Patient on tofacitinib 5 mg daily for an inflammatory disease has synovial chondromatosis with surgery scheduled in three months; immediate discontinuation causes severe groin‑hip stiffness limiting ambulation. What peri‑operative management strategies can control stiffness while minimizing infection risk?

Perioperative Management of Tofacitinib in a Patient with Synovial Chondromatosis and Severe Stiffness

Continue tofacitinib 5 mg twice daily until 3 days before surgery, then withhold for only 3 days preoperatively, and add adjunctive therapies to control stiffness during this brief interruption.

Optimal Preoperative Strategy

The 2022 American College of Rheumatology guideline fundamentally changed the recommendation for tofacitinib perioperative management based on pharmacodynamic evidence showing rapid return of immune function and swift disease flare after interruption 1. The current evidence-based approach is to withhold tofacitinib for only 3 days before surgery (reduced from the previous 7-day recommendation), which minimizes both infection risk and disease flare 1.

Timeline for Your 3-Month Surgical Window

• Continue tofacitinib 5 mg twice daily at the current dose until 3 days before the scheduled surgery 1
• This approach provides only a 3-day medication-free window, dramatically reducing the stiffness burden compared to stopping now 1
• The 2017 guideline recommended 7 days of withholding 1, but newer data demonstrated this was unnecessarily long and caused preventable disease flares 1

Adjunctive Therapies to Control Stiffness During the 3-Day Preoperative Window

Since you only need to manage 3 days without tofacitinib rather than 3 months, the following strategies can bridge this brief gap:

Low-Dose Glucocorticoids (Use Cautiously)

• If stiffness becomes intolerable during the 3-day preoperative period, add prednisone ≤10-15 mg daily 1
• Never exceed 20 mg/day prednisone, as doses ≥20 mg/day significantly increase postoperative infection risk (odds ratio approximately 1.68) and impair wound healing 1
• The guideline explicitly states to optimize glucocorticoid doses to <20 mg/day when possible before surgery 1
• Continue the patient's current daily glucocorticoid dose through surgery if already prescribed; do not use "stress dosing" 1

Physical Therapy and Conditioning

• Implement intensive physical therapy with range-of-motion exercises for the hip during the 3-month waiting period to preserve mobility and conditioning before surgery 2
• This maintains functional capacity without altering the medication regimen 2

Analgesic Options (Do Not Address Stiffness Directly)

• Duloxetine 30-60 mg daily may improve pain and functional limitations, though its primary benefit is analgesic rather than mechanical stiffness reduction 2
• Tramadol can provide additional analgesia when pain is a component, but does not directly address inflammatory stiffness 2

Contraindicated Approaches

Do NOT Stop Tofacitinib Now

• Discontinuing tofacitinib weeks or months before surgery provides no additional safety benefit beyond the 3-day recommendation and leads to disease flare and functional decline 1
• The 2022 guideline specifically changed from 7 days to 3 days because trial data showed rapid increases in disease activity after interruption, indicating swift reversal of immunosuppressive effects 1

Avoid High-Dose Steroids

• Systemic corticosteroids ≥20 mg/day prednisone significantly raise postoperative infection risk (OR ≈1.68) and impair wound healing 1
• If steroids are needed for stiffness control, keep the dose ≤15 mg/day 1

No Intra-Articular Injections

• Intra-articular corticosteroid injections are contraindicated when surgery is planned within 3 months 2
• Although they can provide temporary relief for hip osteoarthritis, they must not be performed within this timeframe 2

Postoperative Restart Protocol

• Restart tofacitinib 5 mg twice daily once the surgical wound shows clear healing (approximately 14 days postoperatively) 1, 2
• Confirm that sutures or staples have been removed and there is no significant swelling, erythema, drainage, or clinical evidence of surgical site or systemic infection 1, 2
• The decision to restart should be based on careful wound assessment and clinical judgment for absence of infection 1

Special Perioperative Considerations

Thromboprophylaxis

• Implement prolonged thromboprophylaxis in the postoperative period due to limited evidence suggesting higher incidence of venous thromboembolic events with perioperative tofacitinib use 2, 3
• The 2022 guideline notes this recommendation does not pertain to cardiac events or VTE risk potentially associated with JAK inhibitors, which requires separate risk assessment 1

Infection Risk Monitoring

• Tofacitinib increases serious infection risk (incidence rate 2.91,95% CI 2.27-3.74) and overall infection risk (RR 5.7,95% CI 1.8-18.1) 1
• The FDA has issued a black box warning for all JAK inhibitors regarding increased infection risk, including serious infections 3, 4
• Monitor closely for signs of infection during the perioperative period, as tofacitinib may blunt fever and acute phase reactants 1, 4

Laboratory Monitoring

• Ensure baseline complete blood count, liver function tests, and renal function are checked before surgery 1
• Lymphocyte counts below 500/mm³ significantly increase opportunistic infection risk and should prompt consideration of delaying elective surgery 1, 4

Clinical Pitfalls to Avoid

• Do not withhold tofacitinib for longer than 3 days preoperatively based on outdated 2017 recommendations; the 2022 guideline supersedes this based on superior pharmacodynamic data 1
• Do not use high-dose glucocorticoids (≥20 mg/day) to manage stiffness, as infection risk outweighs benefit 1
• Do not delay restarting tofacitinib beyond 14 days postoperatively if wound healing is adequate, as prolonged withholding causes unnecessary disease flare without added safety benefit 1, 2