DMARDs: what to do if surgery is planned?

Which drugs should be discontinued (or not) before a surgery? SPAQI published relevant new clinical guidelines for rheumatological diseases treatment.

Recommendations for immunosuppressant therapy

Immunosuppressants can usually be continued

The experts agree that most immunosuppressants, such as methotrexate, glucocorticoids or hydroxychloroquine, can and should be continued perioperatively in their usual dosage. It also makes sense to administer these drugs on the actual day of surgery. 

The only exceptions in this group of drugs are cyclophosphamide and voclosporin. It is recommended that cyclophosphamide be discontinued four weeks before the planned surgery. Patients taking voclosporin should stop the current cycle of therapy and schedule surgery after completing the cycle.

Many biologics should be paused

People taking biologics should definitely pause therapy with most medications in this class for one cycle before undergoing surgery. This applies to:

It is recommended to continue treatment with anti-interferons as normal, while Janus kinase inhibitors should be paused three days before the procedure. 

The special case of lupus

The therapy of systemic lupus erythematosus (SLE) occupies a special position:

Pausing NSAIDs

The experts recommend that all NSAIDs should ideally be paused one week before the planned surgery - with the exception of the selective COX2 inhibitor celecoxib, which can be taken without interruption. Depending on the half-life, however, a shorter abstinence of one (for example, ibuprofen) to six days (for example, nabumetone) may be sufficient. In some cases, a break over a period of 10 days makes sense, for example in the case of piroxicam.

Guidelines facilitate therapy decisions

The new clinical guidelines give a detailed overview of the recommended procedure for 108 different drugs. They also discuss whether additional examinations are useful, and if so, which ones.