Preoperative Management of RA Patient on Methotrexate and Deflazacort for Femoral Neck Fracture Repair
Methotrexate Management
Continue methotrexate 7.5 mg weekly through surgery without interruption. 1
The 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline conditionally recommends continuing methotrexate at the usual dose through elective orthopedic surgery, based on low to moderate quality evidence. 1
Continuing methotrexate actually decreases infection risk (RR 0.39,95% CI 0.17-0.91) compared to discontinuation, while also reducing the risk of disease flares (RR 0.06,95% CI 0.0-1.10). 1
The elimination half-life of methotrexate is only 1-2 hours, so stopping it immediately before surgery provides no measurable benefit. 2
This recommendation applies to both elective and urgent orthopedic procedures, including fracture repair. 1
Glucocorticoid (Deflazacort) Management
Continue deflazacort 6 mg on alternate days through surgery at the current dose—do not administer supraphysiologic "stress doses." 1
The 2022 ACR/AAHKS guideline conditionally recommends continuing the current daily dose of glucocorticoids rather than administering supraphysiologic doses on the day of surgery. 1
This patient is on a low dose (6 mg alternate days, equivalent to approximately 5 mg prednisone alternate days), which is below the threshold typically requiring stress-dose supplementation. 1
The traditional practice of stress-dose steroids lacks strong evidence and may increase perioperative complications without clear benefit. 1
Preoperative Assessment
Verify disease remission status and assess for infection or other contraindications to proceeding with current medications: 3
Confirm complete blood count is adequate (WBC >3.5×10^9/L, neutrophils >2×10^9/L). 2, 4
Check liver function tests (transaminases should be <2× upper limit of normal). 2, 4, 3
Assess renal function with creatinine clearance calculation (should be >20 mL/min for methotrexate continuation). 2
Rule out active infection requiring antibiotics, which would necessitate temporary methotrexate discontinuation. 2, 4
Postoperative Medication Resumption
Resume methotrexate immediately when oral intake recommences after surgery. 5, 2
If methotrexate was held for any reason perioperatively, restart once wound shows evidence of healing, sutures/staples are removed, there is no significant swelling/erythema/drainage, and no ongoing infection (typically ~14 days). 1
Continue deflazacort at the same alternate-day dosing postoperatively. 1
Monitor for signs of infection and temporarily cease methotrexate only if postoperative infection develops requiring antibiotics. 2
Important Caveats
This patient's RA is in clinical remission, which supports medication continuation—active disease or severe comorbidities might alter the risk-benefit calculation. 1
Fracture neck of femur repair, while urgent, follows the same perioperative medication principles as elective total hip arthroplasty per ACR guidelines. 1
The low methotrexate dose (7.5 mg/week) and minimal corticosteroid exposure (6 mg alternate days) represent relatively low immunosuppression, further supporting continuation. 1, 6
Ensure folic acid supplementation (minimum 5 mg weekly) is maintained perioperatively to reduce methotrexate-related toxicity. 3