In a patient with mild systemic lupus erythematosus on chronic methylprednisolone 16 mg daily and taking telmisartan/amlodipine 80/10 mg, carvedilol 25 mg, hydroxychloroquine 200 mg, bilastine 20 mg, pregabalin 75 mg, rosuvastatin 10 mg, paracetamol + tramadol as needed, calcium carbonate, vitamin B, fenofibrate 160 mg, and febuxostat 40 mg, which medications should be continued pre‑operatively and which should be withheld?

Perioperative Medication Management for Mild SLE

For this patient with mild SLE undergoing surgery, continue hydroxychloroquine and methylprednisolone at their current doses through the perioperative period, while all other medications should be managed according to their cardiovascular and symptomatic indications rather than SLE-specific considerations. 1, 2

SLE-Specific Medications to CONTINUE

Hydroxychloroquine 200 mg/day

• Continue through surgery without interruption 1
• This is a conditional recommendation with low-to-moderate quality evidence for all SLE patients undergoing elective surgery 1
• Hydroxychloroquine is the backbone therapy for SLE and should be maintained to prevent disease flare 3, 4
• The current dose of 200 mg/day is appropriate and within safe limits (≤5 mg/kg/day) 4, 5

Methylprednisolone 16 mg/day

• Continue at the current daily dose of 16 mg without stress-dose supplementation 1
• The 2022 ACR/AAHKS guideline specifically recommends continuing the patient's baseline glucocorticoid dose rather than administering supraphysiologic stress doses on the day of surgery 1
• This represents a shift from historic practice and applies to all SLE patients regardless of disease severity 1, 2
• After 12 years of corticosteroid use, abrupt discontinuation risks adrenal insufficiency 6

Critical Distinction: Non-Severe vs. Severe SLE

This patient has MILD (non-severe) SLE, as evidenced by:

• Last flare presenting with urticaria, headache, and joint pain (not organ-threatening manifestations) 2
• No mention of lupus nephritis, CNS lupus, severe hematologic involvement, or vasculitis 2

For non-severe SLE, the guideline recommendations differ significantly from severe disease 1, 2:

• Patients with non-severe SLE can tolerate temporary withdrawal of certain immunosuppressants without risking permanent organ damage 2
• However, this patient is only on hydroxychloroquine (not mycophenolate, azathioprine, cyclosporine, or tacrolimus), so no additional immunosuppressants require withholding 1, 2

Non-SLE Medications: Continue Based on Cardiovascular Indications

Cardiovascular Medications - CONTINUE

• Telmisartan/Amlodipine 80/10 mg: Continue through surgery 7
• Carvedilol 25 mg: Continue through surgery
• Rosuvastatin 10 mg: Continue through surgery
• Fenofibrate 160 mg: Continue through surgery

These medications are for cardiovascular risk management (hypertension, likely related to chronic steroid use) and should be continued perioperatively according to standard cardiovascular perioperative protocols, not SLE-specific guidelines 7.

Symptomatic Medications - Continue as Needed

• Bilastine 20 mg (antihistamine for urticaria): Continue as needed
• Pregabalin 75 mg (for neuropathic pain/headache): Continue
• Paracetamol + Tramadol: Use as needed for pain
• Calcium carbonate: Continue (important given 12 years of steroid use and osteoporosis risk) 8
• Vitamin B: Continue
• Febuxostat 40 mg (for hyperuricemia/gout): Continue

Postoperative Medication Restart Protocol

If any medications were withheld (none in this case), restart approximately 14 days after surgery when: 1, 2

• Wound shows evidence of healing
• Sutures/staples are removed
• No significant swelling, erythema, or drainage present
• No ongoing non-surgical site infection

Critical Pitfalls to Avoid

Do NOT Administer Stress-Dose Steroids

• The most important pitfall: Do not give supraphysiologic glucocorticoid doses perioperatively 1, 2
• Simply continue the baseline 16 mg methylprednisolone daily 1, 2
• This recommendation is based on infection risk reduction without compromising adrenal function 1

Do NOT Discontinue Hydroxychloroquine

• Hydroxychloroquine should never be stopped perioperatively in SLE patients 1
• Discontinuation increases risk of disease flare 3, 4
• The medication has demonstrated mortality benefit and should be maintained 9, 4

Monitor for SLE Flare Postoperatively

• Surgical stress can trigger lupus flares 2
• Monitor closely for new symptoms: rash, arthritis, serositis, cytopenias 10
• Have a low threshold for checking complement levels and anti-dsDNA if clinical concern arises 10

Long-Term Steroid Management Consideration

Post-surgical goal: Taper methylprednisolone to ≤5 mg/day or discontinue entirely 8, 5

• Current dose of 16 mg/day is associated with increased damage accrual 8
• Doses >7.5 mg/day are associated with significantly higher risk of glucocorticoid-related damage (avascular necrosis, osteoporotic fractures, diabetes, cataracts) 8
• Doses ≤7.5 mg/day are not associated with damage accrual 8
• Target maintenance dose should be ≤5-2.5 mg/day or complete discontinuation 5, 11
• Consider using methylprednisolone pulses for future flares rather than increasing oral doses 9, 8