The existing literature suggests these drugs may be taken safely during the perioperative period. Observational studies have found no increased risk of infections in patients taking these drugs. This recommendation is unchanged from the previous guideline, but also includes the addition of the synthetic DMARD apremilast.
Recommendation: For patients with non-severe SLE, most medications should be withheld one week prior to surgery (except those listed directly above).
This recommendation, unchanged from the previous guideline, includes such medications as mycophenolate mofetil, azathioprine, cyclosporine and tacrolimus.
Recommendation: For patients with inflammatory arthritis, withhold all biologics prior to surgery and plan the surgery shortly after the next dose would be due.
This timeframe was picked because drug levels and drug biological activity are low during this time, which help maximize safety, Dr. Singh explains. For example, for a patient taking adalimumab, normally dosed every two weeks, surgery could be planned for week 3 after the last given dose; similarly, for rituximab, normally dosed every six months, surgery could be planned for month 7 after the last given dose. This recommendation also applies to the recently introduced biologics ixekizumab, a blocker of interleukin 17, and guselkumab, a blocker of interleukin 23.
Recommendation: For patients with inflammatory arthritis or SLE who had anti-rheumatic therapy withheld prior to surgery, restart therapy once the wound shows evidence of healing without any signs of infection.
Typically, this occurs about 14 days after surgery, but it might be earlier or later, depending on the status of the wound and the patient’s overall health. Dr. Singh explains, “You end up skipping a dose. You maximize safety, but you don’t risk flare by holding it for too long.”
Recommendation: For patients with inflammatory arthritis, hold Janus kinase (JAK) inhibitors for at least three days prior to surgery.
This recommendation, which applies to the targeted synthetic DMARDs tofacitinib, baricitinib and upadacitinib, was changed from a seven-day hold in the previous guideline. Dr. Singh notes that since that time, we’ve gained a better understanding of the clinical effects of these drugs, suggesting a more rapid reversal of immunosuppressive effects than previously believed. This makes it safer to withhold them for a shorter period.
Recommendation: For patients with severe SLE, continue the usual dose of the following drugs through surgery: mycophenolate mofetil, mycophenolic acid, azathioprine, mizoribine [not available in the U.S.], cyclosporine, tacrolimus, anifrolumab, voclosporin, belimumab and rituximab.
