Perioperative Management of Humira and Methotrexate for Back Surgery
Direct Answer
For back surgery, you should stop Humira one dosing cycle before surgery (plan surgery at week 3 after your last dose), continue methotrexate through surgery without interruption, and restart both medications approximately 14 days after surgery once the wound shows evidence of healing. 1
Humira (Adalimumab) Management
Pre-operative Timing
Withhold Humira before surgery and schedule your back surgery to occur after the next dose is due (approximately 2-3 weeks after your last dose). 1
- Since Humira is dosed every 2 weeks, plan your surgery for week 3 (the week after your missed dose). 1
- This timing allows drug levels to be at their lowest while minimizing the risk of disease flare. 1
- The 2022 ACR/AAHKS guideline specifically recommends planning surgery at the end of the dosing interval for all biologics including TNF inhibitors like Humira. 1
Post-operative Timing
Restart Humira approximately 14 days after surgery, once the wound shows evidence of healing. 1
Specific criteria for restarting include: 1
- Wound shows evidence of healing (typically ~14 days)
- All sutures/staples are removed
- No significant swelling, erythema, or drainage present
- No evidence of surgical site or non-surgical site infection
Important Caveat
The FDA label warns that Humira increases risk of serious infections, and you should discontinue it if serious infection or sepsis develops during the perioperative period. 2
Methotrexate Management
Pre-operative Management
Continue methotrexate at your current dose through surgery without interruption. 1, 3, 4
- The 2022 ACR/AAHKS guideline conditionally recommends continuing methotrexate through elective orthopedic surgery, including spine procedures. 1, 3, 4
- This recommendation is based on moderate-quality evidence showing decreased infection risk (relative risk 0.39,95% CI 0.17-0.91) when methotrexate is continued versus stopped. 3, 4
- A landmark prospective randomized study of 388 patients showed only 2% infection rate in patients who continued methotrexate versus 15% in those who stopped it 2 weeks before surgery. 5
Post-operative Management
Resume methotrexate immediately when oral intake recommences after surgery. 3
- Methotrexate has a very short elimination half-life (1-2 hours), so stopping it immediately before surgery provides no measurable benefit. 3
- Continue monitoring for signs of infection; temporarily stop methotrexate only if postoperative infection develops requiring antibiotics. 3, 4
Why This Differs from Old Practice
Older literature from the 1990s suggested stopping methotrexate 2 weeks before surgery, but current high-quality evidence from multiple prospective studies demonstrates this practice actually increases complications. 5, 6, 7, 8
Prolia (Denosumab) Injection Timing
You do not need to postpone your Prolia injection scheduled for [DATE] even if your back surgery is a few weeks later.
- Prolia (denosumab) is a bone-strengthening medication, not an immunosuppressant like Humira.
- There is no evidence that Prolia increases surgical infection risk or wound healing complications.
- Maintaining bone health is particularly important in the perioperative period, especially for spine surgery.
- The provided evidence does not address Prolia specifically, but based on its mechanism of action (RANKL inhibitor for osteoporosis), there is no reason to delay it for elective spine surgery.
Summary Algorithm
2-3 weeks before surgery:
- Stop Humira (last dose should be 2 weeks before surgery, with surgery planned for week 3) 1
- Continue methotrexate at current dose 1, 3
- Proceed with scheduled Prolia injection as planned
Day of surgery:
After surgery:
- Resume methotrexate immediately when oral intake resumes 3
- Resume Humira at approximately 14 days post-op once wound healing criteria are met 1
Critical Pitfalls to Avoid
Do not stop methotrexate before surgery - this outdated practice actually increases infection risk and causes disease flares. 5, 6
Do not restart Humira too early - wait for complete wound healing with sutures/staples removed and no signs of infection. 1
Do not confuse Prolia with immunosuppressive medications - it does not require perioperative adjustment for infection risk.