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.
Key red flags
Fever, increasing wound pain, purulent drainage, spreading erythema, dehiscence, prosthetic pain or systemic deterioration requires immediate infection and source-control assessment.
Prednisolone 5 mg daily or more for four weeks, recent high doses, repeated injections or Cushingoid features indicates possible suppressed stress response.
Investigation priorities
Calculate the final preoperative and first possible postoperative dose from the real product interval.
Management branches
Elective surgery is proposed for a patient taking any immunosuppressive rheumatology medicine.
- Classify procedure and infection consequence, reconcile exact drug dates and assess disease, infection, organ, steroid, wound and thrombosis risk.
- Agree continuation or last preoperative date with surgeon, anaesthetist and rheumatologist and record what will control a flare if treatment is withheld.
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.
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.