Should a patient with rheumatoid arthritis (RA) hold methotrexate (MTX) prior to surgery?

Perioperative Management of Methotrexate in Rheumatoid Arthritis Patients Undergoing Surgery

Methotrexate should be continued throughout the perioperative period in patients with rheumatoid arthritis undergoing elective surgery, particularly orthopedic procedures. This recommendation is supported by multiple clinical guidelines and research studies that demonstrate the safety of continuing methotrexate and the benefits of maintaining disease control during the surgical period 1, 2.

Evidence-Based Recommendations

The 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons (ACR/AAHKS) guidelines provide the most recent and authoritative recommendation:

• Continue the usual dosing of methotrexate through surgery for patients with rheumatoid arthritis undergoing elective total hip or knee arthroplasty 1
• This recommendation is based on low to moderate quality evidence but represents the current standard of care

The 2009 multinational evidence-based recommendations specifically state: "Methotrexate can be safely continued in the perioperative period in RA patients undergoing elective orthopaedic surgery" 1.

Benefits of Continuing Methotrexate

1. Prevents disease flares:

   • Randomized controlled trials show significantly fewer RA flares in patients who continue methotrexate 1, 3
   • One study found 0% flares in patients continuing methotrexate versus 8% in those who discontinued it 3

2. Does not increase infection risk:

   • Multiple studies demonstrate no increased risk of postoperative infections when continuing methotrexate 4, 3
   • Some evidence suggests potentially lower infection rates in patients who continue methotrexate 3

3. Improved wound healing:

   • A retrospective study showed fewer cases of wound morbidity in patients who continued methotrexate (p=0.038) 4

Specific Considerations

• Dosing: Continue the patient's usual methotrexate dose throughout the perioperative period 1, 2
• Timing: No need to adjust the timing of methotrexate administration relative to surgery date 2
• Duration of evidence: Long-term follow-up (10 years) confirms no increased risk of late infections in patients who continued methotrexate perioperatively 5

Important Caveats

• This recommendation applies specifically to elective orthopedic surgery in RA patients 1
• Limited evidence exists for non-orthopedic surgeries, though the principles likely apply
• Patients with significant renal impairment or active infection may require individualized assessment 5
• While methotrexate should be continued, biologic DMARDs should be withheld prior to surgery according to their specific dosing cycles 1

Practical Application

1. Maintain the patient's regular methotrexate dosing schedule before, during, and after surgery
2. Monitor for signs of infection as would be done for any surgical patient
3. Ensure good communication between the rheumatologist and surgical team regarding medication management
4. Distinguish clearly between methotrexate (continue) and biologic agents (withhold) in perioperative planning

The practice of routinely stopping methotrexate before surgery is outdated and can lead to unnecessary disease flares without providing any benefit in reducing surgical complications 2, 3.