Should a patient with rheumatoid arthritis (RA) stop taking methylprednisolone (corticosteroid) before undergoing major foot and bunion surgery?

Perioperative Management of Methylprednisolone for Major Foot and Bunion Surgery in Rheumatoid Arthritis

Do not stop methylprednisolone before surgery—continue the current daily dose through the perioperative period without any interruption or dose adjustment. 1, 2

Core Recommendation

The American College of Rheumatology/American Association of Hip and Knee Surgeons guidelines conditionally recommend continuing the current daily dose of glucocorticoids rather than withholding or administering supraphysiologic "stress doses" for patients with rheumatic conditions undergoing elective orthopedic surgery. 1, 2

• This recommendation applies to patients receiving ≤16 mg/day prednisone equivalent (or equivalent methylprednisolone doses) for their rheumatic condition 1, 2
• The patient should take their usual methylprednisolone dose on the day of surgery and continue it postoperatively without interruption 1, 2

Evidence Supporting Continuation

Hemodynamic stability concerns do not justify stress dosing or medication changes:

• Evidence from observational trials and systematic reviews demonstrates no significant hemodynamic differences between patients given their current daily glucocorticoid dose compared to those receiving stress-dose steroids 2
• The historical practice of "stress dosing" increases infection risk without providing additional benefit 2

Infection risk considerations:

• While observational studies show increased arthroplasty infection risk with long-term steroid use >15 mg/day, patients on lower doses remain appropriate surgical candidates 2, 3
• The CDC defines the immunosuppression threshold at 20 mg prednisone/day for ≥2 weeks 2, 3
• Continuing the current dose does not increase infection risk compared to stress dosing and may actually reduce disease flare risk 1

Practical Implementation

On the day of surgery:

• Administer the patient's usual methylprednisolone dose at the regular time 1, 2
• Do not check morning serum cortisol levels—this would not change management and adds unnecessary testing 2

Postoperatively:

• Resume the usual daily dose immediately after surgery 2
• Monitor for signs of disease flare or adrenal insufficiency in the postoperative period 2

Important Caveats

This recommendation differs from biologic DMARDs:

• Unlike biologic agents (TNF inhibitors, rituximab, etc.) which should be withheld prior to surgery and timed to the end of the dosing cycle, glucocorticoids are continued without interruption 1
• Traditional DMARDs like methotrexate, hydroxychloroquine, and sulfasalazine are also continued through surgery 1

Wound healing timeline:

• Biologic therapy can be restarted once the wound shows evidence of healing (typically ~14 days), all sutures/staples are removed, there is no significant swelling, erythema, or drainage, and there is no clinical evidence of infection 1
• This timeline applies to biologics that were held, not to glucocorticoids which are never stopped 1

Common Pitfalls to Avoid

• Do not administer stress-dose steroids—this increases infection risk without benefit 2
• Do not check cortisol levels—this adds unnecessary testing and would not alter the management plan 2
• Do not withhold glucocorticoids—unlike biologics, corticosteroids should be continued to prevent adrenal crisis and disease flare 1, 2
• Do not confuse this recommendation with biologic management—the approach to glucocorticoids is fundamentally different from the approach to TNF inhibitors and other biologics 1