Early use of disease modifying antirheumatic drug (DMARD) therapy has become the standard of care in the treatment of rheumatoid arthritis (RA). Methotrexate remains the DMARD of choice in patients without contraindications for its use. The addition of a tumor necrosis factor-α antagonist to methotrexate makes clinical remission more likely. Despite the effectiveness of this approach, some patients continue to have active disease. In these patients, the use of rituximab, abatacept, or tocilizumab provides additional options when first-line therapies inadequately control RA. For orthopedic surgeons and rheumatologists, additional therapeutic options increase the complexity of perioperative medical management. No consensus has been reached by rheumatology societies as to the optimal approach for the use of biologic and traditional DMARDs around the time of surgery. Therefore, perioperative medication management should be individualized and based on a discussion of potential risks and benefits involving patients, surgeons, and rheumatologists.