Perioperative Management of Plaquenil (Hydroxychloroquine)
No, patients should continue Plaquenil through the perioperative period without interruption. The American College of Rheumatology explicitly recommends continuing hydroxychloroquine at the current dose for patients with rheumatoid arthritis, spondyloarthropathies, juvenile idiopathic arthritis, or systemic lupus erythematosus undergoing elective surgery 1.
Evidence-Based Rationale
The recommendation to continue Plaquenil is supported by randomized controlled trials demonstrating that:
- Infection risk actually decreases when DMARDs like hydroxychloroquine are continued (relative risk 0.39,95% CI 0.17–0.91) 1
- Disease flares are significantly reduced when DMARDs are maintained perioperatively (relative risk 0.06,95% CI 0.0–1.10) 1
- Evidence from non-surgical settings confirms a low infection risk profile for hydroxychloroquine 1
Clinical Algorithm
For all patients on Plaquenil:
- Continue current daily dose through surgery 1
- No need to adjust timing of surgery based on medication schedule 1
- No washout period required 1
This applies to:
- Rheumatoid arthritis patients 1
- Lupus patients (both severe and non-severe) 1
- Spondyloarthropathies including ankylosing spondylitis and psoriatic arthritis 1
- Juvenile idiopathic arthritis 1
Key Distinction from Other Medications
Unlike biologic agents (which should be withheld and timed to the end of dosing cycles) 1, 2 or certain immunosuppressants like azathioprine in non-severe SLE (which should be withheld 1 week prior) 3, hydroxychloroquine belongs to the category of conventional DMARDs that are safe to continue 1.
Important Caveats
- This recommendation is based on low to moderate quality evidence from the 2017 ACR/AAHKS guidelines 1
- The guideline evidence specifically addresses elective total hip and knee arthroplasty, though the principles apply broadly to other surgical procedures 4, 5
- Plaquenil has a very long tissue half-life, meaning discontinuation would require prolonged washout periods that are unnecessary and potentially harmful due to increased flare risk 6