How should an adult patient on rheumatologic therapy be managed preoperatively for an elective surgery regarding NSAIDs, glucocorticoids, conventional synthetic disease‑modifying antirheumatic drugs, biologic agents, and JAK inhibitors to minimize infection risk and avoid disease flare?

Perioperative Management of Rheumatologic Medications for Elective Surgery

For adult patients on rheumatologic therapy undergoing elective surgery, continue conventional DMARDs (methotrexate, hydroxychloroquine, sulfasalazine, leflunomide) through the perioperative period, withhold biologic agents for one dosing cycle before surgery and restart after wound healing (~14 days), hold JAK inhibitors 3-7 days preoperatively, and continue the current daily glucocorticoid dose without stress dosing. 1

NSAIDs Management

• Stop NSAIDs 4-5 half-lives before surgery to avoid antiplatelet effects and bleeding complications 2
• This typically means discontinuing most NSAIDs 2-3 days preoperatively depending on the specific agent
• NSAIDs can be resumed once hemostasis is secure and bleeding risk has diminished

Glucocorticoids Management

• Continue the patient's current daily glucocorticoid dose throughout the perioperative period rather than administering supraphysiologic "stress doses" 1, 3
• This recommendation applies to patients receiving ≤16-20 mg/day prednisone equivalent for their rheumatic condition 1, 3
• Optimize glucocorticoid dosing to <20 mg/day prednisone equivalent before elective surgery when possible, as this represents the CDC threshold for immunosuppression and the inflection point for increased infection risk 1, 3
• For patients on >20 mg/day, consider postponing elective high-risk procedures until disease is controlled with lower doses 4
• This recommendation does NOT apply to patients with primary adrenal insufficiency or hypothalamic-pituitary axis disorders, who require supplementary perioperative dosing 3, 2

Conventional Synthetic DMARDs

Methotrexate

• Continue methotrexate through the perioperative period without interruption 4, 5, 6
• High-quality evidence demonstrates that continuing methotrexate actually reduces infection risk (2%) compared to stopping it (15%) 5
• Discontinuing methotrexate increases flare risk (8% vs 0%) without reducing infection risk 5

Hydroxychloroquine

• Continue hydroxychloroquine perioperatively 4, 2
• Available data show no increased infection risk with continuation 2

Sulfasalazine

• Continue sulfasalazine perioperatively 4
• Limited data available, but no evidence suggests increased risk with continuation 2

Leflunomide

• Continue leflunomide perioperatively 4
• Due to its extremely long half-life (14-18 days), discontinuation would require stopping weeks in advance and is likely unnecessary 4, 2
• Evidence is conflicting but trending toward safety with continuation 2, 7

Biologic DMARDs (TNF Inhibitors, IL-6 Inhibitors, etc.)

• Withhold biologic agents for one dosing cycle prior to surgery 1, 4, 6
• Schedule surgery at the end of the dosing cycle when drug levels are lowest 1
• Restart biologic therapy once the wound shows evidence of healing (typically ~14 days postoperatively), all sutures/staples are removed, there is no significant swelling/erythema/drainage, and no clinical evidence of surgical or non-surgical site infection 1, 8, 6
• The decision to restart should be based on careful wound assessment and clinical judgment 1, 8
• Use screening mechanisms (visiting nurses, wound photographs via telemedicine) to assess healing if the patient cannot return in person 1

Common Pitfalls with Biologics

• Restarting biologics too early (before adequate wound healing) increases infection risk 8
• Delaying restart unnecessarily increases disease flare risk and worsens outcomes 8
• Patients with history of prior severe infections or prosthetic joint infections may warrant longer withholding periods 8

JAK Inhibitors (Tofacitinib, etc.)

• Withhold JAK inhibitors at least 3-7 days before surgery 1, 4
• Despite extremely short serum half-life, the duration of immunosuppression after discontinuation is not well understood 1
• Restart 3-5 days after surgery in the absence of wound healing complications or infection 4
• Evidence shows increased serious infection risk (incidence rate 2.91,95% CI 2.27-3.74) with tofacitinib in non-surgical populations 1

Special Considerations for Systemic Lupus Erythematosus (SLE)

Severe SLE

• Continue mycophenolate mofetil, azathioprine, cyclosporine, or tacrolimus through the surgical period without interruption 1
• The risk of life-threatening organ flares outweighs infection risk in severe SLE 1, 4
• Indirect evidence from organ transplant patients supports continuing anti-rejection therapy perioperatively 1
• Decisions regarding elective surgery in severe SLE should be individualized with the patient's rheumatologist 1

Non-Severe SLE

• Withhold mycophenolate mofetil, azathioprine, cyclosporine, or tacrolimus 1 week prior to surgery 1
• Restart 3-5 days after surgery in the absence of wound healing complications or infection 1
• This conservative approach permits some immune function recovery while minimizing flare risk 1

Risk Prioritization Framework

The 2017 ACR/AAHKS guideline explicitly prioritized infection risk over flare risk based on patient panel input, recognizing that prosthetic joint infection morbidity is more severe than most disease flares 1

This framework drives the recommendation to withhold medications when evidence suggests increased infection risk, even with low-quality evidence 1

Evidence Quality Caveat

All recommendations carry conditional strength with low-quality evidence due to paucity of high-quality randomized trials and indirect nature of available data 1

Despite limited evidence quality, these guidelines represent consensus among major stakeholders (orthopedic surgeons, rheumatologists, and patients) and provide necessary guidance for common clinical scenarios 1