Is a new medication or surgery medically indicated for a patient with rheumatoid arthritis?

Medical Necessity of New Medication or Surgery for Rheumatoid Arthritis

For a patient with rheumatoid arthritis, new medication or surgery is medically indicated when disease activity remains moderate-to-high despite current therapy, or when severe joint damage causes significant functional impairment requiring arthroplasty. 1, 2

When New Medication is Indicated

Disease Activity Assessment

• Initiate or escalate therapy when the patient has not achieved remission or low disease activity within 3-6 months of current treatment. 1, 2
• Measure disease activity using validated instruments; treatment target is remission or at minimum low disease activity. 2, 3
• If methotrexate monotherapy (optimized to 25 mg weekly with glucocorticoids) fails to achieve target within 6 months, adding biologic DMARDs or targeted synthetic DMARDs is indicated. 2, 3

Treatment Escalation Algorithm

• For patients on conventional synthetic DMARDs alone with persistent moderate-to-high disease activity, adding a biologic DMARD (TNF inhibitor, IL-6 inhibitor) or JAK inhibitor is strongly indicated. 1, 2
• Sequential application of targeted therapies allows up to 75% of patients who fail initial methotrexate therapy to reach treatment targets. 2
• Early aggressive therapy prevents irreversible joint damage in up to 90% of patients. 2, 4

High-Risk Populations Requiring Medication Adjustment

• Patients with hepatitis, heart failure, malignancy history, or recurrent serious infections require specific medication selection based on contraindications. 1, 3
• TNF inhibitors are contraindicated in active infection, recurrent infections, or recent malignancy; alternative agents (IL-6 inhibitors, JAK inhibitors, or non-biologic options like apremilast) should be selected. 5

When Surgery (Total Hip or Knee Arthroplasty) is Indicated

Surgical Candidacy Criteria

• Surgery is indicated when patients have end-stage symptomatic joint damage with severe pain and functional impairment despite optimal medical management. 1, 6
• RA patients undergoing THA or TKA report significant improvement in pain and function postoperatively. 1
• Young RA patients require special consideration due to longer life expectancy, implant survival concerns, and potential need for revision surgery. 6

Preoperative Optimization Requirements

• Disease activity must be optimized before proceeding to surgery, as uncontrolled RA increases perioperative complications including infection, dislocation, and readmission. 6
• RA patients have 50% increased risk of periprosthetic joint infection compared to osteoarthritis patients. 1, 6
• Modifiable risk factors (disease severity, recurrent infection history, overall disability level) should be addressed preoperatively. 6

Perioperative Medication Management When Surgery is Indicated

Medications to Continue Through Surgery

• Continue methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, and apremilast at usual doses through surgery without interruption. 1, 6
• These conventional DMARDs do not increase postoperative infection risk and prevent disease flares. 1, 6
• Continue current daily glucocorticoid dose through surgery rather than administering supraphysiologic stress doses. 1, 6

Medications to Withhold Before Surgery

• Withhold all biologic agents (TNF inhibitors, IL-6 inhibitors, rituximab) prior to surgery and schedule the procedure when the next dose would be due (approximately one dosing cycle). 1, 6
• Withhold JAK inhibitors (tofacitinib, baricitinib, upadacitinib) for at least 3 days before surgery. 6
• This timing minimizes infection risk while limiting time off medication. 1, 6

Postoperative Medication Resumption

• Resume all antirheumatic therapy once the wound shows evidence of healing, sutures/staples are removed, there is no significant swelling/erythema/drainage, and no ongoing infection—typically 14 days postoperatively. 1, 6

Critical Pitfalls to Avoid

• Do not delay DMARD therapy in newly diagnosed RA; early treatment within 6 months prevents irreversible joint damage. 2, 4
• Do not continue biologic agents through elective surgery; the increased infection risk outweighs flare risk according to patient preference data. 1, 6
• Do not withhold conventional synthetic DMARDs perioperatively; continuation prevents flares without increasing infection risk. 1
• Do not proceed with elective surgery in patients with uncontrolled disease activity; optimize medical management first. 6

Coordination Requirements

Close communication between rheumatologist and orthopedic surgeon is mandatory regarding medication timing, disease optimization, and postoperative management. 6, 5