Does hydroxychloroquine need to be held prior to surgery/anesthesia?

Hydroxychloroquine Does NOT Need to Be Held Prior to Surgery

Hydroxychloroquine should be continued through the perioperative period without interruption for patients undergoing elective surgery, including major orthopedic procedures. 1

Primary Recommendation

• Continue hydroxychloroquine at the current dose through surgery for patients with rheumatoid arthritis, spondyloarthritis, juvenile idiopathic arthritis, and systemic lupus erythematosus undergoing elective total hip or knee arthroplasty 1
• This recommendation applies to all nonbiologic DMARDs including hydroxychloroquine, methotrexate, leflunomide, and sulfasalazine 1

Evidence Supporting Continuation

The 2017 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline provides the strongest evidence for this approach:

• Continuing DMARDs including hydroxychloroquine actually decreases infection risk compared to stopping them, with a relative risk of 0.39 (95% CI 0.17–0.91) 1
• Disease flares after surgery are significantly reduced when hydroxychloroquine is continued (RR 0.06 [95% CI 0.0–1.10]) 1
• There is indirect evidence demonstrating low infection risk with hydroxychloroquine in various surgical settings beyond joint replacement 1

Key Distinction from Biologic Agents

This recommendation for hydroxychloroquine is fundamentally different from biologic DMARDs, which should be withheld:

• All biologic agents (TNF inhibitors, rituximab, abatacept, etc.) should be stopped prior to surgery and timed at the end of their dosing cycle 1
• Biologics increase infection risk with relative risks around 1.5 or higher 1
• Hydroxychloroquine is a nonbiologic DMARD with a completely different safety profile perioperatively 2, 3

Historical Context Supporting Safety

Older studies actually used hydroxychloroquine specifically for thromboembolism prophylaxis in surgical patients:

• A large series of 2,144 hip arthroplasty patients received hydroxychloroquine perioperatively with fatal emboli in only 0.28% and non-fatal emboli in 4.15%, with no deaths from bleeding 4
• Another study found hydroxychloroquine safe with no hemorrhagic complications when used pre- and postoperatively 5

Practical Implementation

On the day of surgery:

• Administer hydroxychloroquine on the usual schedule, including the morning of surgery 1
• No dose adjustment is necessary 1
• Resume immediately postoperatively once oral intake is tolerated 1

For all surgery types:

• This recommendation applies broadly, not just to joint replacement surgery 2, 3
• The evidence supports continuation for both low and high bleeding-risk procedures 1

Common Pitfalls to Avoid

• Do not confuse hydroxychloroquine with biologic DMARDs – they have opposite perioperative management strategies 1, 3
• Do not stop hydroxychloroquine "to be safe" – this actually increases both infection risk and disease flare risk 1
• Do not delay restarting postoperatively – resume as soon as the patient can take oral medications 2

Quality of Evidence

This is a conditional recommendation based on low-to-moderate quality evidence, meaning it applies to the vast majority of patients but allows for shared decision-making in exceptional circumstances 1. The conditional nature reflects the indirect evidence base (studies outside the surgical context) rather than safety concerns with continuation 1.