Management of RA Medications When Taking Ciprofloxacin
You should temporarily discontinue most RA medications while taking ciprofloxacin and restart them once the antibiotic course is completed and wound healing is evident, typically after 14 days.
Decision Algorithm for RA Medication Management with Ciprofloxacin
Medications to Discontinue
Biologic DMARDs (bDMARDs):
- TNF inhibitors (adalimumab, certolizumab, etanercept, golimumab, infliximab)
- IL-6 receptor inhibitors (sarilumab, tocilizumab)
- T-cell costimulation inhibitor (abatacept)
- Anti-CD20 therapy (rituximab) - if possible, plan ciprofloxacin treatment for the end of the dosing cycle
Targeted synthetic DMARDs (tsDMARDs):
- JAK inhibitors (tofacitinib, baricitinib, upadacitinib)
Conventional synthetic DMARDs (csDMARDs):
- Methotrexate
- Leflunomide
- Sulfasalazine
Medications That Can Be Continued
- Glucocorticoids: Continue current daily dose rather than administering supraphysiologic doses 1
- Hydroxychloroquine: Generally considered safe to continue
Timing of Medication Discontinuation and Restart
When to Stop
- Stop biologic and targeted synthetic DMARDs 1-2 dosing cycles before starting ciprofloxacin
- Stop conventional synthetic DMARDs when starting ciprofloxacin
When to Restart
According to the 2022 American College of Rheumatology guidelines, antirheumatic therapy should be restarted once:
- The wound shows evidence of healing
- Any sutures/staples are out
- There is no significant swelling, erythema, or drainage
- There is no ongoing infection
- This is typically ~14 days after starting antibiotics 1
Important Considerations
Risk of Disease Flare
- Temporarily stopping RA medications carries a risk of disease flare
- Studies show that more than one-third of patients with RA in low disease activity or remission may temporarily stop DMARD treatment without experiencing a disease flare within the first year 2
- However, flare rates vary widely depending on the medication and patient characteristics
Infection Risk
- Continuing immunosuppressive medications during antibiotic treatment may reduce the effectiveness of ciprofloxacin in treating the infection
- The risk of serious infections increases with higher doses of biologics like infliximab 3
Special Situations
- For patients with severe, difficult-to-control RA, consult with both rheumatology and infectious disease specialists to create an individualized plan
- Patients with a history of prior severe infections may require longer periods off immunosuppressive medications 1
Follow-up Recommendations
- Monitor for signs of infection resolution
- Assess for RA disease activity during and after antibiotic treatment
- If RA symptoms worsen significantly during antibiotic treatment, consider discussing with your rheumatologist about possibly using a short course of glucocorticoids to bridge the gap
This approach balances the need to effectively treat the infection requiring ciprofloxacin while minimizing the risk of RA disease flare and optimizing long-term patient outcomes.