What are the perioperative management guidelines for a patient with Systemic Lupus Erythematosus (SLE) on hydroxychloroquine and methotrexate undergoing surgery?

Perioperative Management of SLE Patients on Hydroxychloroquine and Methotrexate

For patients with SLE undergoing surgery, hydroxychloroquine and methotrexate should be continued throughout the perioperative period without interruption. 1

Medication-Specific Recommendations

Hydroxychloroquine

• Continue regular dosing through surgery and postoperative period
• Do not interrupt treatment at any point during perioperative care
• Rationale: Low risk of surgical complications and infection; discontinuation may trigger disease flares

Methotrexate

• Continue regular dosing through surgery and postoperative period
• Do not interrupt treatment at any point during perioperative care
• Rationale: Studies show continuing methotrexate may actually reduce infection risk compared to discontinuation 2

Perioperative Management Algorithm

1. Pre-operative Assessment:

   • Categorize SLE severity:
     • Non-severe SLE: Stable disease without major organ involvement
     • Severe SLE: Active disease with major organ involvement

2. Medication Management Plan:

   • Hydroxychloroquine: Continue at current dose regardless of SLE severity
   • Methotrexate: Continue at current dose regardless of SLE severity
   • Glucocorticoids: Continue current daily dose; do not administer supraphysiologic doses on day of surgery 1

3. Timing of Surgery:

   • No need to schedule surgery around hydroxychloroquine or methotrexate dosing
   • If patient is also on biologics (e.g., belimumab, rituximab):
     • For non-severe SLE: Withhold biologics prior to surgery 1
     • For severe SLE: Continue belimumab; schedule surgery in last month of rituximab dosing cycle 1

4. Post-operative Management:

   • Continue hydroxychloroquine and methotrexate without interruption
   • Monitor for wound healing complications
   • Watch for signs of disease flare

Evidence Quality and Considerations

The recommendations are based on conditional evidence (low to moderate quality) from the 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guidelines 1. These updated guidelines represent the most recent expert consensus on perioperative management of antirheumatic medications.

Key points from the evidence:

• Continuing conventional DMARDs (including hydroxychloroquine and methotrexate) through surgery does not increase infection risk 1
• Discontinuation of hydroxychloroquine is associated with SLE flares, and long-term treatment has higher continuation rates in SLE than in RA 3
• Studies show that continuing methotrexate during surgery may actually reduce complication rates compared to discontinuation 2

Common Pitfalls and Caveats

1. Avoid unnecessary medication interruption: Discontinuing hydroxychloroquine or methotrexate can trigger disease flares without reducing surgical complications.

2. Consider other medications: If the patient is on additional medications beyond hydroxychloroquine and methotrexate:

   • For non-severe SLE: Withhold mycophenolate mofetil, azathioprine, cyclosporine, tacrolimus, belimumab, or rituximab before surgery
   • For severe SLE: Continue these medications through surgery

3. Monitor for wound healing: While continuing these medications, ensure proper wound healing assessment before restarting any medications that were withheld.

4. Glucocorticoid management: Do not increase glucocorticoid doses perioperatively unless specifically indicated for stress dosing in patients with adrenal insufficiency.

5. Differentiate from other rheumatic conditions: The recommendations for SLE differ from those for RA, PsA, and AS in some aspects, particularly regarding biologics and immunosuppressants in severe disease.

By following these guidelines, you can minimize both the risk of surgical complications and the risk of disease flares in SLE patients undergoing surgery.