Should methotrexate and prednisone be discontinued in a patient with rheumatoid arthritis (RA) prior to surgery to minimize complications?

From the Guidelines

For patients with rheumatoid arthritis undergoing surgery who are on methotrexate and prednisone, methotrexate can generally be continued throughout the perioperative period, while prednisone should be maintained with possible stress-dose supplementation. Methotrexate does not need to be discontinued before surgery as evidence shows that continuing it does not increase infection risk and may actually help prevent disease flares, as supported by a study published in the Annals of the Rheumatic Diseases 1. For prednisone, patients on chronic therapy (typically doses >5 mg daily for >3 weeks) require continued administration with possible supplementation on the day of surgery (typically 50-100 mg hydrocortisone IV) to prevent adrenal insufficiency, although recent guidelines suggest that continuing the current daily dose of glucocorticoids may be sufficient, rather than administering perioperative supra-physiologic glucocorticoid doses 1. The supplemental dose depends on the surgical stress level, with major procedures requiring higher doses. This approach balances the risks of disease flare-up (if medications are stopped) against potential surgical complications. Patients should maintain their usual prednisone dose the morning of surgery, and the surgical team should be informed about the patient's steroid use to ensure appropriate perioperative management. Key considerations include:

• Methotrexate can be safely continued in the perioperative period for patients undergoing elective orthopaedic surgery, with no increased risk of postoperative complications 1.
• The decision to restart antirheumatic therapy after surgery should be based on careful assessment of the patient’s wound status and clinical judgment for absence of surgical and non–surgical site infections 1.
• For patients with severe SLE, the current dose of mycophenolate mofetil, azathioprine, cyclosporine, or tacrolimus should be continued through the surgical period, due to the uncertainty and limited published experience regarding perioperative medication management in these patients 1. However, the most recent and highest quality study, published in 2017 in Arthritis and Rheumatology, provides conditional recommendations for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty, which should be prioritized in clinical decision-making 1.

From the Research

Methotrexate and Prednisone in Rheumatoid Arthritis Patients Undergoing Surgery

• The provided studies do not directly address the question of whether methotrexate or prednisone should be discontinued in patients with rheumatoid arthritis prior to surgery to decrease complications 2, 3, 4, 5, 6.
• However, the studies discuss the importance of methotrexate in the treatment of rheumatoid arthritis, its efficacy, and safety profile 2, 3, 5, 6.
• Methotrexate is considered a cornerstone therapy for patients with rheumatoid arthritis, and its discontinuation may lead to disease flare-ups 2, 5, 6.
• The studies also highlight the potential interactions between methotrexate and other drugs, including prednisone, which may increase the risk of adverse reactions 4.
• There is no clear evidence to suggest that discontinuing methotrexate or prednisone prior to surgery would decrease complications, and any decision to do so should be made on a case-by-case basis, considering the individual patient's disease activity, medical history, and surgical risks.

Considerations for Methotrexate Use in Rheumatoid Arthritis

• Methotrexate should be continued for at least 6 months to achieve an accurate assessment of treatment efficacy 2.
• The dosage and route of administration of methotrexate should be maintained, rather than increased, when switching from oral to subcutaneous delivery 2.
• Folate supplementation can be given routinely to patients treated with methotrexate for rheumatoid arthritis 3.
• Regular monitoring of blood cell counts, serum transaminase, and creatinine levels is recommended for patients taking methotrexate 3.

Interactions between Methotrexate and Other Drugs

• Clinically relevant drug-drug interactions have been described between methotrexate and nonsteroidal anti-inflammatory drugs (NSAIDs), prednisone, and immunosuppressant drugs 4.
• The combination of methotrexate with antitumor necrosis factor-α agents may increase the risk of infections 4.