What medications should be held for a patient with rheumatoid arthritis on Actemra (Tocilizumab) and Methotrexate (MTX) undergoing knee surgery?

Perioperative Management of Actemra and Methotrexate for Knee Surgery

Hold Actemra (tocilizumab) before surgery and schedule the procedure when the next dose is due, but continue methotrexate through surgery without interruption. 1

Specific Medication Management

Methotrexate (MTX): Continue Through Surgery

• Continue your usual MTX dose without any interruption for knee surgery 1
• Continuing MTX actually reduces infection risk (RR 0.39) compared to stopping it 1
• Continuing MTX significantly decreases disease flare risk postoperatively (RR 0.06) 1
• This recommendation applies regardless of whether this is total knee arthroplasty or other knee procedures 1

Actemra (Tocilizumab): Hold Before Surgery

• Withhold tocilizumab prior to surgery and time the surgery to occur when the next dose would be due 1
• For IV tocilizumab (given every 4 weeks): schedule surgery 4 weeks after the last dose 1
• For subcutaneous tocilizumab (given weekly or every 2 weeks): schedule surgery at the corresponding interval after the last dose 1
• This timing allows the drug to clear while minimizing the window of uncontrolled disease activity 1

Rationale for Different Approaches

Why Continue MTX?

The 2022 ACR/AAHKS guidelines specifically recommend continuing conventional DMARDs like methotrexate because 1:

• Low-to-moderate quality evidence shows decreased infection risk when MTX is continued
• Disease flares are significantly more common when MTX is stopped perioperatively
• Patients prioritize avoiding infection over avoiding flares, and MTX helps with both

Why Hold Biologics Like Actemra?

Biologic agents including tocilizumab increase serious infection risk (odds ratios typically ~1.5) in non-surgical settings 1. While direct evidence in surgical patients is limited, the guideline panel determined that:

• The infection risk from biologics outweighs the flare risk during the brief perioperative period 1
• Timing surgery at the end of the dosing cycle minimizes both infection risk and disease activity 1

Restarting Actemra After Surgery

Resume tocilizumab approximately 14 days after surgery once all of the following criteria are met 1:

• Wound shows clear evidence of healing
• All sutures or staples have been removed
• No significant swelling, erythema, or drainage present
• No evidence of surgical site infection
• No other active infections anywhere in the body

Important Caveats

Patient-Specific Considerations

• If the patient has a history of severe or recurrent infections or prior prosthetic joint infection, consider holding MTX as well despite the general recommendation 1
• These recommendations are conditional (not strong) due to low-quality evidence, requiring shared decision-making 1

Glucocorticoids

• If the patient is also on prednisone or other steroids, continue the current daily dose rather than giving stress-dose steroids 1
• Do not increase glucocorticoid doses perioperatively unless there are other specific indications 1

Disease Activity Monitoring

• The brief interruption of tocilizumab (typically 4 weeks) is generally well-tolerated because MTX continues to provide disease control 1
• Monitor for disease flare symptoms during the tocilizumab interruption period, though risk is low with continued MTX 1