In a patient with synovial chondromatosis and early hip osteoarthritis on tofacitinib 5 mg daily who needs hip arthroscopy in 3 months but cannot stop the JAK inhibitor due to severe groin/hip stiffness, what alternative peri‑operative management can be used until surgery?

Management Until Hip Arthroscopy in a Patient with Synovial Chondromatosis Unable to Discontinue Tofacitinib

Continue tofacitinib 5 mg daily until 3 days before surgery, then add low-dose prednisone (≤10–15 mg daily) during those final 3 days if stiffness becomes intolerable, and restart tofacitinib approximately 14 days post-operatively once the wound has healed.

Rationale for Continuing Tofacitinib Until 3 Days Pre-Operatively

• The 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline changed the recommendation from withholding tofacitinib for 7 days to only 3 days before surgery 1.

• This revision was based on trial data demonstrating that tofacitinib's immunosuppressive effects reverse rapidly after discontinuation, with disease activity increasing swiftly when the drug is stopped 1.

• Research confirms that tofacitinib efficacy can be re-established after temporary withdrawal of only 2 weeks, with disease control parameters returning to baseline within 28 days of reinitiation 2.

• Withholding tofacitinib for longer than 3 days provides no additional safety benefit and leads to preventable disease flares and functional decline 3, 4.

• The guideline explicitly acknowledges that patients whose disease has been challenging to control may elect to continue their medications rather than risk loss of disease control when medications are withheld 1.

Bridging Strategy for the 3-Day Pre-Operative Window

Low-Dose Glucocorticoids (First-Line Adjunct)

• Add prednisone 10–15 mg daily during the 3-day tofacitinib-free interval if stiffness becomes intolerable 3, 4.

• Doses ≥20 mg/day prednisone significantly increase postoperative infection risk (odds ratio ≈1.68) and impair wound healing, so they must be avoided 3, 4.

• If the patient is already on glucocorticoids, maintain the current dose through surgery without "stress dosing" 4.

Physical Therapy and Range-of-Motion Exercises

• Implement pre-operative physical therapy conditioning to preserve hip mobility during the 3-month waiting period 3.

• Range-of-motion exercises help maintain function without altering medication regimens 3.

Additional Analgesic Options

• Duloxetine 30–60 mg daily may improve pain and functional limitations, though its primary benefit is analgesic rather than addressing mechanical stiffness 3.

• Tramadol can be added for breakthrough pain, but it does not directly address stiffness 3.

Contraindicated Approaches

Do Not Discontinue Tofacitinib Early

• Stopping tofacitinib weeks before surgery provides no extra safety benefit beyond the 3-day recommendation and leads to disease flare and functional decline 1, 3, 4.

• The 2017 guideline's 7-day recommendation has been superseded by the 2022 evidence-based 3-day interval 1, 4.

Avoid High-Dose Systemic Corticosteroids

• Prednisone ≥20 mg/day significantly raises postoperative infection risk (OR ≈1.68) and should not be used for stiffness control 3, 4.

No Intra-Articular Corticosteroid Injections

• Intra-articular hip injections are contraindicated when surgery is planned within 3 months due to infection risk 3.

Post-Operative Tofacitinib Restart Protocol

• Restart tofacitinib once the surgical wound shows clear healing, typically around 14 days post-operatively 1, 3, 4.

• Specific criteria before restarting:

  • Visible evidence of wound healing with no dehiscence 1
  • All sutures or staples removed 1, 3, 4
  • Absence of significant swelling, erythema, or drainage 1, 3, 4
  • No clinical signs of surgical-site or systemic infection 1, 3, 4

• Do not delay restarting beyond 14 days when wound healing is adequate, as prolonged interruption leads to unnecessary disease flare without added safety advantage 3, 4.

Special Considerations for This Patient

Infection Risk Monitoring

• Tofacitinib is associated with an increased serious infection incidence rate of 2.91 (95% CI 2.27–3.74) 4.

• Baseline laboratory evaluation (complete blood count, liver function, renal function) should be performed before surgery 4.

• Lymphocyte counts <500 cells/mm³ markedly increase opportunistic infection risk and should prompt consideration of postponing elective surgery 4.

Thromboprophylaxis

• Limited evidence suggests a higher incidence of venous thromboembolic events with peri-operative tofacitinib use, so prolonged thromboprophylaxis should be implemented post-operatively 3.

• The 2022 guideline notes that standard thromboprophylaxis recommendations do not automatically address the VTE risk linked to JAK inhibitors; separate risk assessment is required 1.

Clinical Pitfalls to Avoid

• Do not withhold tofacitinib for the entire 3-month waiting period; continue it until 3 days before surgery 3, 4.

• Do not use high-dose glucocorticoids (≥20 mg/day) for stiffness control, as infection risk outweighs any potential benefit 3, 4.

• Do not restart tofacitinib prematurely; objective evidence of wound healing must be confirmed rather than using a fixed postoperative day count alone 3, 4.

• Do not rely on the outdated 2017 guideline's 7-day withholding recommendation; the 2022 ACR guideline supersedes it with a 3-day interval 1, 4.