How long should Rituxan (rituximab) be held prior to elective surgery?

Timing of Rituximab Discontinuation Before Elective Surgery

For patients receiving rituximab (Rituxan), surgery should be scheduled during month 7 after the last dose, which is after the next scheduled dose would have been due. 1

Rationale for Recommendation

The 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guidelines provide clear recommendations for perioperative management of biologics, including rituximab:

• Rituximab is typically dosed every 6 months
• Surgery should be planned after the end of the dosing cycle when active drug levels would be low 1
• This means planning surgery during month 7, after the next scheduled dose would have been due 1

This recommendation is based on the principle that withholding biologics prior to surgery reduces the risk of postoperative infections while minimizing disease flares.

Patient-Specific Considerations

The timing may be modified based on:

1. Disease severity and control:

   • Patients with difficult-to-control disease may elect to continue medications rather than risk loss of disease control 1
   • Patients with severe symptoms from the operative joint may choose earlier surgery if pain relief outweighs infection risk 1

2. Infection risk factors:

   • Patients with history of severe/recurrent infections or prior prosthetic joint infection may benefit from longer withholding periods 1

3. Type of surgery:

   • The recommendation applies specifically to elective surgeries
   • Emergency surgeries may require different considerations

Resumption of Therapy

• Rituximab should be restarted once:
  • The wound shows evidence of healing
  • Sutures/staples are removed
  • There is no significant swelling, erythema, or drainage
  • There is no ongoing non-surgical site infection
  • This is typically around 14 days post-surgery 1

Evidence Quality

The recommendation is conditional because:

• Evidence is indirect
• There is a lack of comparator groups in studies 1
• The recommendation is based on the dosing interval rather than serum levels, as the duration of immunologic effects does not always correspond to serum levels 1

Special Considerations

• For patients with systemic lupus erythematosus (SLE), different recommendations apply depending on disease severity 1
• For patients with severe SLE, planning surgery in the last month of the rituximab dosing cycle is conditionally recommended 1

The recommendation to hold rituximab and schedule surgery during month 7 represents the optimal balance between preventing surgical site infections and avoiding disease flares, with the primary goal of reducing morbidity and mortality associated with both infection and uncontrolled autoimmune disease.