General Rheumatology · Surgery
If you are having a planned operation, some of your rheumatology medicines are kept going and others are paused for a while. The aim is to lower the risk of infection and slow wound healing that some of these medicines carry, while not letting your disease flare at the worst possible time. This page explains the general approach so you know what to expect and what to ask.
The clearest guidance comes from the 2022 American College of Rheumatology and American Association of Hip and Knee Surgeons guideline, which was written for planned hip and knee replacement in people with inflammatory arthritis and lupus. The same thinking often guides other planned operations, but your own team decides. The balance it strikes is this: some rheumatology medicines raise the risk of infection or slow wound healing, so they are paused around surgery; but stopping treatment can let the disease flare, which is also bad for recovery. So the guideline continues the lower-risk medicines and pauses the higher-risk ones, timed carefully.
The conventional disease-modifying tablets are generally continued right through surgery, at your usual dose. These include methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide, as well as apremilast. The evidence is that keeping these going does not raise the risk of problems, and it helps keep your disease steady while you recover. So if you are on these, expect to keep taking them unless your team tells you otherwise.
Biologic medicines (the injected or infused treatments such as the anti-TNF drugs, and others like abatacept, tocilizumab, secukinumab, ustekinumab, and rituximab) are usually paused for surgery. The neat part is how the timing is done: rather than a fixed number of days, your operation is planned for the end of your dosing cycle, so surgery happens when the medicine is at its lowest level, and your next dose is given afterwards once healing is under way.
What that means in practice depends on your drug. For a medicine taken every two weeks, surgery is planned in the third week; for one taken weekly, in the second week; for one given every twelve weeks, in the thirteenth week; and so on. Rituximab, which is given every few months, is planned differently again. You do not need to work this out yourself. Your rheumatology team will tell you when to have your last dose before surgery and give you a date that fits.
The JAK inhibitor tablets (tofacitinib, baricitinib, and upadacitinib) are usually stopped about three days before surgery and restarted afterwards once your team is happy. If you are on one of these, ask exactly which day to take your last dose.
If you take a steroid such as prednisone for your rheumatic condition, the usual advice is to keep taking your normal daily dose around surgery, rather than being given a large extra dose on the day. Continuing your usual dose was found to be a safer approach than routine large stress doses for most people. Your team will confirm what is right for you.
For people with lupus, the plan depends on how active or severe the disease is. In severe lupus, several medicines are deliberately continued through surgery to avoid a dangerous flare, decided together with your rheumatologist. In milder lupus, some of those same medicines may be paused. This is very much an individual decision, so if you have lupus, have this conversation with your rheumatologist well before the operation.
Paused medicines are generally restarted once your wound shows clear signs of healing, any stitches or staples are out, and there is no sign of infection. In practice this is often around two weeks after surgery, but it depends on how your wound is healing, so it is guided by how you are doing rather than a fixed date.
Make sure your surgeon and your rheumatologist each have your complete, current medicine list, including doses.
Ask which medicines to keep taking, which to pause, and the exact date of your last dose for anything being paused.
If you are on a biologic, ask your rheumatology team to line up your last dose so surgery falls at the end of the cycle.
Ask how you will know when to restart, and who to contact if your wound is slow to heal or you think you are flaring.
Based on: Goodman SM, Springer BD, Chen AF, et al. 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty. Arthritis Care Res. 2022;74:1399 to 1408. This is patient information for planning purposes; your own plan is set by your rheumatologist and surgeon and may differ for your operation and your disease.