Perioperative Management of Rheumatology Patients on Immunosuppressive Therapy


Aine Stakelum; Azhar Abbas; Bernie McGowan; Miriam O'Sullivan; Bryan Whelan; Carmel Silke


Northwestern Rheumatology Unit, Our Lady’s Hospital, Manorhamilton, Co Leitrim


Disease Modifying Anti-Rheumatic Drugs (DMARDs) and Biologics are an important part of treatment for many rheumatology patients. They have been shown to slow disease progression in patients with inflammatory arthritis and allow patients to maintain high levels of independence. The decision on when to continue, withhold and restart these medications in the perioperative period has varied between both rheumatologists and surgeons over the past number of years. Randomised control trials have demonstrated increased risk of infection in patients on biologics undergoing surgery [1]. It is important to balance this risk of infection with the risk of disease flare if therapy is stopped. Until recently there were no definitive guidelines on the subject and practices varied between institutions and between specialists. In June 2017 the American College of Rheumatology and the American Association of Hip and Knee Surgeons published guidelines [1] on the optimal perioperative management of anti rheumatic medications. These recommend that methotrexate, hydroxychloroquine, leflunomide and sulfasalazine may be continued, while biologic agents should be held prior to surgery and where possible surgery should be planned at the end of the dosing cycle.


Our aim was to survey a selection of patients and assess their knowledge regarding medication changes in the perioperative period. We also aimed to examine the literature regarding the optimal management of patients on DMARDs and ensure our unit was compliant with current guidelines.


We surveyed a random selection (n=42) of our outpatients on DMARD therapy over a two-week period. We included patients on methotrexate, hydroxychloroquine, leflunomide and/or biologic therapy.


Of the patients surveyed, 19% (8) had a surgical procedure since commencing their anti-rheumatic therapy. 36%(15) of the patients surveyed were on Methotrexate. Of these, 13% said they would continue their medication if they had to undergo elective surgery, 33% said they would discontinue their Methotrexate and 53% were unsure what they would do.

45% (19) of our patients were on biologic therapy. Of these, 26% said they would stop their biologic prior to a surgical procedure, 5% would continue biologic therapy and the remaining 68% were unsure.


Our study showed that the majority of our patients were unsure whether they should stop or continue their anti-rheumatic medication if they were to have elective surgery. One third would unnecessarily discontinue their Methotrexate. In our unit, it is policy that all patients attend an education session prior to starting treatment where they are educated on the risks and side effects of their new medication. This study highlights the need for more patient education on medication changes in the perioperative period. Although the ACR and AAHKS guidelines include a number of recommendations for perioperative dosing of anti-rheumatic medications, these recommendations are based on low quality scientific evidence and there is a need for more high quality RCTs to assess the safety and efficacy of stopping and resuming biologic therapy in the perioperative period.