DMARDs: what to do if surgery is planned?

Which drugs should be discontinued (or not) before a surgery? SPAQI published relevant new clinical guidelines for rheumatological diseases treatment.

Recommendations for immunosuppressant therapy

Most immunosuppressants can be continued and should also be taken on the day of surgery.
Cyclophosphamide should be paused four weeks before surgery.
It is recommended to interrupt therapy with most common biologics for one cycle - with a few exceptions.
NSAIDs should be discontinued seven days before surgery. The only exception is celecoxib, which can be continued perioperatively.

Immunosuppressants can usually be continued

The experts agree that most immunosuppressants, such as methotrexate, glucocorticoids or hydroxychloroquine, can and should be continued perioperatively in their usual dosage. It also makes sense to administer these drugs on the actual day of surgery.

The only exceptions in this group of drugs are cyclophosphamide and voclosporin. It is recommended that cyclophosphamide be discontinued four weeks before the planned surgery. Patients taking voclosporin should stop the current cycle of therapy and schedule surgery after completing the cycle.

Many biologics should be paused

People taking biologics should definitely pause therapy with most medications in this class for one cycle before undergoing surgery. This applies to:

TNF-alpha inhibitors
IL-1 inhibitors
IL-6 inhibitors
IL-17 inhibitors
IL-12/23 and IL-23 inhibitors
Costimulation blockades such as Abatacept
B-cell agents such as rituximab

It is recommended to continue treatment with anti-interferons as normal, while Janus kinase inhibitors should be paused three days before the procedure.

The special case of lupus

The therapy of systemic lupus erythematosus (SLE) occupies a special position:

While most immunosuppressants can be continued, as already mentioned, mycophenolate, azathioprine, cyclosporine and tacrolimus should be paused for seven days preoperatively in mild to moderate SLE.
Continuation of medication is recommended only in severe disease.
Treatment with the biologics rituximab and belilumab should not be interrupted in people with severe SLE, but should be continued as usual.

Pausing NSAIDs

The experts recommend that all NSAIDs should ideally be paused one week before the planned surgery - with the exception of the selective COX2 inhibitor celecoxib, which can be taken without interruption. Depending on the half-life, however, a shorter abstinence of one (for example, ibuprofen) to six days (for example, nabumetone) may be sufficient. In some cases, a break over a period of 10 days makes sense, for example in the case of piroxicam.

Guidelines facilitate therapy decisions

The new clinical guidelines give a detailed overview of the recommended procedure for 108 different drugs. They also discuss whether additional examinations are useful, and if so, which ones.

Source:

Russell LA et al: Preoperative Management of Medications for Rheumatologic and HIV Diseases: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Mayo Clin Proc. 2022 Aug;97(8):1551-1571. PMID: 35933139.