From the Guidelines
For a patient taking Rinvoq (upadacitinib) for rheumatoid arthritis who is scheduled for a total laparoscopic hysterectomy (TLH), the medication should be withheld for at least 3 days prior to surgery, as conditionally recommended by the 2022 American College of Rheumatology guideline 1. This approach is based on the guideline's conditional recommendation for withholding tofacitinib, baricitinib, and upadacitinib for at least 3 days prior to surgery in patients with RA, AS, PsA, or JIA undergoing THA or TKA. The decision to withhold Rinvoq is due to its immunosuppressive effects, which may increase the risk of infection and potentially affect wound healing. During the perioperative period, the patient may continue their other RA medications, such as NSAIDs, until 3-5 days before surgery, and acetaminophen can be used for pain management. Corticosteroids, if the patient is on them, should be continued at their usual dose and may require stress-dose supplementation on the day of surgery, as recommended by the guideline for patients with RA, AS, PsA, or SLE undergoing THA or TKA who are receiving glucocorticoids for their rheumatic condition 1. The timing of medication resumption should be individualized based on the patient's recovery, wound healing, and absence of infection, and the rheumatologist should be consulted before surgery to coordinate this medication management plan. Some key points to consider in the perioperative management of patients taking Rinvoq for RA include:
- Withholding Rinvoq for at least 3 days prior to surgery to minimize the risk of infection and potential effects on wound healing
- Continuing other RA medications, such as NSAIDs, until 3-5 days before surgery, and using acetaminophen for pain management
- Continuing corticosteroids at their usual dose, with possible stress-dose supplementation on the day of surgery
- Individualizing the timing of medication resumption based on the patient's recovery and absence of infection
- Consulting with the rheumatologist before surgery to coordinate the medication management plan.
From the Research
Perioperative Management of Rinvoq (Upadacitinib) for RA Patients Undergoing TLH
- The provided studies do not directly address the perioperative management of Rinvoq (upadacitinib) for RA patients undergoing total laparoscopic hysterectomy (TLH) 2, 3, 4, 5, 6.
- However, it is known that upadacitinib is a JAK inhibitor with an increased risk of serious infections, herpes zoster, malignancies, major cardiovascular events, and venous thromboembolic events 3, 4, 5.
- Considering the potential risks associated with upadacitinib, it is essential to weigh the benefits and risks of continuing or withholding the medication perioperatively.
- The decision to continue or discontinue upadacitinib before TLH should be made on a case-by-case basis, taking into account the individual patient's risk factors, disease activity, and surgical complexity.
- Patients should be closely monitored for any signs of infection, bleeding, or other complications during the perioperative period.
- It is recommended to consult with a rheumatologist and anesthesiologist to determine the best course of action for each patient.
Key Considerations
- Upadacitinib's immunosuppressive effects may increase the risk of perioperative infections 3, 4, 5.
- The medication's potential to increase the risk of bleeding may also be a concern during surgery 3, 4, 5.
- The decision to continue or discontinue upadacitinib should be based on the individual patient's overall health status and the specific surgical procedure.
Further Research
- More studies are needed to provide specific guidance on the perioperative management of upadacitinib in patients with RA undergoing TLH.
- Until more evidence is available, healthcare providers should exercise caution and consider the potential risks and benefits of continuing or withholding upadacitinib in the perioperative period.