Methotrexate Management for Elective Appendectomy
For an elective, non-infected appendectomy, methotrexate should be continued through the perioperative period without interruption. 1
Rationale
The 2017 ACR/AAHKS guideline explicitly recommends continuing methotrexate through the surgical period for patients with rheumatoid arthritis undergoing elective total hip or knee arthroplasty 1. While this guideline addresses joint replacement surgery specifically, the principles apply even more strongly to appendectomy, which is a less invasive procedure with lower infection risk than major joint arthroplasty.
Supporting Evidence
Continuation reduces flare risk: Perioperative discontinuation of methotrexate may increase the risk of disease flare (RR 32.99,95% CI 4.54 to 239.53), with 36% experiencing flares when stopped versus 0% when continued 2
No increased infection risk with continuation: A prospective randomized study of 388 patients with RA undergoing elective orthopedic surgery found that continuing methotrexate resulted in only 2% infection/complication rate compared to 15% when methotrexate was discontinued 2 weeks before and after surgery (p<0.003) 3
Continuation may actually be protective: The same study demonstrated that stopping methotrexate paradoxically increased surgical complications, likely due to disease flare and inflammatory effects 3
Key Clinical Considerations
Why Continuation is Preferred
Methotrexate has a relatively short half-life but its immunomodulatory effects are mild compared to biologics. The drug does not significantly impair wound healing when used at standard rheumatologic doses (typically ≤25 mg weekly) 4.
Common Pitfall to Avoid
Do not reflexively stop methotrexate for "minor" surgery. The outdated practice of discontinuing methotrexate 2 weeks before and after surgery was based on theoretical concerns rather than evidence, and has been contradicted by subsequent research showing worse outcomes with discontinuation 3.
Exception Requiring Consideration
If the patient is on high-dose methotrexate (>15-20 mg/week) and has additional high-risk features for infection (diabetes, chronic lung disease, concurrent high-dose corticosteroids >10 mg/day), consider reducing to ≤15 mg/week in the weeks prior to surgery rather than complete discontinuation 5.
Postoperative Management
Resume normal methotrexate dosing schedule immediately after surgery. There is no need to delay restart as wound healing typically proceeds normally 1, 3.