Should sulfasalazine be discontinued prior to surgery?

From the Guidelines

Sulfasalazine should not be discontinued prior to surgery, as continuing its usual dosing through surgery is conditionally recommended for patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. This recommendation is based on the 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline, which suggests that continuing disease-modifying antirheumatic drugs (DMARDs) like sulfasalazine through surgery is low to moderate evidence 1.

The guideline provides recommendations for the perioperative management of anti-rheumatic drug therapy in patients with inflammatory arthritis and those with systemic lupus erythematosus (SLE) undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA). Key points from the guideline include:

• Continuing the usual dosing of DMARDs like methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, and/or apremilast through surgery is conditionally recommended for patients with RA, AS, PsA, JIA, or all SLE undergoing THA or TKA 1.
• Withholding all biologics, including rituximab, prior to surgery and planning the surgery after the next dose is due is conditionally recommended for patients with RA, AS, PsA, or JIA undergoing THA or TKA 1.
• The decision to continue or discontinue sulfasalazine should be individualized based on the patient's specific medical condition, the type of surgery, and their overall health status 1.

It is essential to disclose all medications, including sulfasalazine, to the surgical team during pre-operative assessment to ensure the best possible outcome. In specific situations, such as if the patient has developed blood count abnormalities while on sulfasalazine or has kidney or liver dysfunction, the surgeon might recommend temporary discontinuation 1. However, in general, sulfasalazine can be safely continued during the perioperative period, and its benefits in reducing inflammation and preventing disease flares likely outweigh the risks.

From the FDA Drug Label

WARNINGS ... Discontinue treatment with sulfasalazine while awaiting the results of blood tests. ... Discontinue sulfasalazine if a patient develops a serious infection. ... Sulfasalazine should be discontinued at the first appearance of skin rash, mucosal lesions, or any other sign of hypersensitivity ... Sulfasalazine should be discontinued if an alternative etiology for the signs or symptoms cannot be established.

The FDA drug label does not answer the question.

From the Research

Sulfasalazine and Surgery

• The use of sulfasalazine in the perioperative period has been studied, and it appears that conventional synthetic disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine are safe during this time 2.
• There is no clear evidence to suggest that sulfasalazine should be discontinued prior to surgery, as it is considered to be safe in the perioperative period.
• However, it is essential to consider the individual patient's condition and the type of surgery being performed.

Potential Risks and Interactions

• Sulfasalazine has been associated with various adverse effects, including nephrotoxicity, which can lead to renal failure 3.
• There have been reports of sulfasalazine-induced lupus erythematosus, which can manifest with serositis and pulmonary parenchymal involvement 4.
• Sulfasalazine can also interact with other medications, such as warfarin, and lead to warfarin resistance 5.
• These potential risks and interactions should be taken into account when deciding whether to continue or discontinue sulfasalazine prior to surgery.

Management of Sulfasalazine in the Perioperative Period

• The management of sulfasalazine in the perioperative period should be based on the individual patient's condition and the type of surgery being performed.
• Patients with a history of adverse effects or interactions with sulfasalazine should be closely monitored, and alternative treatments should be considered if necessary.
• The decision to continue or discontinue sulfasalazine prior to surgery should be made in consultation with the patient's healthcare team, taking into account the potential benefits and risks of the medication.