Managing Stiffness in a Patient on Tofacitinib Awaiting Hip Surgery
Continue tofacitinib until 3 days before surgery rather than stopping it now, as premature discontinuation will worsen your patient's stiffness and mobility without providing meaningful surgical benefit. 1
Rationale for Continuing Tofacitinib Until Surgery
The 2022 American College of Rheumatology guidelines updated their recommendation to withhold tofacitinib for only 3 days prior to surgery (changed from the previous 7-day recommendation), based on evidence showing rapid disease activity increases after interruption, suggesting quick reversal of immunosuppressive effects 1. The 2017 guidelines required 7 days of withholding 1, but newer data demonstrates that tofacitinib's immune effects resolve much faster than initially thought 1.
Key evidence supporting short-term discontinuation:
- Research demonstrates that tofacitinib efficacy deteriorates rapidly within 2 weeks of withdrawal, with patients experiencing significant worsening in disease activity scores, pain, and functional status 2, 3
- Studies show that disease control can be re-established after temporary withdrawal and reinitiation, but the intervening period causes measurable functional decline 2, 4
- In withdrawal studies, patients experienced worsening stiffness and quality of life measures within days to weeks of stopping tofacitinib 3, 4
Practical Management Algorithm
If surgery is scheduled within the next 2 weeks:
- Continue tofacitinib at current dose until 3 days before surgery 1
- No additional bridging therapy needed for this short interval 1
If surgery is more than 2 weeks away:
- Continue tofacitinib at current dose until 3 days before surgery 1
- Add physical therapy for preoperative conditioning to maintain mobility 5
- Consider low-dose glucocorticoids (≤10-15 mg prednisone daily) if stiffness becomes intolerable, though avoid doses ≥20 mg/day which significantly increase postoperative infection risk (OR 1.68) 1, 5
Alternative Symptom Management Options
For additional stiffness control while continuing tofacitinib:
- Intra-articular corticosteroid injection can provide temporary relief for hip osteoarthritis, but must be avoided within 3 months of planned joint replacement surgery 1
- Duloxetine 30-60 mg daily may help with pain and functional limitations, though it addresses pain more than mechanical stiffness 1
- Physical therapy with range-of-motion exercises can help maintain mobility without medication changes 1, 5
- Tramadol may provide additional analgesia if pain becomes a component, though it does not directly address stiffness 5
Critical Pitfalls to Avoid
Do not stop tofacitinib weeks before surgery – this provides no additional safety benefit beyond the 3-day recommendation and will cause unnecessary disease flare and functional decline 1. The updated 2022 guidelines specifically changed this based on pharmacodynamic data showing rapid return of immune function 1.
Do not add systemic corticosteroids at doses ≥20 mg/day prednisone – this significantly increases postoperative infection risk (OR 1.68 for infectious complications) and impairs wound healing 1, 5. If steroids are necessary, keep doses ≤15 mg/day 5.
Do not use intra-articular corticosteroid injections if surgery is within 3 months – this is explicitly contraindicated in the perioperative period 1.
Postoperative Considerations
After surgery, restart tofacitinib once the wound shows evidence of healing (typically ~14 days), all sutures/staples are removed, there is no significant swelling/erythema/drainage, and no clinical evidence of infection 1. Studies confirm that tofacitinib can successfully re-establish disease control after temporary perioperative interruption 2, 3.
Note on thromboprophylaxis: Limited data suggest increased venous thromboembolic events with perioperative tofacitinib use, so ensure prolonged thromboprophylaxis is implemented 1.