Should Hydroxychloroquine Be Held for Surgery?
No, hydroxychloroquine should be continued through surgery without interruption. 1, 2
Primary Recommendation
The 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline conditionally recommends continuing the usual dose of hydroxychloroquine through elective surgery for patients with rheumatoid arthritis, psoriatic arthritis, juvenile idiopathic arthritis, and all forms of systemic lupus erythematosus (both severe and non-severe). 1
Evidence Supporting Continuation
- Continuing hydroxychloroquine through surgery reduces postoperative infection risk (RR 0.39,95% CI 0.17-0.91) 2
- Continuation significantly decreases postoperative disease flare-ups (RR 0.06,95% CI 0.0-1.10) 2
- This recommendation applies to all types of elective surgery, though the evidence base is strongest for orthopedic procedures 1, 2
Management Algorithm
For patients on hydroxychloroquine alone:
- Continue the usual daily dose (typically 200-400 mg daily) through the day of surgery 1, 2
- No dose adjustment or timing modification needed 2
For patients on hydroxychloroquine plus biologics:
- Continue hydroxychloroquine through surgery 2
- Withhold biologic agents and schedule surgery when the next biologic dose would be due 1, 2
For patients with severe SLE on multiple immunosuppressants:
- Continue hydroxychloroquine through surgery 1, 2
- Continue other immunosuppressants (mycophenolate, azathioprine, tacrolimus) if SLE is severe 1
For patients with non-severe SLE on multiple immunosuppressants:
- Continue hydroxychloroquine through surgery 1, 2
- Withhold other immunosuppressants (mycophenolate, azathioprine, tacrolimus) 1 week before surgery 1
Critical Cardiac Considerations
While the guideline recommends continuation, important caveats exist for patients with cardiac risk factors:
Absolute contraindications to perioperative hydroxychloroquine:
- Known congenital or acquired QT prolongation 3
- Recent ventricular arrhythmias or torsades de pointes 3, 4
- Severe bradycardia (<50 bpm) 3
- Uncorrected hypokalemia or hypomagnesemia 3
- Concomitant use of other QT-prolonging medications 3
Relative concerns requiring careful assessment:
- Hydroxychloroquine can prolong the QTc interval and has been associated with ventricular arrhythmias in case reports 3, 4, 5
- Cardiomyopathy has been reported with chronic use, though this is rare 3, 6
- However, population-based studies show no significantly increased risk of cardiac arrhythmia in SLE patients on hydroxychloroquine (adjusted OR 1.49,95% CI 0.98-2.25) 7
Practical cardiac screening approach:
- Review preoperative ECG for QTc prolongation (>470 ms in women, >450 ms in men) 3
- Correct electrolyte abnormalities before surgery 3
- Review medication list for other QT-prolonging agents 3
- If significant cardiac concerns exist, consider cardiology consultation rather than empirically holding hydroxychloroquine 3, 8
Common Pitfalls to Avoid
- Do not routinely hold hydroxychloroquine "to be safe" – this increases infection and flare risk without clear benefit 1, 2
- Do not confuse hydroxychloroquine management with biologic management – they have opposite recommendations 1, 2
- Do not delay restarting hydroxychloroquine postoperatively if it was held – it should resume once wound healing is evident (typically ~14 days) 1
- Do not assume cardiac toxicity is common – while serious when it occurs, population studies show minimal arrhythmia risk at therapeutic doses 7, 8
Strength of Evidence
The recommendation to continue hydroxychloroquine is based on low-to-moderate quality evidence, making it a conditional rather than strong recommendation 1. However, the direction is clear: the benefits of continuation (reduced infection and flare risk) outweigh the theoretical risks in patients without severe cardiac contraindications 1, 2.