When is it safe to start Disease-Modifying Rheumatic Surgery (DMRS) medication after surgery?

From the Guidelines

It is generally safe to restart Disease-Modifying Rheumatic Surgery (DMRS) medication after surgery once the wound shows evidence of healing, typically around 14 days post-operation, in the absence of significant swelling, erythema, or drainage, and no ongoing nonsurgical site infection. This recommendation is based on the most recent and highest quality study available, which suggests that restarting antirheumatic therapy after surgery should be done once the wound is healed and there are no signs of infection 1. The timing of restarting DMRS medication depends on several factors, including the type of surgery, presence of infection, wound healing status, and the specific medication.

• Conventional DMARDs like methotrexate can often be restarted sooner, around 1-2 weeks post-operation.
• Biologics like TNF inhibitors (adalimumab, etanercept) should be held longer, usually 2-4 weeks after surgery.
• For major surgeries or procedures with high infection risk, longer delays may be necessary.
• Patients should monitor for signs of poor wound healing or infection, such as increased pain, redness, swelling, or drainage from the surgical site.
• The decision to restart antirheumatic therapy should be based on careful assessment of the patient’s wound status and clinical judgment for absence of surgical and non-surgical site infections, as recommended by the 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty 1.

It is essential to consult with both your rheumatologist and surgeon before restarting any DMRS medication after surgery to determine the optimal timing for your specific situation, considering the potential risks and benefits of restarting therapy, including the risk of disease flares and the risk of infection or poor wound healing 1.

From the FDA Drug Label

Methotrexate 12 g/m2 IV as 4 hour infusion (starting dose) 4,5,6,7,11,12,15,16,29,30,44,45 Administration of methotrexate should be delayed until recovery if: the WBC count is less than 1500/microliter the neutrophil count is less than 200/microliter the platelet count is less than 75,000/microliter the serum bilirubin level is greater than 1. 2 mg/dL the SGPT level is greater than 450 U mucositis is present, until there is evidence of healing persistent pleural effusion is present; this should be drained dry prior to infusion.

It is safe to start Disease-Modifying Rheumatic Surgery (DMRS) medication, specifically methotrexate, after surgery at treatment weeks 4,5,6,7,11,12,15,16,29,30,44,45 as indicated in the table, provided that the patient's condition meets the guidelines for methotrexate therapy with leucovorin rescue, including adequate renal function and recovery from any adverse conditions that may delay administration 2.

• Key considerations include:
  • Adequate renal function: Serum creatinine must be normal, and creatinine clearance must be greater than 60 mL/min.
  • Recovery from adverse conditions: Delay administration if the patient has certain conditions such as low WBC or platelet count, high serum bilirubin or SGPT levels, mucositis, or persistent pleural effusion.
  • Hydration and urinary alkalinization: Patients must be well hydrated and treated with sodium bicarbonate for urinary alkalinization.

From the Research

Disease-Modifying Rheumatic Surgery (DMRS) Medication

• The safety of starting DMRS medication after surgery depends on the type of medication and the individual patient's condition 3.
• Conventional synthetic DMARDs, such as methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, can be continued perioperatively 3, 4.
• Targeted synthetic DMARDs should be suspended at least 3 to 7 days before surgery and restarted 3-5 days after the procedure 3.
• Biologic DMARDs should be withheld a dosing cycle prior to surgery and resumed at least 14 days after the procedure, with evidence of complete wound healing 3.
• The decision to discontinue immunomodulators, such as mycophenolate mofetil, azathioprine, cyclosporine, or tacrolimus, in patients with Systemic Lupus Erythematosus (SLE) should be based on the severity of the condition 3.

Specific Medications

• Methotrexate is a commonly used DMARD that can be continued perioperatively 3, 4, 5, 6, 7.
• Methotrexate combination therapy with other DMARDs, such as leflunomide, cyclosporine, azathioprine, sulfasalazine, gold, and hydroxychloroquine, may be used to treat patients with rheumatoid arthritis 6, 7.
• Biologic DMARDs, such as abatacept, adalimumab, etanercept, infliximab, rituximab, and tocilizumab, should be used with caution perioperatively due to their immunosuppressive effects 3, 4, 7.