Should the dosing of csDMARDs and tsDMARDs be altered prior to elective surgery

Should the dosing of conventional synthetic DMARDs (csDMARDs) and targeted synthetic DMARDs (tsDMARDs) be altered prior to elective surgery?

The choice to continue or stop DMARDs perioperatively depends on the underlying disease and disease activity, type of surgery, and type of DMARD. Minimizing the risk for infection and poor wound healing should be balanced against the risk of disease flare. Recent guidelines for patients undergoing total knee arthroplasty (TKA) and total hip arthroplasty (THA) recommend continuing csDMARDs, including methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, and doxycycline, throughout the perioperative period. Tofacitinib, baricitinib, and upadicitinib, tsDMARDs should be stopped 7 days prior to surgery according to these guidelines. In SLE, the choice to continue csDMARDs perioperatively also depends on disease severity. For example, in patients with severe SLE, it is recommended to continue agents such as mycophenolate, azathioprine, cyclosporine, and tacrolimus throughout the operative period to maintain disease control. This is in contrast to patients with non-severe SLE where these medications are recommended to be temporarily held in the perioperative period.

Dosing Cycles for Selected Biologic Disease-Modifying Antirheumatic Drugs

AgentsDosing Cycle
AdalimumabWeekly or every 2 weeks
EtanerceptWeekly or twice weekly
GolimumabEvery 4 weeks (SQ) or every 8 weeks (IV)
InfliximabEvery 4, 6, or 8 weeks
AbataceptWeekly (SQ) or every 4 weeks (IV)
CertolizmabEvery 2 or 4 weeks
RituximabDose at time 0, then 2 weeks later, re-dosing every 4–6 months
TocilizumabWeekly (SQ) or every 4 weeks (IV)
AnakinraDaily
SecukinumabEvery 4 weeks
UstekinumabEvery 12 weeks
BelimumabEvery 4 weeks
SarilumabEvery 2 weeks
IxekizumabEvery 4 weeks

IV, Intravenous; SQ, subcutaneous.

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