Post-Operative Complications in Rheumatoid Arthritis
Patients with rheumatoid arthritis (RA) undergoing surgery have higher rates of complications including infection, dislocation, and readmission compared to patients with osteoarthritis, requiring careful perioperative medication management to minimize these risks. 1
Common Post-Operative Complications in RA Patients
Infection Risk
- Higher infection rates compared to non-RA patients
- Prosthetic joint infections are particularly concerning
- Risk factors include:
- Disease activity/severity
- Overall disability
- Immunosuppressive medications
- Concurrent chronic diseases (diabetes, hypertension, bronchiectasis, etc.) 2
Other Complications
- Wound healing problems
- Dislocation (especially in total hip arthroplasty)
- Higher readmission rates
- Disease flares if medications are discontinued inappropriately
Perioperative Management of Antirheumatic Medications
Conventional DMARDs
- Methotrexate: Continue through surgery
- Hydroxychloroquine, Sulfasalazine: Continue through surgery
- Leflunomide: Continue through surgery (despite conflicting data, guidelines recommend continuation due to long half-life)
- Apremilast: Continue through surgery 1
Biologic Agents
- Withhold all biologics prior to surgery for one dosing cycle 1
- Plan surgery after the next dose is due
- Examples:
- Adalimumab (every 2 weeks): Schedule surgery in week 3
- Infliximab (every 8 weeks): Schedule surgery in week 9
- Rituximab (every 6 months): Schedule surgery during month 7
JAK Inhibitors
- Withhold tofacitinib for at least 7 days prior to surgery 1
- Despite short half-life, duration of immunosuppression after discontinuation is not well established
Special Considerations for SLE
- For severe SLE (lupus nephritis, CNS involvement, etc.):
- For non-severe SLE:
- Withhold mycophenolate mofetil, azathioprine, cyclosporine, or tacrolimus 1 week before surgery 1
Glucocorticoids
- Continue current daily dose of glucocorticoids 1
- Do NOT use "stress dosing" (supraphysiologic doses) on the day of surgery
- Attempt to taper to <20 mg/day prednisone equivalent before surgery when possible
- Higher glucocorticoid exposure increases risk of hyperglycemia and other complications 1
Restarting Medications Post-Surgery
Restart biologics approximately 14 days after surgery when: 1
- Wound shows evidence of healing
- All sutures/staples are out
- No significant swelling, erythema, or drainage
- No clinical evidence of non-surgical site infections
Restart conventional DMARDs immediately after surgery (if they were continued) or within 3-5 days if they were withheld
Risk Mitigation Strategies
Optimize disease control before surgery
- Minimize disease activity to reduce disability-related complications
Minimize glucocorticoid use when possible
- Consistently associated with increased infection risk 4
- Taper to lowest effective dose before surgery
Screen for wound healing before restarting biologics
- Consider visiting nurse services
- Wound photography for review
- In-person evaluation for high-risk patients
Monitor for signs of infection
- Increased pain, erythema, warmth, drainage
- Systemic symptoms (fever, malaise)
- Prompt intervention if infection suspected
Balance infection risk against disease flare risk
- Particularly important in SLE patients where flares may be organ-threatening
Special Considerations for Older RA Patients
- Higher baseline infection risk
- More likely to have comorbidities that increase surgical risk
- May require more careful medication management
- Consider longer withholding periods for biologics in patients with history of recurrent infections 5
By following these evidence-based guidelines for perioperative medication management, the risk of post-operative complications in RA patients can be significantly reduced while maintaining disease control.