Do patients with rheumatoid arthritis (RA) need to discontinue methotrexate (MTX) before undergoing minor surgery?

Methotrexate Continuation During Minor Surgery for Rheumatoid Arthritis Patients

Methotrexate should be continued during minor surgery in patients with rheumatoid arthritis as it does not increase the risk of surgical complications and helps maintain disease control. 1

Evidence for Continuing Methotrexate During Surgery

• The 2022 American College of Rheumatology (ACR)/American Association of Hip and Knee Surgeons guideline conditionally recommends continuing the usual dosing of methotrexate through surgery for patients with rheumatoid arthritis undergoing total hip or knee arthroplasty 1
• This recommendation is based on low to moderate quality evidence showing that continuing DMARDs like methotrexate is associated with a decreased risk of infections (relative risk 0.39,95% CI 0.17-0.91) 1
• The British Association of Dermatologists' guidelines (2016) also support that methotrexate can be continued during the perioperative period when it is controlling an individual's disease 1
• Multiple randomized controlled trials have demonstrated that continuing methotrexate during orthopedic surgery does not increase infection risk and actually reduces the frequency of rheumatoid arthritis flares postoperatively 1

Benefits of Continuing Methotrexate

• Patients who continue methotrexate during surgery experience significantly fewer rheumatoid arthritis flares compared to those who discontinue the medication 1, 2
• A large prospective randomized study of 388 RA patients found that those who continued methotrexate had fewer complications (2%) compared to those who discontinued methotrexate (15%) 2
• Continuing methotrexate helps maintain disease control, which is crucial for optimal recovery and rehabilitation after surgery 1, 3

Special Considerations and Exceptions

• For patients with significant comorbidities that increase infection risk (such as diabetes), the decision to continue methotrexate should be made on a case-by-case basis 1
• In contrast to methotrexate, biologic agents should be withheld prior to surgery according to their dosing cycle 1
• Patients on JAK inhibitors (tofacitinib, baricitinib, upadacitinib) should withhold these medications for at least 3 days prior to surgery 1
• If methotrexate is withheld for any reason, it should be restarted once the wound shows evidence of healing, typically around 14 days post-surgery 1

Historical Context and Conflicting Evidence

• Older studies (pre-2000) suggested temporarily withholding methotrexate for 2 weeks perioperatively due to theoretical concerns about infection risk 4, 5
• A small prospective study from 1996 found higher infection rates in patients continuing methotrexate (4 infections in 16 procedures) versus those discontinuing it (0 infections in 26 procedures) 5
• However, more recent and larger studies have consistently shown that continuing methotrexate is safe and beneficial 2, 6, 3
• A 2009 systematic review concluded that continuing low-dose methotrexate is safe during the perioperative period in RA patients without relevant comorbidities undergoing elective orthopedic surgery 6

Practical Approach

• For minor surgery in RA patients, continue the regular methotrexate dosing schedule without interruption 1
• Maintain the patient's usual folic acid supplementation (at least 5 mg weekly) 1
• Monitor for signs of infection post-surgery, but recognize that continuing methotrexate does not increase this risk 2
• For patients on multiple immunosuppressive medications, consider the cumulative immunosuppressive effect when making decisions about perioperative medication management 1