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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Perioperative management of immunosuppression

Rheumatology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Urgent surgery or postoperative infection

Sepsis, wound dehiscence, prosthetic infection, haemodynamic instability or emergency surgery in a patient taking immunosuppression requires action before a routine drug interval can be completed; chronic steroid exposure adds adrenal-crisis risk.

Action: Do not delay life-saving surgery for washout, withhold due targeted doses, give standard antimicrobial and thrombosis measures, continue essential glucocorticoid with stress cover when indicated, and coordinate postoperative source control and delayed restart with surgery, anaesthesia and rheumatology.

Synopsis

Coordinate conventional DMARD, biologic, JAK-inhibitor and glucocorticoid decisions around surgery, balancing infection and wound risk against flare, adrenal crisis and thrombosis with a dated stop-and-restart plan.

  • 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.

Key red flags

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.

Adrenal-risk patient

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

Postoperative wound infection

Investigation priorities

01
First-line exact medicine timelineFirst stepFirst line

Calculate the final preoperative and first possible postoperative dose from the real product interval.

Management branches

First planning stepCreate one dated perioperative table

Elective surgery is proposed for a patient taking any immunosuppressive rheumatology medicine.

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

Key medicines

MethotrexateContinue 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.
AdalimumabFor 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.
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Sources and review status7 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • UKCPA perioperative methotrexate guidanceContinuation, high-risk individualisation and postoperative renal or infection review.
  • UKCPA perioperative adalimumab guidanceOne-missed-dose timing, high-risk longer hold and restart criteria.
  • UKCPA perioperative tofacitinib guidanceThree-day hold, high-risk seven-day option and early restart.
  • UKCPA perioperative prednisolone guidanceContinuation, adrenal-risk threshold and operative stress cover.
  • BSR biologic DMARD safety guidelineDosing-interval and half-life approaches and postoperative restart.
  • NICE NG125 surgical site infection recommendationsPerioperative antimicrobial, skin, wound and infection prevention.
  • Adalimumab UK product informationDose interval, infection and surgical safety context.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem ·

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

Postoperative VTE

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

Content changes
Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom