Perioperative management of immunosuppression

01Purpose and principlesWhat the treatment does and how it fits into care.

Perioperative immunosuppression is a balance between infection and flare, not a universal stop rule. Continuing a medicine can impair host defence or wound healing, but withdrawing effective control can trigger synovitis, vasculitis or organ flare, immobility and glucocorticoid rescue. Glucocorticoid escalation itself raises infection, glucose and wound risk. Decisions therefore incorporate drug pharmacology, operation contamination and consequence, implants, disease severity and patient vulnerability.

Begin early with exact reconciliation: conventional DMARD dose and weekly day, biologic brand, route, interval and last dose, JAK or targeted drug, all glucocorticoid routes, anticoagulants, renal function, infection history and vaccination. Define whether the procedure is minor and clean, major with implant, contaminated, emergency, or likely to impair oral intake. The surgeon, anaesthetist and rheumatologist must share the same dated plan.

When infection would be catastrophic, such as selected prosthetic, vascular or contaminated surgery, BSR permits considering three to five drug half-lives before operation. This can be substantially longer than one dosing interval and raises flare risk. Conversely, minor procedures without a break in sterile technique, such as selected dermatological, ophthalmic or endoscopic interventions, may proceed while continuing many biologics after surgeon and rheumatology agreement.

Rituximab cannot be washed out by skipping a near-term dose because B-cell depletion persists for months. Plan elective surgery toward the later part of the treatment cycle when disease allows, review IgG and infection history and delay the next course until wound recovery. An operation needed for cancer or major disability should not be deferred solely to wait for B-cell repopulation without a multidisciplinary benefit analysis.

Restart timing is clinical. For a biologic, wait until the wound shows evidence of healing, there is no important erythema, swelling or drainage, sutures or staples are removed when appropriate and no nonsurgical infection remains; this is often around 14 days. JAK treatment can often resume after three to five days when wound and systemic stability are satisfactory, ideally before 14 days to limit flare, but do not restart into sepsis, unresolved drainage or ileus.

Chronic glucocorticoid is continued through surgery; abrupt withdrawal risks adrenal crisis. Identify adrenal suppression from prednisolone 5 mg daily or more for at least four weeks, recent higher dose, repeated injections or other potent routes. For major surgery, anaesthetic guidance commonly uses hydrocortisone 100 mg IV at induction followed by 200 mg over 24 hours, then returns toward the usual dose as oral intake and recovery permit. Stress cover replaces cortisol response; it does not treat rheumatic flare.

Key points

Write one perioperative medicine table showing exact drug, last dose, intended operation date, hold interval, postoperative tests and named restart authority; do not rely on stop all immunosuppression.
For most elective operations, continue methotrexate, hydroxychloroquine and sulfasalazine because withdrawal can provoke flare and evidence does not show a routine infection benefit from stopping.
Leflunomide is often continued for ordinary elective surgery, but its long persistence, liver or blood toxicity and high-consequence infection require an individual plan; simply omitting one dose gives little washout.
For most biologics, schedule surgery after one dosing interval so one dose is missed; for very high infection-consequence operations, BSR allows consideration of three to five half-lives after balancing flare and steroid rescue.
For adalimumab 40 mg every two weeks, UKCPA advises scheduling non-minor surgery at least 15 days after the last dose so one dose is missed.
Hold tofacitinib for three days before most surgery and schedule the procedure on day four after the last dose; consider seven days only when infection consequence is especially high.
Continue the patient's usual glucocorticoid dose. Do not stop chronic prednisolone abruptly; assess hypothalamic-pituitary-adrenal suppression and arrange stress hydrocortisone according to surgical stress and anaesthetic guidance.
Restart a held biologic when the wound is healing, sutures or staples are out as appropriate, there is no significant swelling, erythema, drainage or ongoing infection, commonly about 14 days after surgery.
JAK inhibitors can often restart three to five days after surgery once wound and clinical stability permit, aiming to avoid an interruption beyond 14 days, but infection or VTE overrides early restart.
Emergency surgery proceeds without waiting for a full drug washout: withhold immediate postoperative doses, document last exposure and intensify infection, adrenal, renal and thrombosis surveillance.

02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.

Low-risk continuation setting

Stable disease, normal monitoring and a clean minor procedure without implant or cavity entry often permits continued conventional and selected biologic treatment after agreement.

High infection-consequence setting

Prosthetic implantation, contaminated surgery, recurrent infection, diabetes, smoking, malnutrition, neutropenia or high-dose glucocorticoid favours longer optimisation and cautious restart.

Adrenal-risk patientRed flag

Prednisolone 5 mg daily or more for four weeks, recent high doses, repeated injections or Cushingoid features indicates possible suppressed stress response.

Postoperative wound infectionRed flag

Increasing pain, drainage, erythema, wound separation, fever or prosthetic dysfunction precludes targeted-therapy restart and needs urgent surgical review.

Perioperative flare

New synovitis, inflammatory stiffness, rash, renal change or organ symptoms after withholding should be measured and distinguished from infection before rescue treatment.

Postoperative VTERed flag

New unilateral swelling, pleuritic pain, hypoxaemia or unexplained tachycardia after surgery needs emergency thrombosis assessment regardless of prophylaxis.

Red flags requiring action

Fever, increasing wound pain, purulent drainage, spreading erythema, dehiscence, prosthetic pain or systemic deterioration requires immediate infection and source-control assessment.
Hypotension, vomiting, hyponatraemia, hypoglycaemia or collapse after interrupted chronic glucocorticoid may represent adrenal crisis and requires immediate hydrocortisone.
New unilateral leg swelling, chest pain, unexplained tachycardia or hypoxaemia postoperatively requires emergency VTE assessment, especially after recent JAK exposure.
Acute kidney injury, major blood loss, liver injury or inability to take oral medicine changes methotrexate, JAK and other restart safety even when the wound looks satisfactory.
A rapidly active vasculitis, severe lupus flare or organ-threatening inflammation during a perioperative hold needs joint specialty rescue rather than prolonged unplanned interruption.
Neutropenia, hypogammaglobulinaemia or active infection before elective surgery may justify postponement and optimisation after multidisciplinary review.

03Assessment before treatmentTests and checks that guide safe selection.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
First-line exact medicine timelineFirst stepFirst line
Why
Calculate the final preoperative and first possible postoperative dose from the real product interval.
Interpretation and limitations
Record brand, route, dose, last administration, usual next due date, half-life where relevant, renal clearance and any active metabolite; calendar dates prevent one-dose plans becoming vague.
02
FBC, renal and liver profile
Why
Confirm marrow and organ safety for surgery, anaesthesia and conventional-DMARD continuation.
Interpretation and limitations
Neutropenia, thrombocytopenia, AKI or liver injury can justify postponement or a medicine hold; use recent stable results for minor procedures and repeat when clinical risk has changed.
03
Clinical infection assessment
Why
Find a current focus that changes elective timing and restart.
Interpretation and limitations
Examine skin, wound, respiratory, dental and urinary symptoms and investigate selectively; active serious infection usually postpones elective surgery, while asymptomatic colonisation follows procedure-specific policy.
04
Disease activity and flare risk
Why
Estimate the consequence of interruption and need for bridge therapy.
Interpretation and limitations
Document recent flares, organ threat, steroid dependence and previous missed-dose response; high flare risk may favour one dosing interval rather than three to five half-lives.
05
Adrenal suppression assessment
Why
Determine whether usual steroid alone is insufficient for operative stress.
Interpretation and limitations
Use dose, duration, timing and routes and, when elective uncertainty remains, morning cortisol or endocrine testing; emergency stress cover must not wait for an assay.
06
Operation and wound-risk classification
Why
Match medicine interruption to contamination, implant, healing and oral-intake consequences.
Interpretation and limitations
A minor sterile procedure differs from prosthetic arthroplasty or bowel surgery; planned drains, stoma, vascular graft and expected ileus influence restart.
07
Postoperative wound and organ review
Why
Confirm conditions for restarting a held DMARD or targeted medicine.
Interpretation and limitations
Check healing, drainage, erythema, systemic infection, cultures, FBC, renal and liver recovery and ability to absorb oral treatment before authorisation.

04Treatment approachPreparation, options, escalation and aftercare.

01First planning stepCreate one dated perioperative tableFirst stepElective surgery is proposed for a patient taking any immunosuppressive rheumatology medicine.

1Classify procedure and infection consequence, reconcile exact drug dates and assess disease, infection, organ, steroid, wound and thrombosis risk.
2Agree continuation or last preoperative date with surgeon, anaesthetist and rheumatologist and record what will control a flare if treatment is withheld.
3Specify earliest restart criteria and the named clinician who will inspect the wound and authorise each medicine.

02Conventional-DMARD routeContinue most, revisit organ changeA patient on methotrexate, hydroxychloroquine, sulfasalazine or leflunomide undergoes elective surgery.

1Continue methotrexate, hydroxychloroquine and sulfasalazine for most operations; individualise leflunomide and exceptionally high-infection-risk procedures.
2Verify FBC, liver and renal stability and avoid an unplanned glucocorticoid substitution solely because a conventional DMARD was stopped.
3Withhold postoperatively if AKI, severe infection, cytopenia, liver injury or inability to take the medicine creates a new contraindication.

03Biologic and JAK routeMiss one dose or use a defined short holdA non-minor elective operation requires temporary targeted-therapy interruption.

1For most biologics schedule surgery after one dosing interval; consider three to five half-lives only when infection consequence justifies the longer flare exposure.
2For tofacitinib omit three days and operate on day four, extending to seven days only for especially high infection risk; use the exact handbook entry for other JAK drugs.
3Restart biologics after clear wound healing, commonly about day 14, and JAK treatment after three to five days when wound, infection, organ and VTE status permit.

04Glucocorticoid routeContinue baseline and replace stress responseChronic or recent steroid exposure suggests hypothalamic-pituitary-adrenal suppression.

1Continue the usual daily glucocorticoid and avoid abrupt taper immediately before surgery; minimise chronic excess earlier when elective disease control allows.
2For major stress, use anaesthetic or endocrine hydrocortisone cover, commonly 100 mg IV at induction followed by 200 mg over 24 hours.
3Return toward the normal oral regimen as haemodynamics and intake recover, monitoring glucose, electrolytes, pressure, infection and delirium.

05Emergency and complication routeOperate, support and delay restartUrgent surgery, sepsis, wound complication or major organ injury prevents the planned interval.

1Do not delay source control or life-saving surgery; record last immunosuppressant, withhold due doses and give procedural antimicrobial and VTE measures.
2Provide adrenal cover when indicated and investigate postoperative infection, kidney, liver, marrow and wound complications before resuming treatment.
3Use rheumatology input for flare rescue and create a new restart date only after surgical and systemic recovery are demonstrable.

05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.

Maintains inflammatory-disease control and avoids a flare when routine continuation does not materially increase surgical infection risk.

Methotrexate

Continue the usual once-weekly rheumatology dose through most elective operations; ensure the named weekly day is preserved and reassess dosing if perioperative acute kidney injury, sepsis or oral-intake failure develops.

Individualise high-consequence infection and organ impairment, monitor FBC, liver and renal function and never give a catch-up dose after interruption.

Dosing-interval strategy that limits perioperative TNF suppression while avoiding an unnecessarily long inflammatory flare.

Adalimumab

For most non-minor elective surgery in a patient dosing every two weeks, give the last injection at least 15 days before the procedure so one dose is missed; restart after wound healing, often around 14 days.

Longer interruption may be chosen for very high infection-risk surgery; do not restart with drainage, erythema, systemic infection or an unhealed wound.

Short interruption of JAK signalling around non-minor surgery, balancing infection, VTE and flare.

Tofacitinib

Stop three days before most surgery and schedule the operation on day four after the last dose; consider a seven-day preoperative hold for especially high infection risk, then restart three to five days after surgery when stable.

Assess renal and liver function, serious infection, wound and thrombosis risk before restart and aim to avoid an interruption beyond 14 days unless complications require it.

Prevents adrenal crisis while preserving necessary rheumatic control; stress cover replaces cortisol response rather than escalating disease treatment.

Prednisolone with stress hydrocortisone

Continue the usual prednisolone dose; for major surgery in a patient with adrenal suppression, give hydrocortisone 100 mg IV at induction then 200 mg over 24 hours, followed by step-down as oral intake and recovery allow.

Monitor glucose, pressure, electrolytes, fluid, delirium, infection and wound healing and seek endocrine advice when suppression or postoperative taper is uncertain.

Maintains disease control when brief tablet interruption would not remove the long-lived active metabolite.

Leflunomide

Continue the usual 10–20 mg orally once daily for many elective procedures; if severe toxicity or high-consequence infection requires rapid removal, use cholestyramine 8 g three times daily for 11 days under specialist direction.

Individualise liver injury, cytopenia, sepsis and prosthetic or contaminated surgery; washout is not routine and can provoke a substantial flare.

Cycle-based coordination for a biologic whose immune effect persists far beyond its plasma administration window.

Rituximab

Plan elective surgery toward the later part of the treatment cycle when feasible and defer the next infusion until wound healing and infection status are satisfactory; no short preoperative omission reverses existing B-cell depletion.

Review IgG, recurrent infection, hepatitis B prophylaxis and vaccine response and do not delay urgent cancer or life-preserving surgery solely for B-cell recovery.

06Complications, monitoring and follow-upAdverse effects, response and longer-term review.

Before surgery confirm the final plan against the actual last administration and operation date; update it if the procedure is postponed because a missed-dose interval can otherwise become prolonged.
Monitor wound appearance, drainage, temperature, pain, cultures, blood counts and renal and liver recovery before every targeted-therapy restart decision.
Track inflammatory disease activity during a hold and distinguish flare from infection; repeated glucocorticoid rescue may carry more surgical risk than a shorter biologic interruption.
For steroid-exposed patients monitor haemodynamics, sodium, potassium and glucose and document stress-dose administration and return to the regular regimen.
Apply routine procedure-specific VTE assessment and prophylaxis, with particular attention to previous VTE, immobility, active inflammation, cancer and recent JAK treatment.
At discharge reconcile every DMARD and biologic with exact restart date or criteria, responsible team, next blood test and urgent wound or infection contacts.

07Special situationsVariants, exceptions and circumstances that change the usual approach.

One missed dose is a calendar rule

The relevant date comes from the patient's actual interval; two-weekly adalimumab and eight-weekly infliximab cannot share one stop date.

Plasma half-life is not immune recovery

Rituximab's B-cell depletion and leflunomide's active metabolite persist long after the immediate tablet or infusion window.

Flare has surgical consequences

Pain, immobility and steroid rescue can increase thrombosis, glucose and infection risk, so longer interruption is not automatically safer.

Stress steroid is physiological cover

Hydrocortisone for operative stress prevents cortisol failure and should not be counted as intentional treatment of the rheumatic disease.

Restart is based on tissue, not day alone

Fourteen days is a common guide for biologics, but drainage or infection delays treatment while rapid uncomplicated healing may support agent-specific decisions.

Emergency surgery changes sequence, not safety

Washout cannot precede life-saving source control, so the focus shifts to last-dose documentation and postoperative infection, adrenal and organ surveillance.

08Common pitfallsFrequent interpretation and management errors.

01
Writing stop biologic before surgery without an exact last dose, procedure date, missed-dose interval or restart owner.
02
Stopping methotrexate, hydroxychloroquine and sulfasalazine routinely and then treating the resulting flare with high-dose prednisolone.
03
Skipping one leflunomide tablet and assuming its long-lived active metabolite has cleared.
04
Stopping chronic prednisolone abruptly to reduce infection risk and precipitating perioperative adrenal crisis.
05
Restarting a biologic automatically on postoperative day 14 despite wound drainage, cellulitis, AKI or another active infection.
06
Delaying emergency source-control surgery while waiting for a biologic washout that cannot reverse established immune effects.