What short‑term regimen should be given to a patient with hip synovial chondromatosis and marked groin stiffness awaiting surgery, who is currently taking tofacitinib?

Short-Term Management of Groin Stiffness in Hip Synovial Chondromatosis While on Tofacitinib

For a patient with hip synovial chondromatosis experiencing marked groin stiffness while awaiting surgery and currently taking tofacitinib, continue tofacitinib up to 3 days before surgery and add regular paracetamol (acetaminophen) as the primary analgesic, with low-dose oral corticosteroids (≤10-15 mg prednisone daily) as a second-line option if stiffness remains intolerable. 1

Primary Analgesic Strategy

• Paracetamol should be the first-line agent for pain and stiffness relief, offered at regular dosing intervals rather than as-needed to maintain therapeutic levels 2
• Paracetamol has demonstrated approximately 30% reduction in post-traumatic swelling and provides effective pain control without the bleeding risks associated with NSAIDs 3
• Regular dosing (e.g., 1000 mg every 6 hours, maximum 4000 mg daily) is more effective than intermittent use for managing ongoing musculoskeletal symptoms 2

Tofacitinib Perioperative Management

The 2022 American College of Rheumatology guideline supersedes older recommendations and advises withholding tofacitinib for only 3 days before surgery (not the outdated 7-day interval), which markedly reduces preoperative stiffness compared with longer discontinuations 1

• Continue tofacitinib 5 mg twice daily up to 3 days before the scheduled operation 1
• This brief medication-free window provides rapid restoration of immune function while minimizing disease flare 1
• The shorter 3-day hold is based on pharmacodynamic data showing swift disease flare after interruption, making longer discontinuations unnecessarily burdensome 1

Adjunctive Corticosteroid Therapy

If stiffness becomes intolerable during symptom management, add low-dose oral corticosteroids (prednisone ≤10-15 mg daily) 1

• Critically, avoid prednisone ≥20 mg/day, as this significantly raises postoperative infection risk (odds ratio ≈1.68) and impairs wound healing 1
• Single-dose or short-term glucocorticoid administration can reduce pain and excessive inflammation by approximately 50% in acute musculoskeletal conditions 3
• If already on corticosteroids, maintain the current dose through surgery without "stress dosing" 1

Therapies to Avoid

• Do NOT use oral NSAIDs or COX-2 inhibitors in this patient already on tofacitinib, as the combination increases infection risk without clear added benefit for mechanical hip pathology 2, 1
• Acetylsalicylic acid (aspirin) should be avoided as it has failed to reduce or even tended to increase swelling in acute trauma models 3
• Do NOT withhold tofacitinib for longer than 3 days preoperatively; the 2022 guideline supersedes the outdated 2017 recommendation of 7 days 1

Non-Pharmacological Adjuncts

• Local heat applications can provide symptomatic relief for hip stiffness 2
• Manipulation and stretching are particularly recommended for osteoarthritis of the hip and may help with mechanical stiffness 2
• Assistive devices such as walking sticks can reduce mechanical stress on the affected hip while awaiting surgery 2

Critical Safety Considerations

Tofacitinib carries an FDA black box warning for increased infection risk (serious infection incidence rate 2.91,95% CI 2.27-3.74) and venous thromboembolic events 4, 1

• Baseline laboratory evaluation (complete blood count, liver function tests, renal function) should be confirmed before surgery 1
• Lymphocyte counts <500 cells/mm³ markedly increase opportunistic infection risk and should prompt consideration of postponing elective surgery 1
• Enhanced VTE prophylaxis protocols should be implemented perioperatively given the dual thrombosis risk from both tofacitinib and the surgical procedure 4

Postoperative Restart Protocol

• Restart tofacitinib 5 mg twice daily only after confirming adequate wound healing, typically around 14 days postoperatively 4, 1
• Specific criteria before restarting: removal of sutures/staples, absence of significant swelling, erythema, drainage, or any clinical evidence of surgical-site or systemic infection 4, 1
• Do not delay restarting beyond 14 days when wound healing is adequate, as prolonged interruption leads to unnecessary disease flare without added safety advantage 1