Should a patient with a history of autoimmune disorders, such as rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE), continue taking hydroxychloroquine (HCQ) prior to undergoing surgery?

Hydroxychloroquine Prior to Surgery

Continue hydroxychloroquine at the current dose through surgery without interruption for patients with rheumatoid arthritis or systemic lupus erythematosus undergoing elective procedures. 1, 2

Primary Recommendation

The American College of Rheumatology (ACR) and American Association of Hip and Knee Surgeons (AAHKS) 2022 guidelines explicitly recommend continuing hydroxychloroquine through surgery for patients with RA, SLE, and other rheumatic diseases. 1 This applies to all elective orthopedic procedures, including total hip and knee arthroplasty. 1, 2

Evidence Supporting Continuation

The decision to continue hydroxychloroquine is based on superior outcomes when the medication is maintained:

• Infection risk is actually reduced when hydroxychloroquine is continued perioperatively, with a relative risk of 0.39 (95% CI 0.17-0.91) compared to stopping the medication. 1, 2

• Disease flares are significantly decreased when hydroxychloroquine is continued, with a relative risk of 0.06 (95% CI 0.0-1.10) for postoperative flares. 1, 2

• The evidence quality is rated as low to moderate, but consistently demonstrates benefit rather than harm from continuation. 1

Contrast with Biologic Agents

Hydroxychloroquine management differs fundamentally from biologic DMARDs:

• While biologic agents (TNF inhibitors, rituximab, tocilizumab, etc.) should be withheld prior to surgery and the procedure scheduled at the end of the dosing cycle, hydroxychloroquine belongs to the conventional DMARD category that is continued. 1, 2

• The distinction exists because biologics increase serious infection risk (most odds ratios ≥1.5), whereas conventional DMARDs like hydroxychloroquine do not. 1

Special Considerations

Patients with severe or recurrent infection history may warrant individualized assessment:

• The 2022 ACR/AAHKS guidelines note that patients with a history of severe or recurrent infections or prior prosthetic joint infection may elect to withhold conventional DMARDs including hydroxychloroquine before surgery. 1

• However, this is an exception rather than the rule, and the default recommendation remains continuation. 1

For patients with SLE specifically:

• Hydroxychloroquine should definitely be continued for both severe and non-severe SLE during surgery. 2

• Other immunosuppressants in SLE (mycophenolate, azathioprine, tacrolimus) should be suspended 1 week before surgery if the SLE is not severe, but hydroxychloroquine is maintained. 2

Practical Implementation

No dosing adjustments are required:

• Continue the patient's usual daily dose of hydroxychloroquine on the day of surgery and throughout the perioperative period. 1

• No need to hold doses before surgery or delay resumption after surgery. 1, 2

Glucocorticoid management:

• If the patient is also taking glucocorticoids for their rheumatic condition, continue the current daily dose rather than administering supraphysiologic stress doses on the day of surgery. 1

Common Pitfall to Avoid

Do not conflate hydroxychloroquine with biologic agents. The most common error is unnecessarily withholding hydroxychloroquine because of confusion with the recommendations for biologics. Hydroxychloroquine is a conventional DMARD with a favorable safety profile that reduces rather than increases perioperative infection risk. 1, 2