Should Rinvoq (upadacitinib) be held prior to hip replacement surgery in an 81-year-old female patient with Crohn's disease?

Perioperative Management of Rinvoq (Upadacitinib) for Hip Replacement Surgery

Yes, Rinvoq (upadacitinib) should be withheld for at least 7 days prior to hip replacement surgery in an 81-year-old female with Crohn's disease to reduce infection risk. 1

Rationale for Withholding Rinvoq

Upadacitinib is a JAK inhibitor that works similarly to tofacitinib in terms of immunosuppressive effects. According to the 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guidelines:

• JAK inhibitors should be withheld prior to major orthopedic surgery due to increased infection risk
• Specifically, tofacitinib (which has a similar mechanism to upadacitinib) should be withheld for at least 7 days prior to surgery 1
• This recommendation is based on evidence showing increased risk of serious infections with JAK inhibitors
• Although upadacitinib has a short serum half-life, the duration of immunosuppression after discontinuation is not fully known 1

Timing Considerations

For optimal surgical outcomes:

• Withhold Rinvoq for at least 7 days before the scheduled hip replacement
• This timing allows for some return of normal immune function while minimizing risk of disease flare
• The recommendation is conditional (moderate evidence quality) but applies to most patients with inflammatory conditions undergoing major orthopedic surgery 1

When to Restart Rinvoq

Restart Rinvoq approximately 14 days after surgery when:

• The wound shows clear evidence of healing
• All sutures/staples have been removed
• There is no significant swelling, erythema, or drainage
• There is no clinical evidence of non-surgical site infections 1

Special Considerations for Elderly Patients with Crohn's Disease

While the ACR/AAHKS guidelines primarily address rheumatologic conditions, the principles apply to patients with Crohn's disease on JAK inhibitors:

• Older patients (81 years) have inherently higher infection risk
• Prosthetic joint infections are serious complications with significant morbidity and mortality
• The risk of infection outweighs the risk of disease flare in the perioperative period
• Recent studies show good efficacy of upadacitinib in Crohn's disease patients, suggesting that temporary discontinuation is unlikely to cause immediate severe disease flare 2, 3

Potential Pitfalls and Caveats

• If the patient has severe, difficult-to-control Crohn's disease, consult with her gastroenterologist to develop a bridging strategy if needed
• Monitor for signs of disease flare during the perioperative period
• Be vigilant for signs of infection both at the surgical site and elsewhere
• Consider that elderly patients may have delayed wound healing, which might necessitate postponing medication restart beyond the typical 14-day window

Summary Algorithm

1. Stop Rinvoq at least 7 days before scheduled hip replacement
2. Proceed with surgery as planned
3. Monitor wound healing closely
4. Restart Rinvoq approximately 14 days post-surgery if:
   • Wound is healing well
   • No signs of infection
   • All sutures/staples removed
   • No significant swelling, erythema, or drainage
5. If wound healing is delayed or complications arise, consider extending the period before restarting Rinvoq

This approach balances the risk of infection against the risk of disease flare, with infection prevention being the priority for this elderly patient undergoing major orthopedic surgery.