Recommendation for Holding Rinvoq Before Surgery
For patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, or juvenile idiopathic arthritis undergoing elective surgery, withhold upadacitinib (Rinvoq) for at least 3 days prior to surgery. 1
Rationale and Evidence Base
The 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline provides the most authoritative recommendation for JAK inhibitor management perioperatively. This represents an updated and shortened withholding period compared to the previous 2017 guideline, which recommended 7 days.
Why the Change to 3 Days?
The revision was based on:
- Rapid pharmacologic reversal: Trial data demonstrated that disease activity increases rapidly after stopping tofacitinib, suggesting the immunosuppressive effects reverse quickly 1
- Similar half-lives: Upadacitinib has a comparable serum half-life to tofacitinib (8-14 hours), supporting the same 3-day withholding period 2
- Balancing infection risk vs disease control: The shorter interval minimizes disease flare risk while allowing drug clearance before surgery
Surgical Planning Strategy
Schedule surgery to occur after the 3-day withholding period has elapsed. This means:
- If the patient takes Rinvoq daily, the last dose should be 3 days before surgery
- Active drug levels will be minimal at the time of surgery
- This applies to elective procedures where timing can be controlled
Important Clinical Considerations
When to Consider Longer Withholding
Extend the withholding period beyond 3 days in patients with:
- History of recurrent or severe infections
- Prior prosthetic joint infection
- Immunocompromised state from other causes
The guideline explicitly acknowledges that "patients and their physicians might withhold JAK inhibitors for a longer period if a patient has a history of infections or a prior prosthetic joint infection" 1.
When Patients May Continue Through Surgery
Some patients may elect to continue Rinvoq if:
- Severe joint symptoms where pain relief from surgery outweighs infection risk (e.g., advanced osteonecrosis)
- Disease has been extremely difficult to control and risk of flare is unacceptable
- This requires shared decision-making between patient and physician 1
Critical Caveats
This Recommendation Does NOT Address:
- Cardiovascular event risk: The guideline explicitly states this recommendation "does not pertain to the risk of a cardiac event or a venous thromboembolic event (VTE) potentially associated with JAK inhibitors" 1
- Emergency surgery: These recommendations apply to elective procedures only
Monitoring Requirements
The 2021 consensus statement on JAK inhibitors recommends baseline monitoring including 3:
- Complete blood count with differential
- Liver function tests
- Renal function
- Lipid levels
Ensure these are optimized before elective surgery.
Postoperative Restart
Resume upadacitinib as soon as wound healing permits and infection risk is acceptable. While the guidelines focus on preoperative management, the German Society for Rheumatology notes that treatment should be restarted "as soon as possible for all substances, depending on wound healing" 4.
Practical Restart Approach:
- Assess wound healing status
- Confirm absence of surgical site infection
- Typically can restart within 1-2 weeks for uncomplicated procedures
- Coordinate with the surgical team
Type of Surgery Matters
The primary evidence base comes from total hip and knee arthroplasty studies 1. For other surgical procedures:
- Apply the same 3-day principle for moderate-to-major surgery
- For minor procedures with minimal infection risk, shorter withholding may be reasonable
- Use clinical judgment based on procedure invasiveness and infection risk
Strength of Evidence
This is a conditional recommendation because 1:
- Evidence is indirect (not from randomized controlled trials)
- Lack of direct comparator groups in studies
- Based on pharmacokinetic principles and observational data
However, it represents the most current expert consensus from major rheumatology and orthopedic surgery societies, making it the standard of care for perioperative JAK inhibitor management.