Humira (Adalimumab) Perioperative Management
For patients on adalimumab 40 mg every 2 weeks, schedule elective surgery during week 3 (one week after the missed dose), and resume therapy approximately 14 days postoperatively once the wound shows evidence of healing.
Pre-operative Timing
Withhold adalimumab prior to surgery and plan the procedure at the end of the dosing cycle 1. This approach minimizes active drug levels while limiting time off therapy.
Specific Timing for Adalimumab:
- Standard dosing (every 2 weeks): Schedule surgery during week 3 1
- Weekly dosing: Schedule surgery during week 2 (one week after the last dose) 1
Rationale for This Approach:
- Randomized controlled trials in non-surgical patients demonstrate increased infection risk with biologic agents 1
- The serum half-life does not correspond to the duration of immunosuppressive effects, making the dosing interval more clinically relevant than pharmacokinetics 1
- The 2022 ACR/AAHKS guideline maintains this recommendation based on additional observational studies showing no difference in outcomes between short (~1 dosing interval) versus longer medication interruptions 1
Post-operative Resumption
Resume adalimumab when the surgical wound demonstrates adequate healing, typically around 14 days postoperatively 1.
Specific Criteria Before Restarting:
- Evidence of wound healing is present 1
- All sutures or staples have been removed 1
- No significant swelling, erythema, or drainage at the surgical site 1
- No clinical evidence of surgical site infection or systemic infection 1
Supporting Evidence:
- Normal wound closure typically requires approximately 14 days 1
- The decision should be based on careful wound assessment and clinical judgment for absence of infection 1
Important Clinical Caveats
Patient-Specific Modifications:
- Patients with severe joint symptoms: May elect surgery within the dosing cycle if anticipated pain relief outweighs possible infection risk (e.g., advanced osteonecrosis) 1
- Patients with difficult-to-control disease: May choose to continue medication rather than risk loss of disease control 1
- History of recurrent infections or prior prosthetic joint infection: Consider longer withholding periods 1
Context Limitations:
- These recommendations are primarily derived from total hip and knee arthroplasty data 1
- The ACR explicitly cautions against extrapolating to other surgical procedures until further data are available 2
- However, recent data in hidradenitis suppurativa surgery showed no increased complications with continued adalimumab, though this represents a different surgical context 3
Common Pitfalls to Avoid:
- Do not base timing solely on serum half-life – the immunologic effects persist beyond drug clearance 1
- Do not resume therapy prematurely – wait for objective evidence of wound healing, not just a fixed time interval 1
- Do not ignore concurrent glucocorticoid use – patients on >20 mg/day prednisone equivalent have increased infection risk and should be tapered when possible prior to surgery 1