yes, patients scheduled for elective knee replacement must hold specific medications before surgery, with the exact timing and duration depending on the drug class—particularly biologics, JAK inhibitors, and certain immunosuppressants—while other medications like conventional DMARDs, hydroxychloroquine, and cardiovascular drugs should be continued through surgery.
Medications That MUST Be Held Before Surgery
Biologic DMARDs
- Withhold all biologic agents prior to surgery and schedule the procedure when the next dose would be due (i.e., at the end of the dosing cycle, not during active drug coverage). 1
- For example, if adalimumab is dosed every 2 weeks, plan surgery for week 3; if rituximab is dosed every 6 months, plan surgery during month 7. 1
- This recommendation applies to patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, or juvenile idiopathic arthritis. 1
- The rationale is to minimize infection risk by ensuring active drug levels are low at the time of surgery. 1
JAK Inhibitors
- Withhold tofacitinib, baricitinib, and upadacitinib for at least 3 days prior to surgery. 1
- This shorter interval (compared to older 7-day recommendations) reflects trial data showing rapid loss of disease control after JAK inhibitor interruption, indicating quick reversal of immunosuppression. 2
- The 3-day withholding period applies to the same inflammatory arthritis populations undergoing total knee arthroplasty. 2
Immunosuppressants in Non-Severe SLE
- For patients with non-severe systemic lupus erythematosus, withhold mycophenolate mofetil, mycophenolic acid, azathioprine, cyclosporine, mizoribine, or tacrolimus 1 week prior to surgery. 1
- Belimumab and rituximab should also be withheld in this population. 1
Corticosteroid Injections
- Avoid intra-articular corticosteroid injections within 4 weeks before knee replacement. 3
- Injections administered within 2 weeks of surgery significantly increase postoperative infection risk (odds ratio 2.89), and injections within 2-4 weeks show a trend toward increased infection. 3
- Delaying surgery beyond 4 weeks after injection does not provide additional infection risk reduction. 3
Medications That Should Be CONTINUED Through Surgery
Conventional DMARDs
- Continue methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, and apremilast at their usual doses through surgery. 1
- Four observational studies found no relationship between these drugs and postoperative infection risk. 1
- Do not discontinue hydroxychloroquine perioperatively, as interruption raises the risk of disease flare and eliminates documented mortality benefit. 4
Glucocorticoids
- Maintain the patient's baseline glucocorticoid dose (e.g., methylprednisolone 16 mg daily) without administering supraphysiologic stress-dose steroids on the day of surgery. 1, 4
- This approach reduces infection risk without compromising adrenal function. 4
- Avoid routine administration of high-dose stress steroids perioperatively; doing so increases infection risk and offers no proven benefit. 4
Cardiovascular Medications
- Continue ACE inhibitors and ARBs through surgery; moderate-quality evidence shows no increase in adverse cardiovascular outcomes. 4
- Continue chronic beta-blocker therapy (e.g., carvedilol) perioperatively; stopping increases cardiac events. 4
- Maintain statin therapy (e.g., rosuvastatin) in patients already on a statin. 4
- Intraoperative hypotension can be managed with fluids and vasopressors rather than drug withdrawal. 4
Antiplatelet Agents
- Celecoxib (COX-2 inhibitor) does not need to be discontinued before surgery; it does not increase perioperative blood loss and reduces postoperative pain. 5
- Clopidogrel may be safely continued in patients undergoing elective knee arthroplasty without increased risk of wound complications, infections, or major medical complications, though transfusion rates may be slightly higher (9.1% vs 0%). 6
- Older NSAIDs with half-lives longer than 6 hours should be stopped in time to allow drug elimination due to increased bleeding complications. 7
Postoperative Medication Restart Criteria
For Medications That Were Held
- Restart antirheumatic therapy approximately 14 days after surgery once ALL of the following criteria are met: 1, 2
- The surgical wound shows evidence of healing
- All sutures or staples have been removed
- No significant swelling, erythema, or drainage is present
- No ongoing infection at the surgical site or elsewhere
Special Considerations for High-Risk Patients
- Extend the withholding period beyond 14 days in patients with: 2
- History of severe or recurrent infections
- Prior prosthetic joint infection
- Compromised wound-healing capacity
- Wound-healing complications (e.g., dehiscence)
- Persistent wound drainage or inflammatory signs
Critical Pitfalls to Avoid
- Do NOT give supraphysiologic stress-dose glucocorticoids perioperatively in patients on chronic steroids; continue their baseline dose only. 1, 4
- Do NOT discontinue hydroxychloroquine perioperatively in SLE patients; this increases flare risk and eliminates mortality benefit. 4
- Do NOT schedule surgery within 4 weeks of an intra-articular corticosteroid injection due to significantly elevated infection risk. 3
- Do NOT restart immunosuppressive medications before adequate wound healing is confirmed, even if the typical 14-day window has passed. 1, 2
- Patients with severe or recurrent infections or prior prosthetic joint infection may elect to withhold even conventional DMARDs before surgery through shared decision-making. 1
Anticoagulation Management
- Therapeutic anticoagulation management remains controversial with contradictory evidence regarding the need for discontinuation of therapeutic warfarin. 8
- Individual risk stratification with multi-modal prophylaxis appears to result in minimal complications, but specific protocols vary. 8
- This guideline focuses on infection risk and does not incorporate cardiovascular or venous thromboembolism considerations in detail. 2