How long should methotrexate (MTX) be held prior to elective surgery?

Methotrexate Management During Surgery

Methotrexate can be safely continued in the perioperative period for patients with rheumatoid arthritis undergoing elective surgery. 1

Evidence-Based Recommendations

The 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guidelines specifically recommend continuing the usual dosing of methotrexate through surgery for patients with rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, juvenile idiopathic arthritis, or systemic lupus erythematosus undergoing total hip or knee arthroplasty 1.

This recommendation is supported by multiple studies that demonstrate:

• No increase in postoperative complications when methotrexate is continued 1
• Significantly fewer rheumatoid arthritis flares in patients who continue methotrexate 1
• No increased risk of wound morbidity with perioperative use of methotrexate 1

Clinical Decision Algorithm

1. For patients with rheumatoid arthritis undergoing elective orthopedic surgery:

   • Continue methotrexate at the usual dose throughout the perioperative period 1
   • Monitor for standard post-surgical complications as you would for any patient

2. For patients with severe systemic lupus erythematosus:

   • Continue methotrexate through surgery 1
   • This approach is supported by evidence from organ transplant patients who continue anti-rejection therapy through surgical periods 1

3. For patients with non-severe systemic lupus erythematosus:

   • Consider withholding methotrexate for 1 week prior to surgery 1
   • Restart 3-5 days after surgery if no wound healing complications or infections 1

Important Considerations

• Infection risk: Multiple randomized controlled trials have shown no significant increase in infection rates when methotrexate is continued during the perioperative period 2, 3

• Disease flares: Discontinuing methotrexate increases the risk of disease flares in the postoperative period 2, 4

• Wound healing: A multivariate analysis showed that perioperative use of methotrexate was not associated with wound morbidity (p=0.84) 1

• Long-term safety: A 10-year follow-up study found no evidence that continued methotrexate therapy in the perioperative period increases the risk of late deep infections 5

Common Pitfalls to Avoid

1. Unnecessarily stopping methotrexate: This can lead to disease flares without providing any benefit in reducing surgical complications 2, 4

2. Inconsistent perioperative management: Follow evidence-based guidelines rather than outdated practices of routinely withholding methotrexate

3. Failure to distinguish between medication types: While biologics should be withheld prior to surgery, conventional DMARDs like methotrexate can be safely continued 1

4. Overlooking special circumstances: In patients with renal failure or active infection, temporary discontinuation of methotrexate may be warranted 5

By following these evidence-based recommendations, you can minimize the risk of disease flares while maintaining patient safety during the perioperative period.