When should a patient stop taking Rinvoq (upadacitinib) before undergoing bunion surgery?

When to Stop Rinvoq Before Bunion Surgery

For patients taking Rinvoq (upadacitinib) undergoing bunion surgery, withhold the medication for at least 3 days prior to the procedure. 1

Evidence-Based Timing

The 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline provides clear direction for JAK inhibitor management:

• Stop Rinvoq (upadacitinib) at least 3 days before surgery 1
• This recommendation applies to patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), or juvenile idiopathic arthritis (JIA) 1
• The guideline is based on the short serum half-life of JAK inhibitors and trial data showing rapid disease activity increases after interruption, suggesting rapid reversal of immunosuppressive effects 1

Rationale for the 3-Day Window

The 2022 guideline represents an update from the 2017 recommendation, which previously suggested withholding tofacitinib (another JAK inhibitor) for 7 days 1. The change was informed by:

• Evidence demonstrating rapid increases in disease activity after interrupting JAK inhibitor therapy 1
• This rapid disease reactivation suggests equally rapid reversal of immunosuppressive effects 1
• The serum half-life of upadacitinib is similar to tofacitinib, justifying the same 3-day withholding period 1

Important Caveats and Exceptions

Consider extending the withholding period beyond 3 days if the patient has:

• History of recurrent infections 1
• Prior prosthetic joint infection 1
• Other significant infection risk factors 1

Note: This recommendation addresses infection risk only and does not account for cardiac events or venous thromboembolic events potentially associated with JAK inhibitors 1

When to Restart Rinvoq After Surgery

Resume Rinvoq once the surgical wound shows evidence of healing, which typically occurs around 14 days postoperatively when: 1, 2

• Sutures or staples are removed 1, 2
• No significant swelling, erythema, or drainage is present 1, 2
• No ongoing infection at the surgical site or elsewhere 1, 2

Application to Bunion Surgery

While the ACR guideline specifically addresses total hip and knee arthroplasty, the principles apply to bunion surgery because:

• Bunion surgery involves bone and soft tissue manipulation with infection risk 3, 4
• The immunosuppressive effects of Rinvoq are systemic and affect wound healing regardless of surgical site 5
• The 3-day withholding period balances infection risk against disease flare risk 1

Common Pitfalls to Avoid

Do not continue Rinvoq through surgery - Unlike conventional DMARDs (methotrexate, hydroxychloroquine, sulfasalazine), JAK inhibitors must be withheld due to their immunosuppressive effects on wound healing 1, 2

Do not withhold for only 1-2 days - The minimum 3-day interruption is necessary to allow adequate clearance of immunosuppressive effects 1

Do not delay restarting indefinitely - Failure to restart medications in a timely manner after adequate wound healing can lead to disease flares 1, 2